Department of Surgery, Denver Health Medical Center and the University of Colorado Denver, Denver, CO 80204, USA.
J Am Coll Surg. 2011 Apr;212(4):628-35; discussion 635-7. doi: 10.1016/j.jamcollsurg.2010.12.020.
Preperitoneal pelvic packing/external fixation (PPP/EF) for controlling life-threatening hemorrhage from pelvic fractures is used widely in Europe but has not been adopted in North America. We hypothesized that PPP/EF arrests hemorrhage rapidly, facilitates emergent operative procedures, and ensures efficient use of angioembolization (AE).
In 2004 we initiated a PPP/EF guideline for pelvic fracture patients with refractory shock requiring ongoing blood transfusion at our regional trauma center.
Among 1,245 patients admitted with pelvic fractures, 75 consecutive patients underwent PPP/EF (age 42 ± 2 years and injury severity score 52 ± 1.5). Emergency department systolic blood pressure was 76 ± 2 mmHg and heart rate 119 ± 2 beats/min. Time to operation was 66 ± 7 minutes, and 65 patients (87%) underwent 3 ± 0.3 additional procedures. Blood transfusion before PPP/EF compared with the first postoperative 24 hours was 10 ± 0.8 units versus 4 ± 0.5 units (p < 0.05). The fresh frozen plasma-red blood cell ratio was 1:2. After PPP/EF, 10 patients (13%) underwent angioembolization with a documented blush; time to angioembolization was 10.6 ± 2.4 hours (range 1 to 38 hours). Mortality for all pelvic fractures was 8%, with 21% mortality in this high-risk group. There were no deaths due to acute hemorrhage.
PPP/EF was effective in controlling hemorrhage from unstable pelvic fractures. None of these high-risk patients died due to pelvic bleeding. Secondary angioembolization was needed in a minority, permitting selective use of this resource-demanding intervention. Additionally, PPP/EF temporizes arterial hemorrhage, providing valuable transfer time for facilities without angiography. With other urgent operative interventions required in >85% of patients, combining these procedures with PPP/EF for operative pelvic hemorrhage control appears to optimize patient care.
经腹膜外骨盆填塞/外固定术（PPP/EF）可用于控制骨盆骨折导致的危及生命的大出血，在欧洲广泛应用，但尚未在北美采用。我们假设 PPP/EF 可迅速止血，便于紧急手术，并确保血管栓塞（AE）的有效利用。
2004 年，我们在区域性创伤中心为需要持续输血的难治性休克骨盆骨折患者制定了 PPP/EF 指南。
在收治的 1245 例骨盆骨折患者中，连续 75 例患者接受了 PPP/EF（年龄 42±2 岁，损伤严重程度评分 52±1.5）。急诊时收缩压为 76±2mmHg，心率为 119±2 次/分。手术时间为 66±7 分钟，65 例（87%）患者进行了 3±0.3 次额外的手术。PPP/EF 前与术后 24 小时内的输血量分别为 10±0.8 单位和 4±0.5 单位（p<0.05）。新鲜冰冻血浆与红细胞的比例为 1:2。PPP/EF 后，10 例（13%）患者因有明确的出血“染色”而行血管栓塞，血管栓塞时间为 10.6±2.4 小时（1~38 小时）。所有骨盆骨折患者的死亡率为 8%，高危组死亡率为 21%。无因急性出血死亡的病例。
PPP/EF 可有效控制不稳定骨盆骨折的出血。这些高危患者无一例因骨盆出血死亡。少数患者需要二次血管栓塞，这允许对这种资源需求较高的干预措施进行选择性应用。此外，PPP/EF 可使动脉出血暂时停止，为没有血管造影设备的医疗机构提供有价值的转运时间。由于超过 85%的患者需要进行其他紧急手术干预，因此将这些手术与 PPP/EF 相结合以控制手术性骨盆出血，似乎可优化患者的治疗。
