Paper Reading Int. 林泰祺

Introduction Pelvic fracture patients who are hemodynamically unstable are a diagnostic and therapeutic challenge for the trauma team These injuries often occur in conjunction with other life-threatening injuries, and there is not universal agreement among clinicians on management The mortality for these high-risk patients exceeds 40%

Introduction Time to definitive stabilization followed by appropriate interventional radiology access and embolization may consume hours while the patient remains hemodynamically compromised Additionally, in patients with indications for laparotomy such as evidence of intra-abdominal hemorrhage on Focused Assessment with Sonography for Trauma (FAST) examination, this time delay may be even longer

Introduction We have modified this technique to directly address pelvic hemorrhage through direct packing of the pelvis using a preperitoneal approach for all patients with hemodynamic instability and a pelvic fracture Such an approach would simplify the often difficult decision between immediate operative intervention and interventional radiology Additionally, this approach more rapidly and directly addresses the primary source of bleeding with pelvic fractures—venous and bone hemorrhage

Introduction We hypothesized that preperitoneal pelvic packing (PPP) reduces need for angiography, decreases blood transfusion requirements, and lowers mortality

Results During the study period, from September 2004 to June 2006, 139 patients qualified for inclusion in the pelvic fracture KCP and received blood transfusions Of these, 28 consecutive patients met the KCP criteria of an SBP 90 mm Hg despite the transfusion of two units of PRBCs and underwent external fixation and PPP There was one protocol deviation of prePPP angiography to evaluate an extremity vascular injury

Outcome Patients required 4± 1.2 units of PRBCs during 82 ± 13 minutes in the ED Blood transfusion requirements before postoperative SICU admission compared with the subsequent 24 postoperative hours were significantly different Abdominopelvic complications included infection of the pelvic space (3 total; 2 in patients with a bladder rupture), infection of the buttock and back related to a perineal degloving with rectal injury Superficial wound infections (2 total; 1 anterior PPP incision, 1 posterior incision used for fixation of a comminuted sacral fracture) Two patients had intra-abdominal abscesses associated with visceral injuries

Outcome Patients required a mean of 14± 2.8 days of mechanical ventilation and remained in the surgical intensive care unit for 18 ± 2.9 days Overall length of hospital stay was 26 ± 3.4 days Seven (25%) patients died during their hospitalizationas a result of multiple organ failure (MOF) (2), postinjury myocardial infarction/pulseless electrical activity (PEA) arrest (2), invasive mucormycosis (1), closed head injury (1), and withdrawal of care (1) There were no differences in presenting SBP, HR, base deficit, ISS or transfusion requirement between those who lived versus died The only significance between the two groups was mean patient age (34 ± 3.9 years for patients who lived versus 55±8.1 years for patients who died)

Discussion 85% of bleeding as a result of pelvic fractures is venous or bony in origin Hemorrhage is therefore only arrested by tamponade within the retroperitoneal space Angioembolization does not address such bleeding. In fact, patients undergoing diagnostic angiography frequently do not have active bleeding sites visualized and/or few patients require angioembolization Secondly, although angioembolization may be effective in controlling pelvic arterial bleeding, it has not been shown to decrease the necessity for blood product resuscitation Third, there are a number of institutions that do not have angiographic capabilities

Discussion In our study population, there was a significant reductionin blood transfusion requirements in the postoperative 24hours compared with the prePPP period. By surgically packing the pelvic space The overall potential space required to tamponade bleeding from the pelvis is reduced, therefore hypothetically reducing the amount of blood transfusion required to fill this potential space Since blood transfusion is an independent risk factor for increased ICU length of stay, the development of multiple organ failure, and mortality

Discussion PPP may be ideally suited for austere conditions and in settings where angiography is unavailable or unable Emergent retroperitoneal packing appears to be a safe procedure that has a role in damage control of critically injured patients. It can be done immediately and with ease in conjunction with external fixation of the pelvis and other surgical 24-hour angiographic, the time delay to angiography can be significant. the time to angiography was four times longer in the nonPPP group compared with the PPP study group

Discussion There were five abdominoperineal space infections and two superficial wound infections, although the majority occurred in patients with associated bladder or bowel injuries There was no apparent relationship between the time packs were removed and incidence of infection The 25% mortality rate in this cohort was lower than historical reports of similar patient populations There were no deaths as a result of exsanguination, and two patients died of MOF.

Conclusion Eliminate the often difficult decision between the operating room and interventional radiology Additionally, this approach directly addresses the primary source of bleeding with pelvic fractures—venous and bone hemorrhage. Combined external pelvic fixation and preperitoneal pelvic packing may represent a revolutionary management strategy for these critically multiply injured patients, and offer a life-saving procedure in environments where IR is unavailable

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