Comparison between external fixation and pelvic girdle in patients with pelvic fracture and hemodynamic instability who underwent various hemostatic procedures
Recent studies have reported that PEF plays an important role in hemostasis through stabilization of the pelvic ring in pelvic fracture with shock to reduce further damage and shrinking effect of the pelvic cavity.11,12,13. However, a recent study that analyzed 10-year data on emergent external stabilization using the German Pelvic Trauma Registry showed a downward trend in PEF use in patients with hip fracture. pelvic ring. In contrast, the use of MUAC increased rapidly and was used in nearly 40% of patients.ten. Additionally, in a recent multicenter study conducted at a Level I trauma center in the United States, MUAC was performed in 50% of patients with pelvic fracture and shock, and PEF was performed only in 4% of patients.12. These results show that PB has increasingly been used in place of PEF, and its use has steadily increased due to its simplicity and speed of application.11.15. It is difficult to compare the effects of PEF and PB in the treatment of patients with bleeding due to pelvic fracture versus bleeding due to other injuries because a combination of different modalities is possible. In 2007, in a comparative study between the PEF and PB groups, Croce et al. showed that mortality rates were similar, but the need for red blood cell transfusion at 24 and 48 h was significantly lower in the PB group than in the PEF group. However, there was a difference in characteristics between the two groups. Since recently used procedures such as PPP or REBOA were not analyzed together, it is difficult to accept the results in the current scenario11. In our study, to minimize the effect of other hemostatic procedures and to compare differences between the effects of PB and PEF, the proportions of patients who underwent PPP, PA, and laparotomy were corrected using PSM. The results showed that there were no significant differences in the 7-day, 30-day, and overall mortality rates between the PEF and PB groups. Recent studies have recommended that PB be applied as soon as possible after injury for rapid reduction in pelvic cavity volume16.17. This means that hemostatic modalities such as PPP, PA and REBOA should be used whenever possible to stop bleeding, the cause of most deaths, and simultaneously a pelvic cavity volume reduction procedure applied as quickly as possible. possible should be performed. . There was no difference in clinical outcomes between the two groups in the present study because six of 20 patients in the PEF group underwent PEF with rapid PPP. In 14 patients, PB was immediately applied in the emergency room and then removed immediately before PEF. Thus, the haemostatic effect by volume reduction of the pelvic cavity in the acute phase was obviously similar between the two groups.
If the PB is not removed quickly or too tightly, complications such as skin necrosis and pressure sore may occur; therefore, it is recommended to maintain MUAC for 2.18. In the trauma centers included in this study, MUAC was removed within 48 h when the patient was hemodynamically stabilized; however, the final fixation of the pelvis was determined taking into account the patient’s condition and was achieved after an average of 6 days after the injury. This suggests that reduction in pelvic volume does not significantly affect patient outcome after acute hemostasis, and the results of our study are consistent with the recent trend that the use of PB rather than PEF is increasing. keep on going.
Additionally, the Denver group reported that patients with pelvic fracture and hemodynamic instability undergoing PEF with PPP had a very good overall mortality rate.5.13. However, it is difficult to explain this result only with the effect of the application of PEF; the protocolized multidisciplinary approach for pelvic fractures with shock, the application of the critical pathway and the active use of PPPs apparently acted in combination. The World Society of Emergency Surgery Pelvic Trauma Management Algorithm was used to define severe injury (WSES grade IV) independent of mechanical instability in cases of hemodynamic instability. After application, hemostatic procedures such as PPP, mechanical fixation, REBOA and PA should be performed in addition2. In our study, before PSM, PPP with PEF was most often performed in the PEF group (70.0%), while PA was most often performed in the PB group (54.7%). To overcome this tendency of combining hemostatic procedures and to confirm the pure effect of PEF application, the ratio of hemostatic procedures (PPP, PA, and laparotomy) applied together between the two groups was corrected by PSM.
REBOA has recently been increasingly used in patients with hemodynamic instability instead of urgent resuscitation thoracotomy19,20,21,22. In Korea, REBOA was first used in regional trauma centers in 2016. It is used as a bridge procedure before other hemostasis in patients with pelvic fracture accompanied by severe shock22. In our study, almost all patients underwent both PPP and PA procedures (88.9%). The 7-day and 30-day mortality rates in these patients were 22.2% and 44.4%, respectively, and PEF was performed in only three patients. These results are thought to be due to the fact that REBOA was used in clinically critical patients, and that PB, which can be easily applied, was preferred to PEF when it was necessary to move around the ward. ‘transaction. Although patients were not matched according to REBOA application by PSM, the application rate between the two groups was the same after PSM; therefore, it is judged that the effect of REBOA application did not affect the clinical outcome.
Our study has certain limitations. First, as this was a retrospective study, a selection bias was observed between the two groups. Second, the statistical power was low because the number of patients who underwent PEF was very small. Third, in the PEF group, only six patients received PEF without PB, and the remaining patients received PEF after PB was applied. It is therefore difficult to state strictly speaking that our study compared the hemostatic effects of PEF and PB in the acute phase. However, it is difficult to conduct a randomized controlled trial to compare the effects of PB and PEF on hemostasis in the acute phase. Moreover, since most of the patients included in our study were those receiving PB in the emergency room, we focused on confirming the effect of PEF after the acute phase. For this reason, patients who died within 24 hours of this study were excluded from the analysis. Nevertheless, this study is rare on the effectiveness of pelvic stabilization procedures performed with various hemostatic procedures in patients with hemodynamic instability and pelvic fractures. The advantages of this study are that PSM was performed to correct for various confounders and that patients from three institutions were included in the study. In the future, a larger prospective study is needed to confirm the results of our study.