Transcript Paper Reading - 高雄醫學大學附設中和紀念醫院

Paper Reading
Int. 林泰祺
Introduction
 Pelvic fracture patients who are
hemodynamically unstable are a
diagnostic and therapeutic challenge for
the trauma team
 These injuries often occur in conjunction
with other life-threatening injuries, and
there is not universal agreement among
clinicians on management
 The mortality for these high-risk patients
exceeds 40%
Introduction
 Time to definitive stabilization followed
by appropriate interventional radiology
access and embolization may consume
hours while the patient remains
hemodynamically compromised
 Additionally, in patients with indications
for laparotomy such as evidence of intraabdominal hemorrhage on Focused
Assessment with Sonography for Trauma
(FAST) examination, this time delay may
be even longer
Introduction
 We have modified this technique to directly
address pelvic hemorrhage through direct
packing of the pelvis using a preperitoneal
approach for all patients with hemodynamic
instability and a pelvic fracture
 Such an approach would simplify the often
difficult decision between immediate operative
intervention and interventional radiology
 Additionally, this approach more rapidly and
directly addresses the primary source of
bleeding with pelvic fractures—venous and
bone hemorrhage
Introduction
 We hypothesized that preperitoneal
pelvic packing (PPP) reduces need for
angiography, decreases blood
transfusion requirements, and lowers
mortality
Results
 During the study period, from September
2004 to June 2006, 139 patients qualified for
inclusion in the pelvic fracture KCP and
received blood transfusions
 Of these, 28 consecutive patients met the
KCP criteria of an SBP 90 mm Hg despite
the transfusion of two units of PRBCs and
underwent external fixation and PPP
 There was one protocol deviation of prePPP
angiography to evaluate an extremity
vascular injury
Outcome
 Patients required 4± 1.2 units of PRBCs during 82 ± 13
minutes in the ED
 Blood transfusion requirements before postoperative
SICU admission compared with the subsequent 24
postoperative hours were significantly different
 Abdominopelvic complications included infection of
the pelvic space (3 total; 2 in patients with a bladder
rupture), infection of the buttock and back related to a
perineal degloving with rectal injury
 Superficial wound infections (2 total; 1 anterior PPP
incision, 1 posterior incision used for fixation of a
comminuted sacral fracture)
 Two patients had intra-abdominal abscesses
associated with visceral injuries
Outcome
 Patients required a mean of 14± 2.8 days of mechanical
ventilation and remained in the surgical intensive care
unit for 18 ± 2.9 days
 Overall length of hospital stay was 26 ± 3.4 days
 Seven (25%) patients died during their
hospitalizationas a result of multiple organ failure
(MOF) (2), postinjury myocardial infarction/pulseless
electrical activity (PEA) arrest (2), invasive
mucormycosis (1), closed head injury (1), and
withdrawal of care (1)
 There were no differences in presenting SBP, HR, base
deficit, ISS or transfusion requirement between those
who lived versus died
 The only significance between the two groups was
mean patient age (34 ± 3.9 years for patients who lived
versus 55±8.1 years for patients who died)
Discussion
 85% of bleeding as a result of pelvic fractures
is venous or bony in origin
– Hemorrhage is therefore only arrested by
tamponade within the retroperitoneal space
– Angioembolization does not address such bleeding.
In fact, patients undergoing diagnostic angiography
frequently do not have active bleeding sites
visualized and/or few patients require
angioembolization
 Secondly, although angioembolization may be
effective in controlling pelvic arterial bleeding,
it has not been shown to decrease the
necessity for blood product resuscitation
 Third, there are a number of institutions that
do not have angiographic capabilities
Discussion
 In our study population, there was a significant
reductionin blood transfusion requirements in
the postoperative 24hours compared with the
prePPP period. By surgically packing the
pelvic space
 The overall potential space required to
tamponade bleeding from the pelvis is reduced,
therefore hypothetically reducing the amount
of blood transfusion required to fill this
potential space
 Since blood transfusion is an independent risk
factor for increased ICU length of stay, the
development of multiple organ failure, and
mortality
Discussion
 PPP may be ideally suited for austere
conditions and in settings where angiography
is unavailable or unable
 Emergent retroperitoneal packing appears to
be a safe procedure that has a role in damage
control of critically injured patients. It can be
done immediately and with ease in conjunction
with external fixation of the pelvis and other
surgical
 24-hour angiographic, the time delay to
angiography can be significant. the time to
angiography was four times longer in the
nonPPP group compared with the PPP study
group
Discussion
 There were five abdominoperineal space
infections and two superficial wound
infections, although the majority occurred in
patients with associated bladder or bowel
injuries
 There was no apparent relationship between
the time packs were removed and incidence of
infection
 The 25% mortality rate in this cohort was lower
than historical reports of similar patient
populations
 There were no deaths as a result of
exsanguination, and two patients died of MOF.
Conclusion
 Eliminate the often difficult decision between
the operating room and interventional
radiology
 Additionally, this approach directly addresses
the primary source of bleeding with pelvic
fractures—venous and bone hemorrhage.
 Combined external pelvic fixation and
preperitoneal pelvic packing may represent a
revolutionary management strategy for these
critically multiply injured patients, and offer a
life-saving procedure in environments where
IR is unavailable
Thank you