No one should die from Bleeding Pelvic Fractures ever again

The Abdominal Aortic and Junctional Tourniquet (AAJT) is indicated for pelvic bleeding. It is a part of the current 510(k) submitted and approved by the FDA in 2013. This distinguishes the AAJT from other junctional tourniquets. It is the only junctional tourniquet that is a true truncal tourniquet capable of safely stopping all blood flow to the pelvis.

Junctional hemorrhage is a priority problem in military medicine. Many of the wounds we contend with are high-energy wounds from explosive and ballistic mechanisms. These injuries often destroy tissue in the legs and pelvis. While this injury pattern unfortunately exists in the civilian world as well, it occurs at a much lower incidence. Truncal tourniquets can play a role though in reducing mortality in civilian trauma. Bleeding Pelvic Fracture (BPF) is one area in which truncal tourniquets can make a difference.

Blunt trauma accounts for a large number of difficult to treat patients, especially in the pre-hospital phase of care. Pelvic fractures occur at an incidence of 37 per 100,000 people.1 In the USA alone more than 115,000 pelvic fractures occur each year.

We train our paramedics how to identify patients who may have pelvic fractures. We have no technology for them to distinguish which of those patients have significant bleeding due to those pelvic fractures. The first sign unfortunately occurs when the patient bleeds enough internally to become hypotensive. At that point their mortality is significantly increased. O’Neill et al found that in the setting of pelvic fracture, “the presence of hypotension (systolic blood pressure ≤ 90) at the time of arrival to the trauma center was found to significantly increase mortality “2 Pelvic hemorrhage has been implicated as the cause of death in 50% of patients who die following pelvic fractures.3

Bleeding pelvic fractures (BPF) carry mortality as high as 60%, yet controversy remains over optimal initial management.4 BPF is a real problem and simply binding the pelvis does not solve it. Whether we use a sheet or a commercial pelvic binder the data does not support the idea that these interventions reliably prevent shock. This is what we teach our pre-hospital providers to do but is there something more we can do to impact survivability? Preventing shock is the primary way to impact mortality. What about turning off the blood flow to the pelvis until the patient arrives at definitive surgical care? We can do it externally, with the AAJT, and transport the patient to definitive surgical care while preventing shock.

Lets look at the problem of BPF in the context of the high energy traumatic events that cause pelvic fractures. Hemodynamic instability and multiple organ failure (MOF) as direct consequences of pelvic hemorrhage have been identified as the primary cause of death following pelvic fracture.5 Smith and colleagues reported overall mortality rate of 21% in their review of 187 hemodynamically unstable patients with pelvic fractures.5 What if we knew of an intervention that could change a probable death to a possibly preventable or preventable death in 21% of any patient group? Among patients that did not survive their injuries, autopsy findings demonstrated that the principle cause of death in 74% was exsanguination, while MSOF was the primary cause of death in 18%.5

Preventing shock has been the primary focus at pre-hospital intervention and combat casualty care. It is our primary ability to affect morbidity and mortality both in military and civilian trauma. It is true whether the injuries are due to blunt or penetrating trauma. This is done through timely and correct interventions.

Advance techniques, devices and protocols continue to flow out of the military experience into our civilian communities. The use of tourniquets, massive transfusion protocols, hemostatic agents and intraosseous access devices are examples of this. There is an FDA approved device indicated for pelvic bleeding, the AAJT. Why not use it to stop a problem that continues to cause many to die? No one should die from Bleeding Pelvic Fractures ever again!

References:

1. Medscape Reference: Pelvic Fractures. G Russell, W Jaffe
2. J Trauma. 2003 Mar;54(3):437-43. External fixation or arteriogram in bleeding pelvic fracture: initial therapy guided by markers of arterial hemorrhage. Miller PR, Moore PS, Mansell E, Meredith JW, Chang MC
3. Ann Surg. 1991 Jun;213(6):532-8; discussion 538-9. Pelvic fracture from major blunt trauma. Outcome is determined by associated injuries. Poole GV, Ward EF, Muakkassa FF, Hsu HS, Griswold JA, Rhodes RS.
4. Clinical Orthopaedics & Related Research: August 1996 - Volume 329 - Issue - pp 60-67 Techniques and Outcome in Pelvic Fractures Angiographic Findings in Pelvic Fractures O'Neill, Patricia A. MD; Riina, Joseph MD; Sclafani, Salvatore MD; Tornetta, Paul III MD
5. Bulletin of the NYU Hospital 2010;68(4):281-91 Management of Pelvic Fractures. R McCormack, E Strauss, B Alwattar, N Tejwani