Trauma center establishment has been associated with reduced mortality in several studies, and it is mainly due to increased annual trauma volume, trauma-dedicated resources, and performance improvement program (PIP).(14-16) Before the establishment of a regional trauma center, approximately 250 severely injured patients (ISS > 15) were admitted to our hospital annually. However, after the trauma center opened in 2014, more than 500 severely injured patients were managed annually. The volume of trauma patients and the rate of direct transportation increase year by year.(17) Furthermore, the presence of human resources (trauma-dedicated surgeons, nurses, and a trauma program manager) and a PIP could influence resuscitation practice, time to intervention, and hemorrhage control modalities.(8)
Bleeding pelvic fractures are uncommon but are associated with significant mortality due to hemorrhagic shock. Before the establishment of a trauma center, hemodynamically unstable patients with pelvic fractures were managed mainly by an emergency physician at the initial resuscitation phase. After diagnosis of bleeding pelvic fracture was confirmed using imaging studies, general and orthopedic surgical services were contacted. In many cases, however, there were conflicts between departments when deciding on further treatment interventions. In one study, the application of a multidisciplinary clinical pathway with joint decision making between trauma and orthopedic surgeons resulted in improved outcomes in patients with pelvic fractures.(14) Therefore, rapid hemostasis with appropriate treatment following a multidisciplinary algorithm involving hemostatic interventions is crucial. We implemented this pelvic fracture management protocol in 2014 shortly after the trauma center establishment.
The ATLS guidelines recommend that a pelvic binder (PB) should be used for the external compression of pelvic cavity when there are signs of a pelvic ring fracture.(18) Studies have also demonstrated that commercial PBs are more effective in controlling pelvic bleeding than a conventional “bed-sheet” compression.(19) In Korea, prehospital PB application is very rare, and our hospital used the conventional “bed-sheet” compression in a few cases until 2014. After the official approval of commercial PBs by the Ministry of Food and Drug Safety in 2013, we used these in the management algorithm for suspected pelvic fracture patients in 2014. External pelvic fixations are rarely used in this study because the orthopedic surgeons in our hospital prefer PB application over these. In a study comparing PB and external fixation in patients with pelvic fractures, those who underwent external fixation needed higher amounts of transfusion.(20) Thus, until now, we mainly utilize PB for external compression purposes in the algorithm for pelvic injury management.
AE has been used since the 1970s for hemorrhage control in patients with pelvic bone fractures. It has been proved to be effective and remains the most widely used hemostatic intervention. However, AE may not be an effective intervention to stop bleeding due to pelvic fracture, because approximately 80% of the bleeding is associated with bone or venous bleeding.(9) Venous bleeding cannot be managed by AE, so AE in hemodynamically unstable pelvic injuries results in poor patient outcomes with mortality rates greater than 40%.(9) In addition, the availability of AE varies by institution. AE requires specific facilities, equipment, and human resources, so some centers are unable to perform this technique. Even in centers that can perform AE, it might not be available immediately, specifically during nights or weekends, which can further increase the mortality rate.(11, 21) Several studies have reported that the time from ER arrival to AE takes at least 2 hours up to more than 5 hours.(22, 23) In our study, the time to AE only decreased from 269 minutes in period 1 to 181 minutes in period 2, but this waiting time is still too long for hemodynamically unstable patients.
PPP has been proposed as an alternative intervention to AE. PPP is a simple procedure, so it can be performed in the resuscitation room or operation room by a trauma surgeon within an hour of patient arrival. The time to PPP was 44–55 minutes in recent studies, and this is significantly shorter compared to AE.(5, 24) PPP could significantly decrease the time to intervention in our study also. Studies demonstrated that an implementation of clinical guidelines that include PPP for hemodynamically unstable patients led to a significant decrease in transfused blood products and in mortality.(5, 24) More recent studies have revealed that PPP is a safe and rapid intervention associated with significantly reduced mortality in hemodynamically unstable patients with pelvic fractures compared to patients managed by conventional intervention without PPP.(25, 26) Moreover, unstable pelvic fractures are often associated with intra-abdominal injuries. One study reported that a total of 34.3% of severe pelvic fracture patients had associated intra-abdominal injuries including bladder and bowel injuries.(27) In such cases, AE might delay abdominal exploration, or a laparotomy might delay hemostasis using AE. However, a midline laparotomy and PPP can be performed simultaneously with separate incisions, so it achieves hemorrhage and contamination control rapidly without concerns of cross-contamination in the retroperitoneal space from bowel injuries.(12) In this study, concomitant laparotomy increased in period 2 after inclusion of PPP in the management algorithm. In addition, laparotomy for the decompression of abdominal pressure in patients with suspected abdominal compartment syndrome was only performed in period 2. The World Society of Emergency Surgery (WSES) guidelines for pelvic fracture recommend that PPP should always be considered in hospitals with no AE services and that PPP is an effective surgical measure for early hemorrhage control in hypotensive patients with bleeding pelvic disruptions.(18) Therefore, PPP is recommended as a first intervention for hemodynamically unstable patients (WSES grade IV) in the pelvic trauma management algorithm.(18)
REBOA has recently been reported as a viable alternative to performing an aortic cross clamp (ACC) through emergent thoracotomy.(28, 29) REBOA can be a “bridge” procedure in torso hemorrhages followed by an operation or AE. REBOA can be placed in Zone 1 (supra-celiac) or Zone 3 (infra-renal). Zone 3 REBOA can be optimal, especially for pelvic bleeding, because it can raise blood pressure and reduce arterial bleeding associated with pelvic injury while preventing ischemic insult on visceral organs on top of having a long occlusion time.(30) Although there is little evidence of mortality benefit in previous articles, the WSES guidelines suggest REBOA as an alternative to ACC and that Zone 3 REBOA should be considered to be a bridge to definitive treatment in hemodynamically unstable patients.(18) Our center has implemented REBOA in the pelvic injury management algorithm since 2016, and REBOA was performed in 10 patients; 80% of these were deployed in Zone 3 with 3 patients surviving and getting discharged.
The purpose of this study was to evaluate changes in outcomes after trauma center establishment and pelvic injury management protocol including PPP and REBOA. This study demonstrated significantly decreased time to interventions and mortality due to acute hemorrhage. We believe that these changes are due to (1) an attending trauma surgeon being a leader of multidisciplinary team; (2) management protocols including PB, PPP, and REBOA; (3) an increase in concomitant laparotomy; and (4) changes in blood product usage. We think these changes might not be achieved without the establishment of a trauma center with financial support in developing countries such as Korea.
This study has several limitations. The main limitations are its retrospective study design and small sample size due to the study being only from a single institute. These might have introduced bias. In addition, we investigated in-hospital mortality only, and these might have influenced our results. Finally, we could not evaluate the adherence of individual surgeons to the management algorithm. In the future, a well-designed multi-center prospective study with a larger sample size should be designed to analyze the relationship between trauma center establishment and patient outcomes.