Published 12/1/2007
Paul Tornetta III, MD

Counterpoint: Gold standard still shines

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.

The second major confounder of multiple injury is not within the surgeon’s control and may be the most important factor. Half of both groups required laparotomy to control abdominal bleeding. In this group, it is virtually impossible to dissect out the effect of the pelvic venous or arterial bleeding from the often more important abdominal bleeding. The authors did not do a separate analysis of the 10 patients in each group who did not have abdominal bleeding, which would have isolated the protocols to their effectiveness in controlling pelvic bleeding.

Finally, the authors committed to a protocol change to evaluate the usefulness of a specific step in that protocol, rather than doing a prospective comparison. This is a very reasonable decision to gain experience in a new technique, especially when randomization is difficult. However, it introduces a study bias in terms of the other potential advances in management that occur during the sequence of the protocols, favoring the later protocol.

In conclusion, the authors give us food for thought in the management of patients with pelvic injuries and hemodynamic instability. Each institution has different resources, leading to many variations on the identification and treatment of bleeding. All have a step to rule out abdominal or chest bleeding followed by some method of identifying and treating pelvic bleeding. Mechanical stabilization is the fastest and probably the most effective initial method. Continued bleeding after other sources are ruled out may be pelvic, leading to angiography, or in these authors’ hands, packing. Surgeons should be aware of this method of treatment and be prepared to institute it. While these protocols are being worked out, it would seem that this method would be most effective in patients already going to the operating room for abdominal bleeding, and least effective for patients with stable ring injuries or those in whom external skeletal stabilization can be effected.

Paul Tornetta III, MD, is second past president of the Orthopaedic Trauma Association. He can be reached at ptornetta@gmail.com