Prognostic factors in blunt trauma patients sustaining pelvic fractures: what is the role of severe retroperitoneal hemorrhage?

Abstract

In Brazil, more than three hundred people loose their lives each day due to external causes. A large number survive, but sustaining permanent sequelae. For each death, there are dozens of patients that need hospital admission. Trauma, which involves traffic accidents, falls and interpersonal violence, results in a tremendous socioeconomic impact all around the world. Pelvic fractures are present in 2% of blunt trauma victims. The majority of them are mechanically stable and do not represent an immediate threat for life. However, to fracture the pelvic bones, there is a big energy exchange. As a result, 90% of the trauma patients sustaining pelvic fractures have associated organ injuries in other body segments. Concomitant injuries are believed to be the main prognostic factor in these patients. Severe retroperitoneal hemorrhage (SRH) does not happen frequently, but, when present, is associated to extremely high mortality. SRH treatment is based in a "hemostatic" protocol of volume resuscitation as well as in methods to achieve hemostasis, including early external fixation, angiographic embolization and preperitoneal packing. The sooner these goals are accomplished, the higher it is the survival rate. Early identification of the patient under risk of SRH allows the prompt introduction of hemostatic techniques, but this is not always easy. Clinical, laboratorial and radiologic parameters have been described for the early identification of SRH, but they are not accurated enough. The association of pelvic fracture stability and SRH is also not clear in the literature. Our hypothesis is that SRH, when present, is the most important prognostic factor in patients sustaining pelvic fractures and its presence may be suspected on the basis of pelvic stability. The objectives of this study are: a) to assess the prognostic factors of blunt trauma patients sustaining pelvic fractures with special attention to the role of SRH, b) to identify the predictors of SRH in these patients, c) to assess the correlation of SRH and pelvic stability, and, d) to analyze the treatment protocols used to control SRH and their results. We will carry out a retrospective analysis of charts and trauma protocols, including all adult blunt trauma patients sustaining pelvic fractures admitted from 2008 to 2010. The severity will be stratified by the calculation of Glasgow coma scale, Revised Trauma Score, Abbreviated Injury Scale, Injury Severity Score and TRISS. Pelvic fractures will be categorized using Key and Conwell's and Tile's classifications. Patients will be separated in two groups: A (not survival) and B (survival). Variables will be compared between these groups in order to identify the prognostic factors. Odds ratio will be calculated to estimate the impact of each variable on the prognosis. In a second analysis, we will compare the variables between patients with and without SRH in order to find the predictors for it. We will also search for a correlation between SRH and pelvic fracture classification. The statistical analysis will be carried out together with a professional in this area. The results of this study will give us the predictors of SRH, allowing prompt patient identification and, consequently, the possibility of earlier achievement of hemostatic measures.