All posts by TheTraumaPro

Early Operative Fixation of Pelvic Fractures And Functional Outcome

Disruption of the pelvic bones takes a huge amount of energy, and results in significant bleeding and morbidity from other causes. Repair typically consists of surgical fixation, frequently with temporary external fixation in the interim. These patients require intensive therapy postoperatively, with inpatient rehab prior to discharge home.

How well do patients with severe pelvic fractures do in the longer term? The group at the University of Tennessee in Memphis did a lengthy followup study spanning 18 years of severe pelvic fractures treated at their hospital. These patients had sustained fractures with significant bleeding, an open book component, or SI joint disruption with vertical shear.

open book pelvis pre

The authors used phone interviews and a standardized measurement instrument (Activity Measure for Post-Acute Care, AM-PAC) to gauge daily activity of affected patients. They then looked for factors predictive of functional outcome.

Here are the factoids:

  • 401 patients were identified over the 18 year study period
  • Of these only 71% survived (285), and the study documented followup in 145 (51%)
  • Average ISS was 27 (fairly high) and patients tended to be older (mean 53 years)
  • Even after 8 to 20 years, mobility and activity were significantly impaired as measured by AM-PAC
  • Time to fixation was the only identifiable factor that had an impact on decreased mobility or activity

Bottom line: Early definitive fixation of the pelvis was the only variable found that had an impact on future mobility and activity. Frequently, external fixation is applied soon after admission. But remember, your trauma patient is at their healthiest as they roll through the doors of your ED. The sooner they get all of their problems fixed, the better (and safer).

Impact of early operative pelvic fixation on long-term functional outcome following sever pelvic fracture. AAST 2016, Paper 60.

Spleen Injury, Angiography, And Splenectomy

The shift toward initial nonoperative management of spleen injuries began in the early 1990’s, as the resolution of early CT scans began to improve. Our understanding of the indicators of failure also improved over time, and success rates rose and splenectomy rates fell.

Angiography was adopted as an adjunct to early management, especially when we figured out what contrast extravasation and pseudoaneurysms really meant (bad news, and nearly certain failure in adults). At first, it was used in a shotgun approach in most of the higher grade injuries. But we have refined it over the years, and now it is used far more selectively at most centers.

A group at Indiana University was interested in looking at the impact of angio use on splenic salvage over a long time frame. They queried the National Trauma Data Bank, looking specifically at high grade splenic injury care at Level I and II centers from 2008-2014. Patients undergoing splenectomy were divided into early (<= 6hr after admission) and late (> 6 hrs). Over 50,000 records were analyzed.

Here are the factoids:

  • There was a shift from early splenectomy to late splenectomy over the study period that was statistically significant
  • Use of angio increased from 5 to 12% during the study period
  • Overall splenectomy rate remained about the same

So the authors recognize that late splenectomy has decreased. But they also state that early splenectomy has increased. They attribute it to increased recognition of patient requiring early splenectomy. They then call into question the need to use angiography if it hasn’t decreased the overall splenectomy rate.

Problem: The early splenectomy rate increased from about 13% to 14%, reading their graph, and is probably not significant. These are the failures that occur in the trauma bay and shortly thereafter that must be taken to the OR. The late splenectomy rate decreased from 5% to 3%, which may be significant (p value not included in the abstract). These are failures during nonoperative management, and are decreasing over time. And BTW, the authors do not define what “high grade” splenic injuries they are looking at.

AAST2016-Paper35

Bottom line: This abstract illustrates why it is important to read the entire article, or in this case, listen to the full presentation at AAST. It sounds like one that’s been written to justify not having angiography available as it is currently required. 

The authors showed that overall splenectomy rate was the same, but delayed splenectomy (late failure) has decreased with increasing use of angiography. But remember, this is an association, not cause and effect. Most of the early failures are still probably ones that can’t be prevented, but we’ll see if the authors can dissect out how many went to OR very early (not eligible for angio), or later in the 6 hour period (could have used angio). It looks to me like the use of angiography is having the desired effect. But undoubtedly we could use that resource more wisely. What we really need are some guidelines as to exactly when a call to the interventional radiologists is warranted.

Related posts:

Reference: Overall splenectomy rates remain the same despite increasing usage of angiography in the management of high grade blunt splenic injury. AAST 2016, paper 35.

Efficacy Of Preperitoneal Packing For Pelvic Fractures

A multi-center trial published in 2015 showed an astounding 32% mortality rate for patients with shock from pelvic fracture. And as I continue to preach, going any place but the OR is dangerous for the patient. Unfortunately, it’s generally not feasible to operatively fix the pelvis acutely, and external fixation has limited impact on ongoing hemorrhage.

If the patient can be stabilized to some degree, interventional radiology can be very helpful. Unfortunately, access after hours involves some degree of time delay. Ideally, the team arrives in 30 minutes or less. But the patient may not be ready, so time to procedure may increase significantly.

So preperitoneal packing of the pelvis (PPP) has now become popular. Years ago, we tried to pack the pelvis from the inside (peritoneal cavity), but it never worked very well. You can push sponges deep into the pelvis as firmly as you want, but the intestines will not keep them from expanding back out of the pelvis.

PPP entails making a lower midline incision, but not entering the peritoneal cavity. A hand is then slid along the anterior surface of the peritoneum around the inside of the iliac wing. Sponges can then be pushed around toward the sacrum, applying direct pressure over bleeding fracture sites and the overlying tissues.

preperitoneal-packing

Image courtesy of ACSSurgery.com

But does it work? Denver Health performed an 11 year retrospective review of their experience with 2293 patients with pelvic fractures. They looked at time to intervention, blood product usage, and mortality.

Here are the factoids:

  • A total of 128 patients underwent PPP
  • Most were younger (mean age 43) and badly injured (mean ISS 48)
  • Median time from door to OR was 44 minutes
  • Patients received an average of 8 units of RBCs intraop, and an additional 3 units in the ensuing 24 hours
  • Overall mortality was 21% (27 of 128), but 9 (7%) were due to severe head injury

Bottom line: Compared to other published studies, time to “definitive management” with PPP was very short. Blood usage also dropped quickly after the procedure. Mortality seems to be much better than expected at about 13%. These results suggest that if you have to wait for angio, or your patient is too unstable to go there, run to the OR first to do some PPP.

And don’t forget these other important management tips:

  • If you see any posterior pelvic fracture on the initial pelvic x-ray, call for blood
  • If the blood pressure softens at any point activate your massive transfusion protocol
  • Apply a binder, especially for open book type fractures
  • Always get a CT in stable patients to help your orthopedic surgeons plan, and to identify contrast blushes
  • If the patient has to go to OR first to stabilize them, consider angio afterwards. You’ll probably find something they can fix.
  • Think about using your hybrid OR!

Reference: Preperitoneal pelvic packing reduces mortality in patients with life-threatening hemorrhage due to unstable pelvic fractures. AAST 2016, Paper 32.

Last Chance To Get Early Delivery Of September Trauma MedEd!

Subscribers will receive the newest issue of Trauma MedEd by tomorrow night. So this is your last chance to get on the subscriber list so you don’t have to wait until mid-September.

And the topic this month is…

Traumatic BKA

Field amputation. Topics discussed include:

  • Definitions and incidence
  • Indications
  • Who should perform it?
  • Logistics
  • Equipment
  • and more!

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Are Graduating General Surgery Residents Qualified To Take Trauma Call?

Trauma training during general surgery residency has changed dramatically over the past two decades. Although we like to blame the 80-hour work week rule on everything, there are other factors that may be at play. Increasing use of nonoperative management, availability and increasing scope of interventional radiologists, and the increasing number of surgical subspecialists are certainly significant.

The surgical group at LAC+USC looked at changes in operative caseloads, type of surgery performed, and the impact that concurrent subspecialty training has had on trauma operative volumes. The authors reviewed 16 years of ACGME data on resident surgical procedures in various body regions by year of training. They specifically looked at the impact of implementation of the 80-hour work week.

Here are the factoids:

  • There was a trend only (p=0.07) toward decreased operative trauma cases
  • The number of trauma laparotomies increased, vascular procedures decreased, and neck explorations and thoracotomies remained stable
  • Trauma vascular procedures decreased for surgical residents, but increased for vascular fellows
  • Individual resident operative volumes in chest, abdomen, solid organ, and extremities decreased after implementation of the 80-hour work week
  • Based on this, the authors recommend residents who are interested in a career in trauma and acute care surgery have fellowship training (??)

AAST2016-Paper29

Bottom line: Well, it was a catchy title, at least. Or is it a promotion for trauma fellowships? I hope the authors have some really good statistics to help this paper out. You may not be able to read the table above well, but the differences between pre-80 hour and post-80 hour are not that impressive, and the SD or SEM (can’t tell what they are) are uncommonly narrow, which amplifies the p values. And other than the number of laparotomies going up, the other numbers looked fairly constant. I look forward to the presentation and critique of this paper at the meeting. Not sure it will escape unscathed.

Reference: Is your graduating general surgery resident qualified to take trauma call? A 15-year appraisal of the changes in general surgery education for trauma. AAST 2016, Paper 39.