To pack or plug: American Association for the Surgery of Trauma multicenter evaluation of hemorrhage control interventions in pelvic fracture management

Melike N Harfouche; Leslie Sult; Jason D Sciarretta; Samuel R Todd; Christopher F O'Neil; Jonathan P Meizoso; Allison McNickle; Douglas Fraser; Millicent Croman; Joseph J Dubose

doi:10.1097/TA.0000000000004856

Mortality from pelvic ring fractures (PRFs) complicated by hemorrhagic shock remains high, and there are limited high-quality data to guide care. We compared two primary hemorrhage control interventions: pelvic angiography +/- embolization (PAE) and preperitoneal pelvic packing (PPP), hypothesizing similar odds of death.INTRODUCTIONMortality from pelvic ring fractures (PRFs) complicated by hemorrhagic shock remains high, and there are limited high-quality data to guide care. We compared two primary hemorrhage control interventions: pelvic angiography +/- embolization (PAE) and preperitoneal pelvic packing (PPP), hypothesizing similar odds of death.A prospective, multicenter, observational study was conducted for individuals with blunt trauma-associated PRF with a systolic blood pressure of <90 mm Hg who received ≥4 U of packed red blood cells within 24 hours and/or used a hemorrhage control intervention (2022-2024). Bivariate comparisons, multivariable regression controlling for several clinical factors, and inverse probability treatment weighting analysis were performed. Primary outcomes were 3- and 6-hour mortality.METHODSA prospective, multicenter, observational study was conducted for individuals with blunt trauma-associated PRF with a systolic blood pressure of <90 mm Hg who received ≥4 U of packed red blood cells within 24 hours and/or used a hemorrhage control intervention (2022-2024). Bivariate comparisons, multivariable regression controlling for several clinical factors, and inverse probability treatment weighting analysis were performed. Primary outcomes were 3- and 6-hour mortality.Of 948 patients, 524 underwent either PPP (n = 68, 13.0%), PAE (n = 390, 74.4%), or both (n = 66, 12.6%) and comprise the study cohort. Compared with PAE, PPP patients had higher Injury Severity Scores (41 vs. 34, p < 0.001) and worse physiology (lowest systolic blood pressure, 62 vs. 74 mm Hg; lactate, 6.4 vs. 4.3; p < 0.001) and more frequently underwent laparotomy (67.6% vs. 23.6%, p < 0.001). In-hospital (47.1% vs. 18.5%, p < 0.001) and 24-hour (38.2% vs. 4.1%, p < 0.001) mortality were higher in PPP versus PAE with more earlier deaths (27.9% vs. 0.5% within 3 hours, p < 0.001). Preperitoneal pelvic packing was associated with higher odds of death at 3 hours (odds ratio, 64.0; confidence interval, 8.8-465.1) and 6 hours (odds ratio, 15.1; confidence interval, 4.4-51.7) compared with PAE. Inverse probability treatment weighting analysis demonstrated 19.4% higher probability of death at 6 hours for PPP versus PAE (p < 0.001).RESULTSOf 948 patients, 524 underwent either PPP (n = 68, 13.0%), PAE (n = 390, 74.4%), or both (n = 66, 12.6%) and comprise the study cohort. Compared with PAE, PPP patients had higher Injury Severity Scores (41 vs. 34, p < 0.001) and worse physiology (lowest systolic blood pressure, 62 vs. 74 mm Hg; lactate, 6.4 vs. 4.3; p < 0.001) and more frequently underwent laparotomy (67.6% vs. 23.6%, p < 0.001). In-hospital (47.1% vs. 18.5%, p < 0.001) and 24-hour (38.2% vs. 4.1%, p < 0.001) mortality were higher in PPP versus PAE with more earlier deaths (27.9% vs. 0.5% within 3 hours, p < 0.001). Preperitoneal pelvic packing was associated with higher odds of death at 3 hours (odds ratio, 64.0; confidence interval, 8.8-465.1) and 6 hours (odds ratio, 15.1; confidence interval, 4.4-51.7) compared with PAE. Inverse probability treatment weighting analysis demonstrated 19.4% higher probability of death at 6 hours for PPP versus PAE (p < 0.001).Whereas hypotensive patients with PRFs are more likely to undergo PAE, PPP is reserved for patients with more severe hemorrhagic shock, which may account for the observed higher mortality. Findings from this study suggest that PAE is an appropriate first-line therapy for most patients with bleeding pelvic fractures at trauma centers with rapid access to endovascular therapy.CONCLUSIONWhereas hypotensive patients with PRFs are more likely to undergo PAE, PPP is reserved for patients with more severe hemorrhagic shock, which may account for the observed higher mortality. Findings from this study suggest that PAE is an appropriate first-line therapy for most patients with bleeding pelvic fractures at trauma centers with rapid access to endovascular therapy.Therapeutic/Care Management; Level III.LEVEL OF EVIDENCETherapeutic/Care Management; Level III.