Tag Archives: pelvis

Technique

Preperitoneal Packing Vs Angioembolization: Part 3

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In the previous post in this series, I described an early review article summarizing several older studies comparing these two hemorrhage control techniques for pelvic fractures. Today, I’ll review another paper fresh off the press, published just this month.

This paper comes from the orthopedics and neurosurgical groups at the University of Texas-San Antonio. They scanned five years of data from the National Inpatient Sample, which included data from 35 million inpatient admissions in the US. They separated all patients with acetabular and pelvic ring fractures using ICD-10 codes.

They further narrowed their dataset to patients with angioembolization (AE) or peri-pelvic packing (PPP) as their primary procedure. This eliminated patients who might have received other additional management that could cloud the data. Various hospital outcomes were tabulated, including hospital charges, mortality, and discharge location.

Here are the factoids:

  • Of the 3,780 patients identified, only 160 underwent PPP, and the remaining 3,620 had AE. This is probably a function of PPP’s newer and more novel nature.
  • The AE patients were significantly older than the PPP patients (66 vs 53 years). This suggests that trauma professionals have a lower threshold to order AE in older patients.
  • Time to procedure start was similar for both interventions
  • Overall, there was no difference in mortality between the AE and PPP patients
  • There was no difference in unfavorable discharge (other than home)
  • Hospital charges were significantly lower in the AE group ($369K vs $250K)!

Bottom line: This is the largest comparison of AE and PPP to date. It mostly confirms earlier work and adds significant insights about cost and discharge status.

AE and PPP have equivalent outcomes. This is true even though the AE group is larger and significantly older. However, it is possible that the number of PPP cases was too low for the authors to demonstrate any significant differences. 

What should you do when faced with these patients? First, hemodynamic instability means that PPP is the only choice. You can feel comfortable that outcomes will be the same as AE. If there is concern that there could be ongoing bleeding, PPP can be followed by a trip to the interventional radiology suite. This is a common practice.

I shouldn’t have to say it, but AE should never even be considered in an unstable patient. 

What about stable patients? AE seems to be the way to go. It is tolerated even by older patients. And it ends up saving a lot of money when compared to PPP. 

There is still room for research in this space. As our PPP experience grows, we should hopefully be able to confirm the conclusions  in this paper. If any are refuted, I’ll revisit this post and make the needed updates. Which is what you should also do in your practice!

Reference: Angioembolization Has Similar Efficacy and Lower Total Charges than Preperitoneal Pelvic Packing in Patients With Pelvic Ring or Acetabulum Fractures. J Orthop Trauma 38(5):254-258, 2024.

Technique

Preperitoneal Packing Vs Angioembolization: Part 2

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In my last post, I reviewed an early paper on preperitoneal packing (PPP). Today, I’ll look at an earlier review article summarizing some smaller studies comparing it to angioembolization. In the next post, I’ll look at a brand new paper that includes a cost analysis as well.

Interestingly, the use of AE and PPP vary geographically. Angioembolization has been a mainstay in the US for some time, and PPP has been more commonly used in Europe. The use of both is becoming more widespread, and each has its pros and cons.

Angioembolization requires the presence of a special interventional radiology team and a reasonably stable patient. The procedure can take some time, and the IR suite is not really the place to house an unstable patient. Preperitoneal packing requires a reasonably stable pelvis to hold the packs in place for optimal tamponade, which may require application of an external fixator at the time of the procedure.

But is one better than the other? A number of relatively small studies have been performed, which means that it is time to synthesize them and see if some clearer answers can be found. The trauma group in Newcastle, Australia did just this. They performed a systematic search of the literature, analyzing the impact of each procedure on in-hospital mortality.

Here are the factoids:

  • A total of 18 studies met the authors’ inclusion criteria: 6 studies on AE, 9 studies of PPP, and 3 that compared them to each other
  • ISS was significantly higher in the PPP group vs AE (41 vs 36)
  • Average time to OR in the PPP patients was 60 minutes vs 131 minutes to IR in the AE group (statistically significant)
  • A quarter (27%) of the PPP patients did not get adequate hemorrhage control and required AE
  • In-hospital mortality in the PPP papers was 23% vs 32% in the AE research
  • Mortality in the papers that compared AE directly to PPP was no different

Bottom line: What does this all mean? Is packing “better” than embolization? The simple answer is that we don’t know yet. Due to the way this study was performed, it is not possible to tease out all of the possible confounders. 

We are taught that control of hemorrhage is paramount. The time to definitive management in the AE group was twice that of the PPP patients. This could have a major impact on mortality. Two hours of bleeding can certainly kill. And the lower mortality in the PPP group occurred even though their injury severity was higher.

Many trauma centers have both of these interventions available to choose from. How should we approach their use? Unfortunately the literature is still to scarce to come to strong conclusions. Until we have better research to learn from, I suggest the following:

  • Time is of the essence. Which procedure can you get the fastest? In many cases, this will be preperitoneal packing since it’s just a trip to your trauma OR, which should be ready and waiting. If you have an IR team standing by or available very quickly, you could consider them first.
  • Pay attention to hemodynamic stability. An IR suite is no place for an unstable patient. The resuscitation equipment is not on par with the OR, and one never knows exactly how long the procedure will last.
  • If you have a hybrid room, use it! This is the ideal situation. The surgeon can start the PPP while the orthopedic surgeon applies a fixator. And the radiologist can be preparing to finish it off with a quick squirt as soon as they move away from the groin.
  • The use of one does not rule out the other. If one fails and the patient has increasing fluid and blood requirements move immediately to the other procedure to try to get control.

Reference: Preperitoneal packing versus angioembolization for the initial management of hemodynamically unstable pelvic fracture: A systematic review and meta-analysis. The Journal of Trauma and Acute Care Surgery, 92(5), 931–939.

 

Procedures

Preperitoneal Packing Vs Angioembolization: Part 1

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In this series, I will review the two major techniques for addressing troublesome bleeding from pelvic fractures. This post will review the evolution of packing techniques and more fully describe the concept of preperitoneal packing. Next, I’ll review an early paper that compared the snippets of information we had to angioembolization. In the last post in the series, I’ll discuss a paper in press that compares the efficacy and hospital charges of the two techniques.

A multi-center trial published in 2015 showed an astounding 32% mortality rate for patients with shock from pelvic fracture. As I continue to preach, going anywhere 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.

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 intraoperatively, 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 angiography, 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 angiography 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. The Journal of Trauma and Acute Care Surgery, 82(2), 233–242.

Imaging, Tips

Don’t Repeat Trauma Activation X-rays!!

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You are in the middle of a fast-paced trauma activation. The patient is awake, and mostly cooperative. The x-ray plate is under the patient and everyone stands back as the tech gets ready to fire the x-ray machine. At that very moment, your patient reaches up and places his hand on his chest. Or one of the nurses reaches over to check an IV site.

The x-ray tech swears, and offers to re-shoot the image. What do you do? Is it really ruined? They have an extra plate in hand and are ready to slide it under the patient bed.

The decision tree on this one is very simple. There are two factors in play: what do you need to see, and how hard is it to see? The natural reaction is to discard the original image and immediately get a new one. It’s so easy! Plus, the techs will take heat from the radiologist because of the suboptimal image. But take a look at this example of a “ruined” chest xray.

It’s just the patient’s hand! You can still see everything that you really need to.

Bottom line: You are looking for 2 main things on the chest x-ray: big air and big blood. Only those will change your management in the trauma bay. And they are very easy to see. Couple that with the fact that an arm overlying the image does not add a lot of “noise” to the image. So look at the processed image first. 99% of the time, you can see what you need, and will almost never have to repeat. [Hint: the same holds true for the pelvic x-ray, too. You are mainly looking for significant bony displacements, which are also easy to see.]

Related posts:

Procedures

Efficacy Of Preperitoneal Packing For Pelvic Fractures

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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.