Hemorrhage control in pelvic ring injuries: the role of PCCDs and other acute measures in Germany.

Abstract

Background/purpose: Partially unstable- and unstable pelvic ring injuries (PRI) can result in massive hemorrhage. Early detection and appropriate management are of utmost importance. This retrospective study, utilizing data from the German Pelvis Registry (GPR), evaluates bleeding complications (BC), the effect of pelvic circumferential compression devices (PCCDs) on transfusion requirements and outcomes, and the role of acute measures such as pelvic clamps, external fixators, pelvic tamponade and embolization.

Methods: Inclusion criteria: Adults (≥ 17 and ≤ 64 years) with partially unstable or unstable PRI (Tile type B and C), with (BC) or without bleeding complications (nBC) recorded in the GPR between July 2018 and February 2023. BC was defined as significant pelvis-related bleeding requiring blood transfusions and/or resulting in systolic blood pressure < 100 mmHg. Bleeding complications were identified by transfusions within 3 h of admission, the occurrence of bleeding during the hospital stay, or pre-hospital/ER systolic blood pressure < 100 mmHg.

Exclusion criteria: Patients ≤ 17 or ≥ 64 years, Tile type A-, acetabular-, combined pelvic-acetabular injuries, and inter-hospital transfers.

Results: Of 477 cases, 335 (70.2%) met inclusion criteria, with 133 (39.7%) having bleeding complications (BC) and 202 (60.3%) without (nBC). BC occurred more frequently in patients with Tile types B2-C3 injuries, who also had more concomitant injuries, higher ISS, NISS, and RISC II scores. These patients required more blood transfusions during admission and surgery, had longer ICU and hospital stays, and had worse outcomes with higher mortality rates (21.1%). Most patients with bleeding complications (BC) were stabilized with a PCCD (85%). Those with a PCCD had higher ISS but did not require more blood transfusions compared to patients without a PCCD. There were no differences in ICU or hospital stay duration, though outcomes were worse; however, mortality (23%) was not significantly higher. Pelvic tamponade was performed in 3.8% of cases, and embolization in 0.8%, both deemed 100% effective. Stabilization was done in 57.6% of cases, with pelvic clamps applied in 1.5% in the ER and 6.8% in the OR. External fixators were used in 48.9%, percutaneous osteosynthesis in 8.3%, open osteosynthesis in 2.3%, and combined measures in 12.8%. Effectiveness rates were 77.8% for pelvic clamps, 93.8% for external fixators, 100% for percutaneous osteosynthesis, and 66.7% for open osteosynthesis.

Conclusion: Bleeding complications occurred in 39.7%, mostly in Tile B2-C3 injuries, with 85% receiving PCCD stabilization. Mortality and transfusion rates were similar to those without PCCD, indicating that injury severity and surgical care quality were more impactful than PCCD use. External fixators were the most commonly used measure and demonstrated high effectiveness. While less frequent, pelvic tamponade and embolization also proved to be effective.