Preperitoneal pelvic packing in severe pelvic ring injuries: a French military perspective

Abstract

Despite multidisciplinary approaches, the overall mortality for hemodynamically unstable pelvic traumas ranges from 40% to 90%. As haemorrhage triggers the Moore lethal triad of acidosis–hypothermia–coagulopathy, early hemostatic management during the Golden Hour is essential. Initially, angioembolisation (AE) was the standard. However, only arterial bleeding was affected while lowpressure venous plexuses and bone injuries were shown to be the main sources of bleeding. As a consequence, preperitoneal pelvic packing (PPP) was proposed as a firstline surgical intervention consisting of an early and exclusive preperitoneal approach combined with external fixation of the pelvis, as first described by trauma teams two decades ago, prior to a recommendation by The World Society of Emergency Surgery in 2017. From January 2010 to December 2020, we conducted a prospective study including all severely injured patients presenting with a pelvic fracture in our trauma centre. Review of charts from 287 subjects before data extraction and analysis revealed 20 cases that underwent a preperitoneal pelvic packing in accordance to our guidelines for unstable pelvic trauma. We found that the decrease of blood transfusion and increase of systolic blood pressure between preoperative and postoperative values were statistically significant (p=0.0231 and p<0.001, respectively). Eight patients (40%) had postoperative pelvic arterial blush and needed an AE. Early mortality by refractory haemorrhagic shock was 25% (5/20). The 30day overall mortality was 50% (10/20). The five secondary fatalities were due to neurological failure. Among survivors, PPPrelated infectious complications were limited (5%) and had favourable outcomes. Our surgical technique has improved significantly in the last decade with a systematic cystostomy placement, fast pelvic ring external fixation using a pelvic Cclamp and the use of resuscitative endovascular balloon occlusion of the aorta in the process. Our results demonstrated that PPP was a rare (7%) but relevant firstline treatment in pelvic injuries. Moskowitz et al recently confirmed that PPP was efficacious in controlling haemorrhage in patients with pelvic injuries, regardless of injury mechanism, penetrating or blunt. Penetrating pelvic injuries were less common in civilian settings than in conflict situations. Considering the limited medical resources of a deployed French forward surgical unit with unavailable interventional radiology equipment, selective embolisation was thus excluded from our management chart. As a consequence, PPP with external fixation is the only appropriate procedure for pelvic ring injuries in remote settings, as recommended by the French chair of military surgery. In the last decade, French military surgeons in trauma centres performed PPP for controlling lifethreatening haemorrhage in unstable civilians with mainly blunt trauma–related pelvic injuries. This prerequisite skill is required for optimal efficacy on the battlefield. This experience added to the lessons learnt during Operation PAMIR (Afghanistan), and Operations SERVAL (Mali) and BARKHANE (SaheloSaharan band), which led them to recommend PPP as a firstline procedure on haemodynamically unstable pelvic trauma regardless of the mechanism of injury.