Improved Survival with a Standardized Multidisciplinary 3-in-1 Pelvic Damage Control Protocol for Hemodynamically Unstable Pelvic Fracture

Introduction: Haemodynamically unstable pelvic fracture carries a high mortality rate of up to 60%. Being one of the trauma centers in Hong Kong, we have been developing and modifying a protocol for unstable pelvic fracture since 1996, with continuous improvement in survival rate. In the most updated 3-in-1 Pelvic Damage Control Protocol, three different sources of bleeding, including bony, venous, and arterial bleeding are tackled by external fixation, retroperitoneal pelvic packing and angio-embolization respectively. They are conducted in sequential order in the same operative session and theatre within the golden hour. Methods: All patients with haemodynamically unstable pelvic fractures managed in our center from 1st January 1996 to 31st December 2015 were retrospectively reviewed. The overall survival rates during different phases of protocol modification were compared. Findings: 210 patients were included. The overall survival had improved from 27% in phase I (1996-2001) with external fixation alone, to 57% in phase II (2002June 2008) with added angio-embolization, and to 71% in Phase III (July 2008 onwards) with the latest protocol. The survival in phase III has further improved to 81% in 2015. The expected survival of patients also improved as shown in the W-score according to trauma and injury severity score (TRISS). Conclusion: In hemodynamically unstable pelvic fractures, the use of standardized multidisciplinary protocol results in improved survival. The three different techniques in our protocol are complementary in achieving hemostasis in unstable pelvic fractures.