One in Three Patients With Unstable Pelvic Fractures Die, Study Shows

Despite use of advanced hemorrhage control interventions, more than one in three patients with hemodynamically unstable pelvic fractures died, a retrospective cohort study showed.

Among nearly 1,400 patients who received early transfusions and at least one invasive pelvic hemorrhage control intervention, the 24-hour mortality rate was 15.5%, the emergency department mortality rate was 0.7%, and the in-hospital mortality rate was 35.9%, reported Bellal Joseph, MD, of the University of Arizona in Tucson, and colleagues.

Overall, 41% of patients experienced major in-hospital complications, including cardiac complications (14%), respiratory complications (10.3%), and venous thromboembolism (9.9%), they noted in JAMA Surgery.

While the most common interventions included pelvic angioembolization (55%), preperitoneal pelvic packing (47%), and resuscitative endovascular balloon occlusion of the aorta (REBOA) in zone 3 (9%), regression analyses showed that only pelvic angioembolization was linked to a reduction in mortality (adjusted OR 0.62, 95% CI 0.47-0.82, P<0.001).

On the other hand, preperitoneal pelvic packing was tied to increased odds of complications (aOR 1.39, 95% CI 1.07-1.80, P=0.01).

“These findings underscore the need for an algorithm to standardize care and achieve improved outcomes in pelvic hemorrhage control,” Joseph and team concluded.

Trauma is the leading cause of death among people up to age 46, and the most common cause of premature death is uncontrolled hemorrhage, the study authors said. About 9% of trauma patients present with severe pelvic fractures, which are tied to mortality rates as high as 32%. Nearly 13% of pelvic fracture patients experience hemodynamic instability due to major hemorrhage, which can develop from “arterial, venous, and bony sources,” Joseph’s group explained.

Although hemostatic interventions, such as pelvic angioembolization to occlude active arterial bleeding, may be used alone or in combination with other interventions, managing hemodynamically unstable pelvic fractures is often challenging. A prior study showed significant variation in hemorrhage control interventions among patients with pelvic fractures, which can be attributed to the lack of consensus on the optimal treatment strategy, the authors suggested.

In an accompanying editorial, Haytham Kaafarani, MD, MPH, and Lydia Maurer, MD, MPH, both of Massachusetts General Hospital in Boston, noted that the “real important finding of this study is the significant variation in management strategies across different hospitals. This variation deserves exploration in subsequent studies.”

“Although some variation is always warranted to provide patient-centered, personalized care, literature suggests that variation in processes of care often reflects variation in the quality of care provided,” they wrote. “It is likely that residual confounding remains in this population-based study, and patients who undergo preperitoneal pelvic packing are inherently physiologically different from those who can wait for the interventional radiology team to arrive, but the obvious question from these data remains: what can we do to better rescue these patients and decrease their high mortality rate?”

For this study, Joseph and colleagues retrospectively examined data from the 2017 American College of Surgeons Trauma Quality Improvement Program on 1,396 adults who had pelvic fractures, received early blood transfusions consisting of 4 units of packed red blood cells administered within 4 hours of presentation, and underwent an intervention for pelvic hemorrhage control.

Mean age was 47, 70% were men, and 65.8% were white. The median Injury Severity Score was 24, while the mean lowest systolic blood pressure was 71 mm Hg.

Patients were stratified by the intervention they received: pelvic angioembolization (n=774), preperitoneal pelvic packing (n=659), or REBOA in zone 3 (n=126), and further stratified by the number of interventions. Notably, 104 received a combination of pelvic angioembolization/preperitoneal pelvic packing.

The median time to first pelvic hemorrhage control intervention was 122 minutes. Most of the cohort received one intervention (89%), 11% received two, and 0.2% received three. Average length of stay was 16 days.

An increasing number of interventions was associated with increased adjusted odds of mortality (aOR 1.57, 95% CI 1.05-2.37, P=0.03).

“Perhaps the increasing interventions were not the reason behind worse outcomes; rather, patients were more severely injured and required more interventions,” Joseph and team noted.

Study limitations included the fact that the precise contribution of pelvic fracture-related hemorrhage on outcomes was difficult to assess because of concomitant injuries, the authors said. Furthermore, the results may not be generalizable to trauma centers outside of the U.S.