Hemorrhage Control After Pelvic Trauma: Mass General Algorithm Incorporates Debated Approaches
Key findings
- This retrospective study examined the effectiveness of primary pre-peritoneal packing (PPP), plus temporary external fixation, if indicated, followed by transarterial embolization (TAE) in 61 patients suffering from severe pelvic trauma
- The study also examined the effectiveness of primary TAE for 74 hemodynamically stable patients with pelvic trauma
- In the primary TAE group, one patient required PPP later, and no exsanguination-related deaths were observed
- In the primary PPP group (with TAE in 84% of cases), 11% of patients died due to exsanguination, and the overall in-hospital mortality rate was 46%
- Although in-hospital mortality was high in the PPP group, it was comparable to rates in other studies, and in most cases, was not caused by uncontrollable pelvic hemorrhage
Controlling hemorrhage after pelvic trauma is challenging, and the optimal initial measure remains controversial. Pre-peritoneal packing (PPP) with external fixation (EF) is less time-consuming than transarterial embolization (TAE). Some trauma centers favor initial TAE because it's less invasive and might reduce mortality by decreasing arterial pressure, thereby aiding control of venous bleeding.
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At Massachusetts General Hospital, institutional policy dictates PPP and EF for hemodynamically unstable patients, followed by TAE. Primary TAE is advised for patients who are hemodynamically stable on arrival or responsive to extensive resuscitation but suspected of minor or moderate bleeding.
In an 18-year retrospective study, Dennis Hundersmarck, MD, former PhD student, and Marilyn Heng, MD, MPH, orthopaedic trauma surgeon in the Department of Orthopaedics at Massachusetts General Hospital, and colleagues affirmed the effectiveness and safety of both approaches. Their report appears in Injury.
Study Methods
The researchers analyzed data on 135 adults with pelvic fractures who received PPP or TAE as hemorrhage control measures between January 2001 and January 2019. The patients were treated at either Mass General or Brigham & Women's Hospital, both of which adhere to the same treatment algorithm for pelvic trauma. The algorithm is described in more detail in the article.
Treatment Modalities
61 patients (45%) underwent PPP as the initial hemorrhage control measure. In this group:
- 51 (84%) received subsequent TAE
- TAE was performed bilaterally in 47 patients and unselectively in 44
- Gelfoam alone was the embolic agent in 44 patients
- In two cases, rebleeding after PPP and bilateral, unselective TAE occurred, requiring repeat bilateral embolization in an unselective manner
The other 74 patients (55%) underwent primary TAE. In this group:
- TAE was performed selectively in 48 patients and unilaterally in 38
- Gelfoam alone was used in 55 patients (92%)
- Only one patient required PPP after primary TAE
Ischemic Complications
In-hospital complications potentially related to embolization were observed in three patients in the PPP group and one in the primary TAE group. 13 patients had in- and out-of-hospital ischemic complications potentially related to embolization, of whom 10 had undergone bilateral unselective embolization. On bivariate analysis, in-hospital ischemic complications were more frequent in patients who received bilateral unselective TAE (either primary or after PPP) than in other TAE patients (P=0.03).
Thromboembolic Complications
Twenty patients had in-hospital thromboembolic complications, of whom 14 (70%) had undergone bilateral unselective embolization. On bivariate analysis, thromboembolic complications were more likely in patients who received bilateral unselective TAE than in other TAE patients (P=0.02).
Infections
Pelvic infections were observed in:
- 10 patients in the PPP group (16%), of whom six had open pelvic fractures
- Two patients in the primary TAE group (3%), of whom one had an open pelvic fracture
In-hospital Mortality
- PPP group: The in-hospital mortality rate was 46%, comparable to rates in previous studies. Seven patients (11%) died due to perioperative exsanguination (11%), three of them before embolization could be attempted. Severe traumatic brain injury (n=7) and multiorgan failure (n=6) were also common causes of death
- Primary TAE group: The in-hospital mortality rate was 4%. No deaths were related to exsanguination
Implications for Surgeons
Selective TAE seems to be an effective approach to hemorrhage control in hemodynamically stable patients with pelvic trauma and those responsive to resuscitation. Initial PPP (and EF, if indicated) with bilateral unselective embolization using gelfoam appears effective in pelvic trauma patients who are suspected of having life-threatening pelvic bleeding based on hemodynamic instability.
Bilateral unselective embolization can play a role in the development of ischemic and thromboembolic complications, in addition to the severe pelvic fracture itself. Nevertheless, the potential for these complications might not outweigh the benefit of fast hemorrhage control in severely injured patients.
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