Retroperitoneal packing or angioembolization for haemorrhage control of pelvic fractures--Quasi-randomized clinical trial of 56 haemodynamically unstable patients with Injury Severity Score ≥33.

AIMS: Both retroperitoneal pelvic packing and primary angioembolization are widely used to control haemorrhage related to pelvic fractures. It is still unknown which protocol is the safest. The primary aim of this study is to compare survival and complications of pelvic packing and angioembolization in massive haemorrhage related to pelvic fractures.

METHODS: Patients with haemodynamically unstable pelvic fractures were quasi-randomized to either pelvic packing (PACK) or angiography (ANGIO) using the time of admission as separator. Physiological markers of haemorrhage, time to intervention, procedure/surgical time, transfusion requirements, complications and early mortality were recorded and analyzed.

RESULTS: 29 patients were randomized to PACK and 27 patients to ANGIO. The Injury Severity Score (ISS) in the ANGIO group was lower than in the PACK group (43 ± 7 vs 48 ± 6) (p<0.01). The median time from admission to angiography for the ANGIO group was 102 min (range 76-214), and longer than 77 min (range 43-125) from admission to surgery for the PACK group (p<0.01). The procedure time for the ANGIO group was 84 min (range 62-105); while the surgical time was 60 min (range 41-92) for the PACK group (p<0.001). The ANGIO group received 6.4 units packed red blood cells (range 4-10) in the first 24h after angiography. The PACK group required 5.2 units (range 3-10) in the first 24h after leaving the operating theatre (p=0.124). 9 patients in the ANGIO group underwent pelvic packing for persistent bleeding. 6 patients in the PACK group required pelvic angiography after pelvic packing for ongoing hypotension following packing (p=0.353). 5 patients in the ANGIO group died (2 from exsanguination), while 4 in the PACK group died (none from exsanguination) (p=0.449). Complications occurred without differences in both groups.

CONCLUSIONS: Compared with angioembolization, pelvic packing has shorter time to intervention and surgical time. Thus pelvic packing is the more rapid treatment of severe pelvic trauma than pelvic angioembolization. It is suitable for patients with haemodynamic instability at centers where the interventional radiology staff is not in-house at all times.

REGISTRATION: ClinicalTrials.gov (NCT02535624) and ISRCTN registry (ISRCTN91713422).