We did not find a statistically significant decrease in mortality with PCCD (19.5% vs 29.3%) use for pelvic ring disruption using a matched cohort model to control for confounding variables; however, our post-hoc power analysis suggests we are underpowered. This is largely because of the low sample size of patients receiving binders (n=130). Overall in-hospital mortality for PRD was 11%. When a patient presented with PRD and shock, mortality was 29.7%.
We also found that PCCDs were not extensively used in our Level I trauma center. A total of 396 patients with pelvic ring disruption and hemorrhagic shock over a 5-year period did not have PCCDs, despite recommendations from the ACS for use of PCCDs in all patients with suspected PRD and hemodynamic instability (6). It is difficult to determine the exact reasons for the limited application in this period as decisions were made individually by attending emergency department physicians and trauma surgeons, and there was no defined protocol in place for PCCD application. When PCCDs were used, median time from injury to application was more than 2 hours.
The complex treatment of the polytraumatized patient can lead to delayed assessment of the pelvis (2), with life-threatening results. Hemorrhage associated with blunt pelvic trauma was identified as the cause of 86% of preventable deaths due to delayed identification of the pelvis as the bleeding source (2). Sathy et al. (1) found pelvic fracture to be associated with mortality in a review of more than 63,000 trauma patients. These studies and our data support the importance of early diagnosis and treatment of blunt pelvic injury in the polytraumatized patient, especially considering the elevated mortality rate (29.7%) associated with PRD and hemodynamic instability in our cohort. We advocate routine AP pelvis views early in the evaluation of all blunt trauma patients in accordance with ACS recommendations (6) to promote early identification of this life-threatening injury.
Recent literature has suggested prehospital use of PCCD (13), and the delay in application warrants further investigation regarding expedited application. In addition to our center’s limited use of PCCDs, PCCD application was often delayed. Despite relatively rapid application, when chosen, upon hospital arrival (0.52 hours), PRD patients are at risk of developing irreversible shock when the time of application post-injury (2.07 hours) is considered. Prehospital PCCD should be considered for potential incorporation into future protocols.
PCCD patients in our cohort had higher injury severity scores and lower systolic blood pressures on arrival, indicating a different physiology than patients that did not receive PCCD. The PS model was used to account for this discrepancy between the experimental and control populations. Despite controlling for confounding and selection bias, a statistical significance between PCCD use and mortality reduction was not established.
The study may have been underpowered owing to the limited number of PCCDs. Despite a greater than 30% reduction in odds of mortality among the matched cohort, statistical significance was not achieved. One plausible consideration, in addition to the small sample size, is the high incidence of accompanying traumatic brain injury (TBI), the leading cause of death in PRD patients (8). Given this consideration, other outcome variables, including transfusion requirements, may be studied in future investigations.
The retrospective nature of this study was a significant limitation owing to missing data on several important physiological parameters and variability of treatment based upon the attending emergency department provider. Base value information was absent from 61.3% of all patients, complicating the definition of hemodynamic instability. Time of application was not recorded for a large portion of PCCD patients and precluded an opportunity to correlate any potential benefit associated with early application. Consideration will be made to adapt future protocols with emphasis on inclusion of these data sets.
Although no statistically significant mortality reduction was associated with PCCD use, there were also no significant complications associated with PCCD use. Specifically, there were no documented cases of soft tissue breakdown. While an associated survival benefit remains undetermined, the relative ease of application and limited complications establish use of PCCD as a potential emergent treatment of PRD. Opportunities for earlier application await further study.
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