Inflate and pack! Pelvic packing combined with REBOA deployment prevents hemorrhage related deaths in unstable pelvic fractures

Introduction: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is advocated for hemor-rhage control in pelvic fracture patients in shock. We evaluated REBOA in patients undergoing preperi-toneal pelvic packing (PPP) for pelvic fracture-related hemorrhage. Methods: Retrospective, single-institution study of unstable pelvic fractures (hemodynamic instability de-spite 2 units of red blood cells (RBCs) and fracture identified on x-ray). Management included the place-ment of a Zone III REBOA in the emergency department (ED) for systolic blood pressure < 80 mmHg. All PPP patients were included and analyzed for injury characteristics, transfusion requirements, outcomes and complications. Additionally, patients who received REBOA (REBOA + ) were compared to those that did not (REBOA-). Results: During the study period (January 2015 -January 2019), 652 pelvic fracture patients were ad-mitted; 78 consecutive patients underwent PPP. Median RBCs at PPP completion compared to 24 h post -packing were 11 versus 3 units ( p < 0.05). Median time to operation was 45 min. After PPP, 7 (9%) patients underwent angioembolization. Mortality was 14%. No mortalities were due to ongoing pelvic fracture hemorrhage or physiologic exhaustion; all were a withdrawal of life sustaining support, most commonly due to neurologic insults (TBI/fat emboli = 6, stroke/spinal cord injury = 3). REBOA + patients ( n = 31) had a significantly higher injury severity score (45 vs 38, p < 0.01) and higher heart rate (130 vs 118 beats per minute, p = 0.04) than REBOA-. The systolic blood pressure, base deficit, and number of RBCs trans-fused in the ED, and time spent in the ED were similar between groups. REBOA + had a higher median transfusion of RBCs at PPP completion (11 units vs 5 units, p < 0.01) but similar RBC transfusion in the 24 h after PPP (2 vs 1 units, p = 0.27). Mortality, pelvic infection, and ICU length of stay was not differ-ent between these cohorts. Conclusion: PPP with REBOA was utilized in more severely injured patients with greater physiologic de-rangements. Although REBOA patients required greater transfusion requirements, there were no deaths due to acute pelvic hemorrhage. This suggests the combination of REBOA with PPP provides life-saving hemorrhage control in otherwise devastating injuries. (c) 2022 Elsevier Ltd. All rights reserved.

Automated summary

This study evaluated the use of REBOA in patients undergoing PPP for pelvic fracture-related hemorrhage. It was found that although REBOA patients required greater transfusion requirements, there were no deaths due to acute pelvic hemorrhage.