From the Department of Surgery, Division of Trauma & Critical Care, Tulane University School of Medicine (J.D.), New Orleans, Louisiana; Department of Surgery, Division of Trauma, Surgical Critical Care, and Acute Care Surgery, University of California San Diego Health (T.W.C.), San Diego, California; Imperial College Healthcare NHS Trust, St. Mary's Hospital, Imperial College Healthcare NHS Trust (M.K., J.G.), London, England; UTHealth, McGovern Medical School, Department of Surgery, Division of Acute Care Surgery, Trauma, & Critical Care, Memorial Hermann Texas Medical Center (E.T.), Houston, Texas; Grady Emory University School of Medicine, Department of Surgery Grady Memorial Hospital (P.R., B.M., N.N.), Atlanta, Georgia; Ryder Trauma Center at Jackson Memorial Hospital and DeWitt Daughtry Family Department of Surgery, Division of Trauma, University of Miami Miller School of Medicine (A.S.), Miami, Florida; Division of Trauma/Acute Care Surgery/Surgical Critical Care, Harbor-UCLA Medical Center (D.Y.K., E.H.), Los Angeles, California; Department of Surgery and Critical Care, University of Pittsburgh Medical Center (J.S., V.A.), Pittsburgh, Pennsylvania; Department of Surgery, Trauma/Critical Care & Acute Surgery Division, University of Kansas Medical Center (R.D.W.), Kansas City, Kansas; Department of Surgery, Division of Trauma, Critical Care, and Acute Care Surgery, Oregon Health & Science University (M.S., B.B.), Portland, Oregon; Trauma Specialist Program, Our Lady of the Lake Regional Medical Center (B.M., D.T.), Baton Rouge, Louisiana; and Perelman School of Medicine, Division of Traumatology, Surgical Critical Care, & Emergency Surgery, University of Pennsylvania Health System (S.R., M.S.), Philadelphia, Pennsylvania.
J Trauma Acute Care Surg. 2019 Jul;87(1):117-124. doi: 10.1097/TA.0000000000002316.
Hemodynamically unstable patients with severe pelvic fracture are a significant challenge to trauma surgeons and have high mortality. Significant variability across institutions in hemorrhage control adjuncts used to quell pelvic bleeding has been demonstrated. However, the effect of these methods on time to definitive bleeding control, type of resuscitation given, and outcomes remains unknown. We sought to elucidate those effects.
This was a multicenter retrospective review of severe pelvic fracture patients in shock between 2011 and 2016. Shock was defined as systolic blood pressure less than 90 mm Hg, heart rate greater than 120 beats per minute, or base deficit less than -5. Definitive bleeding control was defined as time to surgical control in the operating room or embolization by interventional radiology. Significance level was at p less than 0.05.
A total of 279 severe pelvic fracture patients with shock on admission from 12 trauma centers were included. The cohort was primarily male (62%) with median (interquartile range) age of 40 years (28-54 years), Injury Severity Score of 38 (29-50), and Glasgow Coma Scale score of 13 (3-15). Overall mortality was 32%. The most common adjunct used was pelvic binder (50%) followed by no adjunct (30.5%); least common was resuscitative balloon occlusion of the aorta (REBOA) (2.5%). Preperitoneal packing alone and REBOA alone/with other adjunct(s) resulted in the fastest times to operating room/interventional radiology but also had the highest blood utilization and mortality rates. Resuscitative balloon occlusion of the aorta was most often used along with pelvic binder (6 of 13; 46%).
Marked variation in management of severe pelvic fracture patients in shock indicates the need for a standardized approach to maximize outcomes and minimize transfusion requirements. The use of preperitoneal packing and/or REBOA yielded fastest times to definitive bleeding control. However, REBOA continues to be infrequently used. Future prospective analysis of this combination needs further validation in patients with severe pelvic hemorrhage.
Therapeutic study, level IV.
血流动力学不稳定伴严重骨盆骨折的患者对创伤外科医生来说是一个重大挑战，其死亡率很高。已证实，不同机构在用于控制骨盆出血的辅助止血手段方面存在显著差异。然而，这些方法对明确止血控制时间、所给予的复苏类型和结果的影响仍不清楚。我们旨在阐明这些影响。
这是一项 2011 年至 2016 年间严重骨盆骨折休克患者的多中心回顾性研究。休克定义为收缩压<90mmHg、心率>120 次/分钟或碱缺失< -5。明确的止血控制定义为手术室中手术控制或介入放射学栓塞的时间。显著性水平为 p<0.05。
共纳入 12 个创伤中心 279 例入院时伴休克的严重骨盆骨折患者。该队列主要为男性（62%），中位（四分位间距）年龄为 40 岁（28-54 岁），损伤严重度评分 38 分（29-50 分），格拉斯哥昏迷评分 13 分（3-15 分）。总体死亡率为 32%。最常使用的辅助手段是骨盆束带（50%），其次是无辅助手段（30.5%）；最少使用的是主动脉复苏球囊阻断（REBOA）（2.5%）。单纯腹膜前填塞和 REBOA 单独/联合其他辅助手段可最快达到手术室/介入放射科，但也有最高的血液利用率和死亡率。REBOA 最常与骨盆束带联合使用（13 例中的 6 例，46%）。
严重骨盆骨折休克患者的治疗方法存在明显差异，表明需要采用标准化方法来最大程度地提高疗效并减少输血需求。腹膜前填塞和/或 REBOA 的使用可最快达到明确止血控制。然而，REBOA 的使用仍然很少。需要进一步在严重骨盆出血患者中对这种联合方法进行前瞻性分析，以进一步验证。
治疗研究，IV 级。
