Downloaded from http://emj.bmj.com/ on June 8, 2015 - Published by group.bmj.com
Original article
Improvement in institutional protocols leads to decreased mortality in patients with haemodynamically unstable pelvic fractures Mina Cheng,1 Moon-Tong Cheung,1 Kin-Yan Lee,1 Kin-Bong Lee,2 Susan-C H Chan,3 Amy-C Y Wu,4 Yu-Fat Chow,4 Annice-M L Chang,5 Hiu-Fai Ho,5 Kelvin-K W Yau6 1
Department of Surgery, Queen Elizabeth Hospital, Hong Kong 2 Department of Orthopaedics & Traumatology, Queen Elizabeth Hospital, Hong Kong 3 Department of Radiology & Imaging, Queen Elizabeth Hospital, Hong Kong 4 Department of Anaesthesiology & Operating Theatre Services, Queen Elizabeth Hospital, Hong Kong 5 Department of Accident & Emergency, Queen Elizabeth Hospital, Hong Kong 6 Department of Management Sciences, City University of Hong Kong, Hong Kong Correspondence to Dr Moon-Tong Cheung, Department of Surgery, Queen Elizabeth Hospital, 30 Gascoigne Road, Kowloon, Hong Kong; [email protected], [email protected] Received 26 September 2012 Revised 4 March 2013 Accepted 21 October 2013 Published Online First 10 December 2013
To cite: Cheng M, Cheung M-T, Lee K-Y, et al. Emerg Med J 2015;32: 214–220. 214
ABSTRACT Background The mortality rate in patients with haemodynamically unstable pelvic fractures is as high as 40–60%. In recent years, angioembolisation and pelvic packing have been introduced as part of a multimodality treatment for these patients. Protocol-driven management has been shown to improve outcomes. Patients and methods This is a Level III retrospective cohort study of patients suffering from unstable pelvic fractures from 1 January 1996 to 30 September 2011. The aim of the study was to review our results, particularly in terms of mortality through the evolution of three phases of treatment protocols: preangiography, angiography and pelvic packing. Results The overall 30-day mortality rate for all patients was 47.2%, with a rate of 63.5% in the preangiography phase, 42.1% in the angiography phase and 30.6% in the pelvic packing phase. Multivariate logistic regression analysis identified the use of retroperitoneal packing as a significant independent predictive factor for 24 h mortality. Conclusions Our results showed an improvement in patient survival with sequential protocols over the study period, during which we incorporated a multidisciplinary approach to managing these complicated pelvic fractures. The results strongly suggest that retroperitoneal packing should be highly recommended for bleeding subsequent to pelvic fracture, in addition to other modalities of treatment.
in the USA.14–19 However, methods for reducing venous bleeding remain to be tackled.19–21 In Europe, pelvic packing (preperitoneal or retroperitoneal packing) has emerged as one of the methods for controlling venous bleeding due to tears caused by bony fragments.21–26 Our early experience suggested that initial pelvic packing, with subsequent angiography if needed, is as good as angiography with embolisation for treating patients with haemodynamically unstable pelvic fractures.27 A high-energy impact is needed to disrupt the pelvic ring, and as such, will often produce major injuries to other critical organs. Up to 90% of patients with unstable pelvic fractures have associated injuries, and 50% of patients have sources of major haemorrhage other than pelvic fractures,1 28 29 approximately 15% have intrathoracic bleeding, 32% have intra-abdominal bleeding, and 40% have long-bone fracture bleeding.30–32 This complicates the management of pelvic fracture patients. Protocol-driven management simplifies the decision-making process of a multidisciplinary team in the initial treatment period and decreases mortality in haemodynamically unstable cases.2 33–35 The time for decision making can be shortened, and the first few hours can be critical for patients suffering from catastrophic bleeding from various sources. The aim of this study is to review our results through the evolution of our treatment protocols in three phases over 15 years and 9 months.
INTRODUCTION
PATIENTS AND METHODS
The management of severe pelvic injury remains a challenging task for trauma surgeons. Overall mortality of patients with any type of pelvic fracture is reported to be around 5–10%,1–5 however, haemodynamically unstable pelvic fractures, have a much higher mortality rate of 40–60%.4 6–8 Bleeding from a patient with a fractured pelvis could be from various sources: bone surface, venous tears or arterial bleeds. Over the years, methods for controlling bleeding from pelvic fractures have undergone various modifications targeting different sources. A laparotomy approach does not allow access to the pelvic site where bleeding occurs. Even worse, it breaks the natural tamponade effect of the true pelvis. External fixation can help to prevent bleeding from bone edges by reducing fracture fragments and restoring the geometry of the pelvis.4 9–13 Studies have shown that arterial bleeding occurs in about 10–15% of patients. Over the past decades, pelvic embolisation has become popular for reducing arterial bleeding, particularly
Queen Elizabeth Hospital is a level I trauma centre in Hong Kong. Data of all trauma patients who attended the Accident and Emergency Department (AED) and being categorised as critical or emergency cases were prospectively collected and entered to a trauma database since 1996. The scoring system based on the Abbreviated Injury Scale 1998 (AIS-1998) was used throughout the period (except in 1996 and 1997, during which AIS-1990 was used). All injuries were coded and recorded by one trauma nurse from 1996 to 2004, and by another one from 2005 till the present (author, AMC). All records were checked by the same trauma physician throughout the years (author, HFH). Haemodynamic instability was defined as systolic BP lower than 90 mm Hg upon arrival at AED or at any time during hospital stay after infusion of 2 L of crystalloids. All patients from 1 January 1996 to 30 September 2011 with pelvic ring fractures of 852 606, 852 608 and 852 610 as denoted by AIS-1998 (representing
Cheng M, et al. Emerg Med J 2015;32:214–220. doi:10.1136/emermed-2012-202009
Downloaded from http://emj.bmj.com/ on June 8, 2015 - Published by group.bmj.com
Original article substantial deformation and displacement with associated vascular disruption or with major retroperitoneal haematoma, or ‘open book’ fractures), and with AIS severity score in pelvis (Pelvis AIS) of four or five (Pelvis AIS 4: blood loss ≤20% by volume; Pelvis AIS 5: blood loss >20%) were retrieved from the database for analysis. Patients’ demographic characteristics, physiological measurements, severity and mechanism of injury, and modalities of treatment were studied. Other severe injuries were defined as brain injuries, chest contusion requiring intervention; intra-abdominal organ injuries as evidenced by imaging or noted during laparotomy, and long-bone fractures requiring operation. We divided the study period into three phases, each after significant modifications of treatment protocols. Modifications were usually implemented after discussion in mortality and audit meetings. In all three periods, pelvic binder was applied in the AED once pelvic fracture was suspected. The subsequent management followed three different protocols in the three periods. Between 1 January 1996 and 31 December 2001, which was the Phase 1 preangiography era (PRE-ANGIO Phase 1), casualties presenting with severe haemodynamic instability and unstable pelvic fractures were subjected to salvage laparotomy and external fixation in the operation theatre. Between 1 January 2002 and 31 July 2008, which was the Phase 2 angioembolisation era (ANGIO Phase 2), patients with haemodynamic instability with no other obvious bleeding sources apart from the pelvis were sent to the angiosuite for immediate angiography and embolisation. Patients with intra-abdominal bleeding, as suggested by positive focused abdominal sonography for trauma (FAST) or diagnostic peritoneal lavage, were sent for exploratory laparotomy and external fixation. Afterwards, they would be sent to the angiosuite for angiography and embolisation (figure 1A). Between 1 August 2008 and 30 September 2011 was the phase three pelvic packing era (PACKING Phase 3). Pelvic fracture patients with haemodynamic instability and a negative FAST scan were sent to the operation theatre for external fixation by orthopaedic surgeons first, in order to stabilise the disrupted bony pelvis and to limit the pelvic volume to facilitate pelvic packing. This was immediately followed by retroperitoneal packing (RPP) by trauma surgeons, technique of which have been described in our previous report.27 In the meantime, equipment for angiography and embolisation would be set up. If the patients were still haemodynamically unstable after external fixation and RPP, angiography and embolisation would be performed in the operation theatre. For patients with a positive FAST scan, they would undergo exploratory laparotomy with the pelvic binder on, followed by external fixation and RPP. Angiography and embolisation would follow if necessary (figure 1B). The means between two groups for scale variables were compared using independent samples t test. Categorical variables were compared using Pearson χ2 test, or Fisher’s Exact test as appropriate. Multivariate analysis was performed by means of multiple logistic regressions with stepwise variable selection method to identify significant independent risk factors that predicted mortality in all patients throughout the whole period. Level of significance was set at 5%. The SPSS V.18.0 software (SPSS, Chicago, Illinois, USA) was used to perform the analysis.
RESULTS During the 15-year-9-month study period, there were 7222 trauma patients registered in our trauma database, among whom 2780 patients had Injury Severity Score (ISS) >15. Five hundred and ninety-eight patients suffered from pelvic fractures. Among these, 199 patients (33%) who sustained unstable pelvic Cheng M, et al. Emerg Med J 2015;32:214–220. doi:10.1136/emermed-2012-202009
fractures with Pelvis AIS scores of four or five were admitted to our hospital and included in our study. In PRE-ANGIO Phase 1, 74 patients were included. There were 76 patients in ANGIO Phase 2 and 49 patients in PACKING Phase 3. All patients sustained blunt trauma; 140 patients (70%) had sustained Pelvis AIS of 5; the other 59 patients (30%) had Pelvis AIS of 4; 122 patients (61%) sustained severe injuries of other organs. Among all of them, were 34% with severe head and neck injury (with head and neck AIS score >3); 39% with severe chest injury (chest AIS >3), and 28% with severe abdominal injury (abdomen AIS >3). Patients’ demographic characteristics, physiological measurements are shown in tables 1 and 2. It appeared that the degree of injury became less severe in later periods in terms of ISS, Trauma and Injury Severity Score (TRISS) and Revised Trauma Score (RTS). There was significant difference in Pelvis AIS score between various periods ( p=0.002) with more Pelvis AIS 4 than Pelvis AIS 5 in the PACKING Phase 3. There were no significant differences in BP, pulse, haemoglobin measured upon arrival at the AED. The median time to angiography was 2.85 h (mean 4.69 h with SD=5.98) during ANGIO Phase 2; median time to operation was 1.20 h (mean 2.89 h with SD=4.44) in PACKING Phase 3. Major complications associated with RPP were uncommon (8%). One patient had wound infection with sepsis, one patient had pelvic collection requiring aspiration, and one had strangulated incisional hernia 1.5 year later—all three patients survived. There were no complications directly related to embolisation. The mortality rates are summarised in table 3. The overall 30-day mortality rate for all patients was 47.2%; and 36.7% for 24 h mortality. A total of 33 covariates/risk factors for all patients throughout the period including all variables, are listed in tables 1 and 2 (except length of stay, 30-day and 24-day death) together with the factor of period of study were entered using univariate logistic regression analysis. Twenty-two variables, such as the first systolic BP in AED, ISS, TRISS, RTS, presence of other injury, use of laparotomy, use of RPP, period of study and so on, are significant factors for 24 h mortality by univariate analysis. By applying multivariate logistic regression analysis, use of RPP was identified to be one of the significant independent predictive factors for 24 h mortality (table 4). The odds ratio for 24 h mortality was 3.48 times higher for those without RPP versus those with RPP.
DISCUSSION Through audit and implementation of new modalities of treatment in three phases over the past 15 years and 9 months, we have shown that protocol-driven multidisciplinary management significantly improved the outcome of patients with complex pelvic fractures. To reduce the bias and ensure consistency, we compared groups of patients who had the same severity of pelvic injury (Pelvis AIS 4 and 5). With the AIS, each injury was categorised by body area, with four being severe and lifethreatening, and five being critical and of uncertain survival.36 Thus, all our patients were suffering from severe pelvic fracture of similar severity throughout. This reduced the possibilities of comparing different groups of patients if we are comparing the success rate of treatment modalities alone. However, this remained a very heterogeneous group of patients. Comparing historic cohorts has several limitations, and the effects of time could have significant influence. There may be an inherent bias because the gradual institution of other new therapies could have led to continual improvements over the years. For example, there were improvements in multidisciplinary care, 215
Downloaded from http://emj.bmj.com/ on June 8, 2015 - Published by group.bmj.com
Original article
Figure 1 (A) Protocol for the management of haemodynamically unstable casualties with pelvic fractures at Queen Elizabeth Hospital, 1 January 2002 to 31 July 2008 (ANGIO Phase 2). (B) Protocol for the management of haemodynamically unstable casualties with pelvic fractures at Queen Elizabeth Hospital, 1 August 2008 to 30 September 2011 (PACKING Phase 3).
more liberal use of CT scanning in AED, improved organ support in intensive care unit, the use of recombinant factor VIIa and massive transfusion protocol. However, prospective multidisciplinary awareness undoubtedly improved the outcome of these high-risk patients at the single-institutional level,2 as shown in our case. Our multidisciplinary approach to treating trauma patients started as early as 1996, although it was necessary to change protocols from time to time. The decision to act needs to be fast and appropriate to salvage these critically ill patients—establishment of protocols shortens the time to make 216
decisions, and the time required for the team, angiosuite or operating theatre, to become available. This has proven to be valuable and to improve outcomes.2 33–35 From the emergency department’s perspective where seconds count, it would be nice to see the protocol driving the decision making, and this could form the basis for protocols elsewhere. Torrential bleeding from a fractured pelvis may be from bone surface, arterial spurts or venous tears. The bleeding sites inside the true pelvis are usually deep-seated. Open laparotomy was used in our patients as a last resort in the 1990s, and proved to be in Cheng M, et al. Emerg Med J 2015;32:214–220. doi:10.1136/emermed-2012-202009
Downloaded from http://emj.bmj.com/ on June 8, 2015 - Published by group.bmj.com
Original article
Figure 1. Continued. vain. The implementation of pelvic embolisation during the second phase of our study significantly reduced the overall mortality rate by more than 30%. There was an improvement in patients with Pelvis AIS 4 and 5. Although 10–20% were bleeding from Cheng M, et al. Emerg Med J 2015;32:214–220. doi:10.1136/emermed-2012-202009
arterial spurts, angiography did nothing to address the potentially torrential venous bleeding that comprised more than 70% of the haemorrhages.19–21 Focusing on early angiography could delay the treatment of associated injuries and might also be logistically 217
Downloaded from http://emj.bmj.com/ on June 8, 2015 - Published by group.bmj.com
Original article Table 1
Overview of age, injury severity, physiological and other parameters by study periods (mean + SD with p value by Student t test)
n=199 Age (years)
Pre-ANGIO Phase 1 n=74 50.69±22.86
First SBP at AED
97.70±50.17
RR on attendance
17.97±8.10
GCS
11.26±4.75
ISS
46.22±17.04
TRISS
0.545±0.371
RTS
6.05±2.36
First Hb at AED
12.41±2.45
Lowest SBP in AED
78.81±42.70
Lowest DBP in AED
39.57±30.86
Fastest Pulse in AED
107.72±41.71
AED unmatched blood
3.82±4.23
Lowest Hb at hospital
8.32±3.09
Total matched blood
16.77±14.20
Total FFP
1.82±5.07
Total Platelets
2.20±5.03
LOS (days)
19.00±38.53
ANGIO Phase 2 n=76 46.84±21.43 46.84±21.43 99.08±46.78 99.08±46.78 21.68±8.62 21.68±8.62 11.21±4.78 11.21±4.78 45.00±15.71 45.00±15.71 0.562±0.383 0.562±0.383 6.16±2.29 6.16±2.29 12.00±2.72 12.00±2.72 88.75±44.25 88.75±44.25 53.43±30.88 53.43±30.88 100.55±33.83 100.55±33.83 2.45±3.53 2.45±3.53 7.98±2.44 7.98±2.44 9.36±11.23 9.36±11.23 2.50±4.45 2.50±4.45 2.00±3.50 2.00±3.50 30.21±43.34 30.21±43.34
PACKING Phase 3 n=49
45.37±21.02 92.04±42.81 21.14±8.13 12.14±4.22 40.10±14.19 0.615±0.347 6.34±2.06 11.83±2.89 90.78±41.96 55.33±31.83 104.14±25.93 1.22±1.77 7.37±2.16 11.76±16.27 3.06±4.96 3.14±5.14 32.00±36.04
p Value 0.289 0.706 0.862 0.398 0.007* 0.727 0.953 0.267 0.650 0.080 0.789 0.430 0.769 0.660 0.409 0.748 0.165 0.799 0.007* 0.741 0.249 0.528 0.032* 0.027* 0.463 0.157 0.001* 0.331 0.387 0.511 0.774 0.141 0.096 0.816
*p
Original article
Improvement in institutional protocols leads to decreased mortality in patients with haemodynamically unstable pelvic fractures Mina Cheng,1 Moon-Tong Cheung,1 Kin-Yan Lee,1 Kin-Bong Lee,2 Susan-C H Chan,3 Amy-C Y Wu,4 Yu-Fat Chow,4 Annice-M L Chang,5 Hiu-Fai Ho,5 Kelvin-K W Yau6 1
Department of Surgery, Queen Elizabeth Hospital, Hong Kong 2 Department of Orthopaedics & Traumatology, Queen Elizabeth Hospital, Hong Kong 3 Department of Radiology & Imaging, Queen Elizabeth Hospital, Hong Kong 4 Department of Anaesthesiology & Operating Theatre Services, Queen Elizabeth Hospital, Hong Kong 5 Department of Accident & Emergency, Queen Elizabeth Hospital, Hong Kong 6 Department of Management Sciences, City University of Hong Kong, Hong Kong Correspondence to Dr Moon-Tong Cheung, Department of Surgery, Queen Elizabeth Hospital, 30 Gascoigne Road, Kowloon, Hong Kong; [email protected], [email protected] Received 26 September 2012 Revised 4 March 2013 Accepted 21 October 2013 Published Online First 10 December 2013
To cite: Cheng M, Cheung M-T, Lee K-Y, et al. Emerg Med J 2015;32: 214–220. 214
ABSTRACT Background The mortality rate in patients with haemodynamically unstable pelvic fractures is as high as 40–60%. In recent years, angioembolisation and pelvic packing have been introduced as part of a multimodality treatment for these patients. Protocol-driven management has been shown to improve outcomes. Patients and methods This is a Level III retrospective cohort study of patients suffering from unstable pelvic fractures from 1 January 1996 to 30 September 2011. The aim of the study was to review our results, particularly in terms of mortality through the evolution of three phases of treatment protocols: preangiography, angiography and pelvic packing. Results The overall 30-day mortality rate for all patients was 47.2%, with a rate of 63.5% in the preangiography phase, 42.1% in the angiography phase and 30.6% in the pelvic packing phase. Multivariate logistic regression analysis identified the use of retroperitoneal packing as a significant independent predictive factor for 24 h mortality. Conclusions Our results showed an improvement in patient survival with sequential protocols over the study period, during which we incorporated a multidisciplinary approach to managing these complicated pelvic fractures. The results strongly suggest that retroperitoneal packing should be highly recommended for bleeding subsequent to pelvic fracture, in addition to other modalities of treatment.
in the USA.14–19 However, methods for reducing venous bleeding remain to be tackled.19–21 In Europe, pelvic packing (preperitoneal or retroperitoneal packing) has emerged as one of the methods for controlling venous bleeding due to tears caused by bony fragments.21–26 Our early experience suggested that initial pelvic packing, with subsequent angiography if needed, is as good as angiography with embolisation for treating patients with haemodynamically unstable pelvic fractures.27 A high-energy impact is needed to disrupt the pelvic ring, and as such, will often produce major injuries to other critical organs. Up to 90% of patients with unstable pelvic fractures have associated injuries, and 50% of patients have sources of major haemorrhage other than pelvic fractures,1 28 29 approximately 15% have intrathoracic bleeding, 32% have intra-abdominal bleeding, and 40% have long-bone fracture bleeding.30–32 This complicates the management of pelvic fracture patients. Protocol-driven management simplifies the decision-making process of a multidisciplinary team in the initial treatment period and decreases mortality in haemodynamically unstable cases.2 33–35 The time for decision making can be shortened, and the first few hours can be critical for patients suffering from catastrophic bleeding from various sources. The aim of this study is to review our results through the evolution of our treatment protocols in three phases over 15 years and 9 months.
INTRODUCTION
PATIENTS AND METHODS
The management of severe pelvic injury remains a challenging task for trauma surgeons. Overall mortality of patients with any type of pelvic fracture is reported to be around 5–10%,1–5 however, haemodynamically unstable pelvic fractures, have a much higher mortality rate of 40–60%.4 6–8 Bleeding from a patient with a fractured pelvis could be from various sources: bone surface, venous tears or arterial bleeds. Over the years, methods for controlling bleeding from pelvic fractures have undergone various modifications targeting different sources. A laparotomy approach does not allow access to the pelvic site where bleeding occurs. Even worse, it breaks the natural tamponade effect of the true pelvis. External fixation can help to prevent bleeding from bone edges by reducing fracture fragments and restoring the geometry of the pelvis.4 9–13 Studies have shown that arterial bleeding occurs in about 10–15% of patients. Over the past decades, pelvic embolisation has become popular for reducing arterial bleeding, particularly
Queen Elizabeth Hospital is a level I trauma centre in Hong Kong. Data of all trauma patients who attended the Accident and Emergency Department (AED) and being categorised as critical or emergency cases were prospectively collected and entered to a trauma database since 1996. The scoring system based on the Abbreviated Injury Scale 1998 (AIS-1998) was used throughout the period (except in 1996 and 1997, during which AIS-1990 was used). All injuries were coded and recorded by one trauma nurse from 1996 to 2004, and by another one from 2005 till the present (author, AMC). All records were checked by the same trauma physician throughout the years (author, HFH). Haemodynamic instability was defined as systolic BP lower than 90 mm Hg upon arrival at AED or at any time during hospital stay after infusion of 2 L of crystalloids. All patients from 1 January 1996 to 30 September 2011 with pelvic ring fractures of 852 606, 852 608 and 852 610 as denoted by AIS-1998 (representing
Cheng M, et al. Emerg Med J 2015;32:214–220. doi:10.1136/emermed-2012-202009
Downloaded from http://emj.bmj.com/ on June 8, 2015 - Published by group.bmj.com
Original article substantial deformation and displacement with associated vascular disruption or with major retroperitoneal haematoma, or ‘open book’ fractures), and with AIS severity score in pelvis (Pelvis AIS) of four or five (Pelvis AIS 4: blood loss ≤20% by volume; Pelvis AIS 5: blood loss >20%) were retrieved from the database for analysis. Patients’ demographic characteristics, physiological measurements, severity and mechanism of injury, and modalities of treatment were studied. Other severe injuries were defined as brain injuries, chest contusion requiring intervention; intra-abdominal organ injuries as evidenced by imaging or noted during laparotomy, and long-bone fractures requiring operation. We divided the study period into three phases, each after significant modifications of treatment protocols. Modifications were usually implemented after discussion in mortality and audit meetings. In all three periods, pelvic binder was applied in the AED once pelvic fracture was suspected. The subsequent management followed three different protocols in the three periods. Between 1 January 1996 and 31 December 2001, which was the Phase 1 preangiography era (PRE-ANGIO Phase 1), casualties presenting with severe haemodynamic instability and unstable pelvic fractures were subjected to salvage laparotomy and external fixation in the operation theatre. Between 1 January 2002 and 31 July 2008, which was the Phase 2 angioembolisation era (ANGIO Phase 2), patients with haemodynamic instability with no other obvious bleeding sources apart from the pelvis were sent to the angiosuite for immediate angiography and embolisation. Patients with intra-abdominal bleeding, as suggested by positive focused abdominal sonography for trauma (FAST) or diagnostic peritoneal lavage, were sent for exploratory laparotomy and external fixation. Afterwards, they would be sent to the angiosuite for angiography and embolisation (figure 1A). Between 1 August 2008 and 30 September 2011 was the phase three pelvic packing era (PACKING Phase 3). Pelvic fracture patients with haemodynamic instability and a negative FAST scan were sent to the operation theatre for external fixation by orthopaedic surgeons first, in order to stabilise the disrupted bony pelvis and to limit the pelvic volume to facilitate pelvic packing. This was immediately followed by retroperitoneal packing (RPP) by trauma surgeons, technique of which have been described in our previous report.27 In the meantime, equipment for angiography and embolisation would be set up. If the patients were still haemodynamically unstable after external fixation and RPP, angiography and embolisation would be performed in the operation theatre. For patients with a positive FAST scan, they would undergo exploratory laparotomy with the pelvic binder on, followed by external fixation and RPP. Angiography and embolisation would follow if necessary (figure 1B). The means between two groups for scale variables were compared using independent samples t test. Categorical variables were compared using Pearson χ2 test, or Fisher’s Exact test as appropriate. Multivariate analysis was performed by means of multiple logistic regressions with stepwise variable selection method to identify significant independent risk factors that predicted mortality in all patients throughout the whole period. Level of significance was set at 5%. The SPSS V.18.0 software (SPSS, Chicago, Illinois, USA) was used to perform the analysis.
RESULTS During the 15-year-9-month study period, there were 7222 trauma patients registered in our trauma database, among whom 2780 patients had Injury Severity Score (ISS) >15. Five hundred and ninety-eight patients suffered from pelvic fractures. Among these, 199 patients (33%) who sustained unstable pelvic Cheng M, et al. Emerg Med J 2015;32:214–220. doi:10.1136/emermed-2012-202009
fractures with Pelvis AIS scores of four or five were admitted to our hospital and included in our study. In PRE-ANGIO Phase 1, 74 patients were included. There were 76 patients in ANGIO Phase 2 and 49 patients in PACKING Phase 3. All patients sustained blunt trauma; 140 patients (70%) had sustained Pelvis AIS of 5; the other 59 patients (30%) had Pelvis AIS of 4; 122 patients (61%) sustained severe injuries of other organs. Among all of them, were 34% with severe head and neck injury (with head and neck AIS score >3); 39% with severe chest injury (chest AIS >3), and 28% with severe abdominal injury (abdomen AIS >3). Patients’ demographic characteristics, physiological measurements are shown in tables 1 and 2. It appeared that the degree of injury became less severe in later periods in terms of ISS, Trauma and Injury Severity Score (TRISS) and Revised Trauma Score (RTS). There was significant difference in Pelvis AIS score between various periods ( p=0.002) with more Pelvis AIS 4 than Pelvis AIS 5 in the PACKING Phase 3. There were no significant differences in BP, pulse, haemoglobin measured upon arrival at the AED. The median time to angiography was 2.85 h (mean 4.69 h with SD=5.98) during ANGIO Phase 2; median time to operation was 1.20 h (mean 2.89 h with SD=4.44) in PACKING Phase 3. Major complications associated with RPP were uncommon (8%). One patient had wound infection with sepsis, one patient had pelvic collection requiring aspiration, and one had strangulated incisional hernia 1.5 year later—all three patients survived. There were no complications directly related to embolisation. The mortality rates are summarised in table 3. The overall 30-day mortality rate for all patients was 47.2%; and 36.7% for 24 h mortality. A total of 33 covariates/risk factors for all patients throughout the period including all variables, are listed in tables 1 and 2 (except length of stay, 30-day and 24-day death) together with the factor of period of study were entered using univariate logistic regression analysis. Twenty-two variables, such as the first systolic BP in AED, ISS, TRISS, RTS, presence of other injury, use of laparotomy, use of RPP, period of study and so on, are significant factors for 24 h mortality by univariate analysis. By applying multivariate logistic regression analysis, use of RPP was identified to be one of the significant independent predictive factors for 24 h mortality (table 4). The odds ratio for 24 h mortality was 3.48 times higher for those without RPP versus those with RPP.
DISCUSSION Through audit and implementation of new modalities of treatment in three phases over the past 15 years and 9 months, we have shown that protocol-driven multidisciplinary management significantly improved the outcome of patients with complex pelvic fractures. To reduce the bias and ensure consistency, we compared groups of patients who had the same severity of pelvic injury (Pelvis AIS 4 and 5). With the AIS, each injury was categorised by body area, with four being severe and lifethreatening, and five being critical and of uncertain survival.36 Thus, all our patients were suffering from severe pelvic fracture of similar severity throughout. This reduced the possibilities of comparing different groups of patients if we are comparing the success rate of treatment modalities alone. However, this remained a very heterogeneous group of patients. Comparing historic cohorts has several limitations, and the effects of time could have significant influence. There may be an inherent bias because the gradual institution of other new therapies could have led to continual improvements over the years. For example, there were improvements in multidisciplinary care, 215
Downloaded from http://emj.bmj.com/ on June 8, 2015 - Published by group.bmj.com
Original article
Figure 1 (A) Protocol for the management of haemodynamically unstable casualties with pelvic fractures at Queen Elizabeth Hospital, 1 January 2002 to 31 July 2008 (ANGIO Phase 2). (B) Protocol for the management of haemodynamically unstable casualties with pelvic fractures at Queen Elizabeth Hospital, 1 August 2008 to 30 September 2011 (PACKING Phase 3).
more liberal use of CT scanning in AED, improved organ support in intensive care unit, the use of recombinant factor VIIa and massive transfusion protocol. However, prospective multidisciplinary awareness undoubtedly improved the outcome of these high-risk patients at the single-institutional level,2 as shown in our case. Our multidisciplinary approach to treating trauma patients started as early as 1996, although it was necessary to change protocols from time to time. The decision to act needs to be fast and appropriate to salvage these critically ill patients—establishment of protocols shortens the time to make 216
decisions, and the time required for the team, angiosuite or operating theatre, to become available. This has proven to be valuable and to improve outcomes.2 33–35 From the emergency department’s perspective where seconds count, it would be nice to see the protocol driving the decision making, and this could form the basis for protocols elsewhere. Torrential bleeding from a fractured pelvis may be from bone surface, arterial spurts or venous tears. The bleeding sites inside the true pelvis are usually deep-seated. Open laparotomy was used in our patients as a last resort in the 1990s, and proved to be in Cheng M, et al. Emerg Med J 2015;32:214–220. doi:10.1136/emermed-2012-202009
Downloaded from http://emj.bmj.com/ on June 8, 2015 - Published by group.bmj.com
Original article
Figure 1. Continued. vain. The implementation of pelvic embolisation during the second phase of our study significantly reduced the overall mortality rate by more than 30%. There was an improvement in patients with Pelvis AIS 4 and 5. Although 10–20% were bleeding from Cheng M, et al. Emerg Med J 2015;32:214–220. doi:10.1136/emermed-2012-202009
arterial spurts, angiography did nothing to address the potentially torrential venous bleeding that comprised more than 70% of the haemorrhages.19–21 Focusing on early angiography could delay the treatment of associated injuries and might also be logistically 217
Downloaded from http://emj.bmj.com/ on June 8, 2015 - Published by group.bmj.com
Original article Table 1
Overview of age, injury severity, physiological and other parameters by study periods (mean + SD with p value by Student t test)
n=199 Age (years)
Pre-ANGIO Phase 1 n=74 50.69±22.86
First SBP at AED
97.70±50.17
RR on attendance
17.97±8.10
GCS
11.26±4.75
ISS
46.22±17.04
TRISS
0.545±0.371
RTS
6.05±2.36
First Hb at AED
12.41±2.45
Lowest SBP in AED
78.81±42.70
Lowest DBP in AED
39.57±30.86
Fastest Pulse in AED
107.72±41.71
AED unmatched blood
3.82±4.23
Lowest Hb at hospital
8.32±3.09
Total matched blood
16.77±14.20
Total FFP
1.82±5.07
Total Platelets
2.20±5.03
LOS (days)
19.00±38.53
ANGIO Phase 2 n=76 46.84±21.43 46.84±21.43 99.08±46.78 99.08±46.78 21.68±8.62 21.68±8.62 11.21±4.78 11.21±4.78 45.00±15.71 45.00±15.71 0.562±0.383 0.562±0.383 6.16±2.29 6.16±2.29 12.00±2.72 12.00±2.72 88.75±44.25 88.75±44.25 53.43±30.88 53.43±30.88 100.55±33.83 100.55±33.83 2.45±3.53 2.45±3.53 7.98±2.44 7.98±2.44 9.36±11.23 9.36±11.23 2.50±4.45 2.50±4.45 2.00±3.50 2.00±3.50 30.21±43.34 30.21±43.34
PACKING Phase 3 n=49
45.37±21.02 92.04±42.81 21.14±8.13 12.14±4.22 40.10±14.19 0.615±0.347 6.34±2.06 11.83±2.89 90.78±41.96 55.33±31.83 104.14±25.93 1.22±1.77 7.37±2.16 11.76±16.27 3.06±4.96 3.14±5.14 32.00±36.04
p Value 0.289 0.706 0.862 0.398 0.007* 0.727 0.953 0.267 0.650 0.080 0.789 0.430 0.769 0.660 0.409 0.748 0.165 0.799 0.007* 0.741 0.249 0.528 0.032* 0.027* 0.463 0.157 0.001* 0.331 0.387 0.511 0.774 0.141 0.096 0.816
*p
