Exsanguination is the second most common cause
of death in patients who suffer severe trauma. The management of
haemodynamically unstable high-energy pelvic injuries remains controversial,
as there are no universally accepted guidelines to direct surgeons
on the ideal use of
We describe the impact of a targeted performance
improvement programme and the associated performance improvement
interventions, on mortality rates, error rates and process of care
for haemodynamically unstable patients with pelvic fractures. Clinical
care and performance improvement data for 185 adult patients with exsanguinating
pelvic trauma presenting to a United Kingdom Major Trauma Centre
between January 2007 and January 2011 were analysed with univariate
and multivariate regression and compared with National data. In
total 62 patients (34%) died from their injuries and opportunities
for improved care were identified in one third of deaths. Three major interventions were introduced during the study period
in response to the findings. These were a massive haemorrhage protocol,
a decision-making algorithm and employment of specialist pelvic
orthopaedic surgeons. Interventions which improved performance were
associated with an annual reduction in mortality (odds ratio 0.64
(95% confidence interval (CI) 0.44 to 0.93), p = 0.02), a reduction
in error rates (p = 0.024) and significant improvements in the targeted
processes of care. Exsanguinating patients with pelvic trauma are
complex to manage and are associated with high mortality rates;
implementation of a targeted performance improvement programme achieved
sustained improvements in mortality, error rates and trauma care
in this group of severely injured patients. Cite this article:
The open blast fracture of the pelvis is considered
to be the most severe injury within the spectrum of battlefield trauma.
We report our experience of 29 consecutive patients who had sustained
this injury in Afghanistan between 2008 and 2010. Their median new
injury severity score (NISS) was 41 (8 to 75), and mean blood requirement
in the first 24 hours was 60.3 units (0 to 224). In addition to
their orthopaedic injury, six had an associated vascular injury, seven
had a bowel injury, 11 had a genital injury and seven had a bladder
injury. In all, eight fractures were managed definitively with external
fixation and seven required internal fixation. Of those patients
who underwent internal fixation, four required removal of metalwork
for infection. Faecal diversion was performed in nine cases. The
median length of hospital stay following emergency repatriation
to the United Kingdom was 70.5 days (5 to 357) and the mean total
operating time was 29.6 hours (5 to 187). At a mean follow-up of
20.3 months (13.2 to 29.9), 24 patients (82.8%) were able to walk
and 26 (89.7%) had clinical and radiological evidence of stability
of the pelvic ring. As a result of the increase in terrorism, injuries that were
previously confined exclusively to warfare can now occur anywhere,
with civilian surgeons who are involved in trauma care potentially
required to manage similar injuries. Our study demonstrates that
the management of this injury pattern demands huge resources and significant
multidisciplinary input. Given the nature of the soft-tissue injury,
we would advocate external fixation as the preferred management
of these fractures. With the advent of emerging wound and faecal
management techniques, we do not believe that faecal diversion is
necessary in all cases.
