Counterpoint: Gold standard still shines

By Paul Tornetta III, MD

Blood loss in patients with pelvic injuries is quite complex. Most patients have multiple injuries, and estimates of the contribution of the pelvic injury to morbidity and mortality are wide ranging. Even in hemodynamically unstable patients, the pelvis is not the most likely source of mortality.

In the short presentation at the Orthopaedic Trauma Association annual meeting, this complex issue could not be fully addressed. I believe three important issues dilute the strength of the comparison and conclusions. One, within the control of the surgeon, is the application of mechanical stabilization. External stabilization was not applied at the same time, and skeletally stable ring injuries were included in the analysis. Patients in the pelvic packing group had more formal stabilization of their skeletal injuries sooner than patients in the pelvic angiography group. This factor alone has been demonstrated to decrease transfusion requirements and mortality. Arterial bleeding in virtually all studies is most commonly associated with tearing of the pelvic floor, such as anteroposterior compression injuries and lateral compression (LC3) injuries. The likelihood of significant pelvic bleeding in stable injuries is much lower.

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