C. Chu2, L. Tennakoon1, D. Spain1, K. Staudenmayer1 1Stanford University,Surgery,Palo Alto, CA, USA 2University Of South Carolina School Of Medicine,Columbia, SC, USA
Introduction: Bleeding from pelvic fractures can be life-threatening. Treatment for bleeding pelvic fractures involves noninvasive means (pelvic binders) and invasive procedures such as angioembolization (AE) and external fixation (EXFIX). It is not known how frequently these modalities are used in U.S. trauma centers or whether there have been trends over time. We hypothesized that there would be an increase in the use of AE and a decrease in the use of EXFIX over time. We also sought to determine if the procedures were associated with a reduction in mortality.
Methods: We used the National Trauma Databank (NTDB) from 2008-2010. Patients were included in the study if they had the International Classification of Diseases, 9th edition and Clinical Modification (ICD-9-CM) codes for pelvic fractures. Patients were excluded if they were <18 years, had an isolated acetabular fracture, were not admitted to the hospital, or had an ISS<15. Only centers that had demonstrated an ability to perform AE or EXFIX were included in the analysis. The primary outcomes were whether the patient had an AE or EXFIX within the first 24 hours after admission. The secondary outcome was mortality. Univariate analyses and multi-level logistic regression (to control for center effects) were used.
Results: A total of 22,568 met inclusion and exclusion criteria. Patients were predominantly male (59.6%), white (70.3%), and between the ages of 18 and 44 (50.7%). Overall, AE and EXFIX were performed in 746 (3.3%) and 663 (2.9%) of patients, respectively. Patients who received AE and EXFIX were different across all measures in unadjusted analyses, but after adjusting for known confounders, only age, injury severity, physiologic instability, and diagnosis of shock were associated with receiving a procedure. Over the study period, there was an increase in the use of AE (2.5% in 2007 to 3.7% in 2010, p<0.001), which remained significant in adjusted analysis (OR per year 1.15, p=0.008). There was no significant trend for EXFIX. AE and EXFIX were associated with a higher mortality in unadjusted analyses compared to those who did not receive a procedure (11.0% for no procedure vs. 20.5% and 13.4% for AE and EXFIX, respectively; p<0.001). In adjusted analyses, AE remained associated with higher mortality (OR 1.63, p<0.001), whereas EXFIX was associated with a slightly lower risk (OR 0.95, p<0.01).
Conclusion: The use of AE in severely injured pelvic fracture patients is increasing. However, this procedure is associated with a higher mortality. It is possible that AE is used more often in patients at high risk of death, but that its use does not reduce this risk. We should carefully examine the use of this expensive resource in future studies.
