Highlights
- •Unstable pelvic fractures managed with an algorithm using preperitoneal packing and REBOA had improved mortality.
- •Pelvic fractures managed with an algorithm using preperitoneal packing and REBOA had no deaths due to pelvic hemorrhage.
- •Preperitoneal packing with REBOA was utilized in more severely injured patients with greater physiologic derangements.
Abstract
Introduction
Resuscitative endovascular balloon occlusion of the aorta (REBOA) is advocated for
hemorrhage control in pelvic fracture patients in shock. We evaluated REBOA in patients
undergoing preperitoneal pelvic packing (PPP) for pelvic fracture-related hemorrhage.
Methods
Retrospective, single-institution study of unstable pelvic fractures (hemodynamic
instability despite 2 units of red blood cells (RBCs) and fracture identified on x-ray).
Management included the placement of a Zone III REBOA in the emergency department
(ED) for systolic blood pressure <80 mmHg. All PPP patients were included and analyzed
for injury characteristics, transfusion requirements, outcomes and complications.
Additionally, patients who received REBOA (REBOA+) were compared to those that did
not (REBOA-).
Results
During the study period (January 2015 - January 2019), 652 pelvic fracture patients
were admitted; 78 consecutive patients underwent PPP. Median RBCs at PPP completion
compared to 24 h post-packing were 11 versus 3 units (p<0.05). Median time to operation was 45 min. After PPP, 7 (9%) patients underwent
angioembolization. Mortality was 14%. No mortalities were due to ongoing pelvic fracture
hemorrhage or physiologic exhaustion; all were a withdrawal of life sustaining support,
most commonly due to neurologic insults (TBI/fat emboli = 6, stroke/spinal cord injury = 3).
REBOA+ patients (n = 31) had a significantly higher injury severity score (45 vs 38, p<0.01) and higher heart rate (130 vs 118 beats per minute, p = 0.04) than REBOA-. The systolic blood pressure, base deficit, and number of RBCs
transfused in the ED, and time spent in the ED were similar between groups. REBOA+
had a higher median transfusion of RBCs at PPP completion (11 units vs 5 units, p<0.01) but similar RBC transfusion in the 24 h after PPP (2 vs 1 units, p = 0.27). Mortality, pelvic infection, and ICU length of stay was not different between
these cohorts.
Conclusion
PPP with REBOA was utilized in more severely injured patients with greater physiologic
derangements. Although REBOA patients required greater transfusion requirements, there
were no deaths due to acute pelvic hemorrhage. This suggests the combination of REBOA
with PPP provides life-saving hemorrhage control in otherwise devastating injuries.
Keywords
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to InjuryAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Resuscitative endovascular balloon occlusion of the aorta and resuscitative thoracotomy in select patients with hemorrhagic shock: early results from the American association for the surgery of trauma's aortic occlusion in resuscitation for trauma and acute care surgery registry.J Am Coll Surg. 2018; 226: 730-740
- Resuscitative endovascular balloon occlusion of the aorta (REBOA) as an adjunct for hemorrhagic shock.J Trauma. Dec 2011; 71: 1869-1872
- Use of an intra-aortic balloon catheter tamponade for controlling intra-abdominal hemorrhage in man.Surgery. 1954; 36: 65-68
- Preperitoneal pelvic packing reduces mortality in patients with life-threatening hemorrhage due to unstable pelvic fractures.J Trauma Acute Care Surg. 2017; 82: 233-242
- Preperitonal pelvic packing for hemodynamically unstable pelvic fractures: a paradigm shift.J Trauma. 2007; 62 (834-9; discussion): 9-42
- Preperitoneal pelvic packing/external fixation with secondary angioembolization: optimal care for life-threatening hemorrhage from unstable pelvic fractures.J Am Coll Surg. 2011; 212 (628-35; discussion 35-7)
- External fixation for acute pelvic ring injuries: decision making and technical options.J Trauma Acute Care Surg. 2013; 75: 882-887
- Retroperitoneal packing as a resuscitation technique for hemodynamically unstable patients with pelvic fractures: report of two representative cases and a description of technique.J Trauma. 2005; 59: 1510-1514
- Preperitoneal pelvic packing: a 2018 east master class video presentation.J Trauma Acute Care Surg. 2018; 85: 224-228
- Pelvic ring disruptions: effective classification system and treatment protocols.J Trauma. 1990; 30: 848-856
- Rapid thrombelastography thresholds for goal-directed resuscitation of patients at risk for massive transfusion.J Trauma Acute Care Surg. 2017; 82: 114-119
- Forty-minute endovascular aortic occlusion increases survival in an experimental model of uncontrolled hemorrhagic shock caused by abdominal trauma.J Trauma. 2011; 71 (720-5; discussion): 5-6
- A novel fluoroscopy-free, resuscitative endovascular aortic balloon occlusion system in a model of hemorrhagic shock.J Trauma Acute Care Surg. 2013; 75: 122-128
- Aortic balloon occlusion is effective in controlling pelvic hemorrhage.J Surg Res. 2012; 177: 341-347
- A clinical series of resuscitative endovascular balloon occlusion of the aorta for hemorrhage control and resuscitation.J Trauma Acute Care Surg. 2013; 75: 506-511
- Resuscitative endovascular balloon occlusion of the aorta for pelvic blunt trauma and life-threatening hemorrhage: a 20-year experience in a Level I trauma center.J Trauma Acute Care Surg. 2018; 84: 449-453
- Examination of hemodynamics in patients in hemorrhagic shock undergoing resuscitative endovascular balloon occlusion of the aorta (REBOA).Injury. 2019; 50: 1042-1048
- Smaller introducer sheaths for REBOA may be associated with fewer complications.J Trauma Acute Care Surg. 2016; 81: 1039-1045
- The AAST prospective Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) registry: data on contemporary utilization and outcomes of aortic occlusion and resuscitative balloon occlusion of the aorta (REBOA).J Trauma Acute Care Surg. 2016; 81: 409-419
- Resuscitative endovascular balloon occlusion of the aorta for control of noncompressible truncal hemorrhage in the abdomen and pelvis.Am J Surg. 2016; 212: 1222-1230
- Nationwide analysis of resuscitative endovascular balloon occlusion of the aorta in civilian trauma.JAMA Surg. 2019; 154: 500-508
- Survival of severe blunt trauma patients treated with resuscitative endovascular balloon occlusion of the aorta compared with propensity score-adjusted untreated patients.J Trauma Acute Care Surg. 2015; 78: 721-728
- Clinical use of resuscitative endovascular balloon occlusion of the aorta (REBOA) in civilian trauma systems in the USA, 2019: a joint statement from the american college of surgeons committee on trauma, the american college of emergency physicians, the national association of emergency medical services physicians and the national association of emergency medical technicians.Trauma Surg Acute Care Open. 2019; 4e000376
- Resuscitative endovascular balloon occlusion of the aorta: implementation and preliminary results at an academic level i trauma center.J Am Coll Surg. 2018; 227: 127-133
- Guidelines for a system-wide multidisciplinary approach to institutional resuscitative endovascular balloon occlusion of the aorta implementation.J Trauma Acute Care Surg. 2019; 86: 337-343
- Practice, practice, practice! effect of resuscitative endovascular balloon occlusion of the aorta volume on outcomes: data from the AAST AORTA registry.J Surg Res. 2020; 253: 18-25
- Basic endovascular skills for trauma course: bridging the gap between endovascular techniques and the acute care surgeon.J Trauma Acute Care Surg. 2014; 77: 286-291
- Pelvic fracture pattern predicts the need for hemorrhage control intervention-Results of an AAST multi-institutional study.J Trauma Acute Care Surg. 2017; 82: 1030-1038
- Angiographic embolization for hemorrhage following pelvic fracture: is it "time" for a paradigm shift?.J Trauma Acute Care Surg. 2017; 82: 18-26
- Impact of a simplified management algorithm on outcome following exsanguinating pelvic fractures: a 10-year experience.J Trauma Acute Care Surg. 2019; 86: 658-663
- Reduced need for extraperitoneal pelvic packing for severe pelvic fractures is associated with improved resuscitation strategies.J Trauma Acute Care Surg. 2016; 81: 644-651
- The effect of hemorrhage control adjuncts on outcome in severe pelvic fracture: a multi-institutional study.J Trauma Acute Care Surg. 2019; 87: 117-124
- Endovascular control of pelvic hemorrhage: concomitant use of resuscitative endovascular balloon occlusion of the aorta and endovascular intervention.J Trauma Acute Care Surg. Jan 2019; 86: 155-159
- Scalpel or sheath? Outcomes comparison between pre-peritoneal pelvic packing and angioembolization for definitive hemorrhage control after REBOA.J Endovasc Resusc Trauma Management. 2020; 4: 49-55
- The complications associated with resuscitative endovascular balloon occlusion of the aorta (REBOA).WJES. 2018; 13: 20
- The pitfalls of resuscitative endovascular balloon occlusion of the aorta: risk factors and mitigation strategies.J Trauma Acute Care Surg. 2018; 84: 192-202
- Vascular complications from resuscitative endovascular balloon occlusion of the aorta: life over limb?.J Trauma Acute Care Surg. 2017; 83 (S120-s3)
- Exclusive clinical experience with a lower profile device for resuscitative endovascular balloon occlusion of the aorta (REBOA).Am J Surg. 2019; 217: 1126-1129
- No wire? No problem: resuscitative endovascular balloon occlusion of the aorta can be performed effectively and more rapidly with a wire-free device.J Trauma Acute Care Surg. 2018; 85: 894-898
- Are we delivering two standards of care for pelvic trauma? Availability of angioembolization after hours and on weekends increases time to therapeutic intervention.J Trauma Acute Care Surg. 2014; 76: 134-139
- Effect of door-to-angioembolization time on mortality in pelvic fracture: every hour of delay counts.J Trauma Acute Care Surg. 2018; 84: 685-692
Article info
Publication history
Published online: July 16, 2022
Accepted:
July 15,
2022
Identification
Copyright
© 2022 Elsevier Ltd. All rights reserved.
