Combined computed tomography and C-arm resuscitation room system (CTCARM) is associated with decreased time to definitive hemostasis and reduces preperitoneal pelvic packing maneuvers in severe pelvic trauma

Objectives Severe pelvic fracture concomitant with massive bleeding is potentially lethal, and intervention for hemorrhage control still depends on institutional supplies. With the recent installation of a CT and C-arm combined resuscitation room system (CTCARM) for treatment of trauma patients in our institution, the strategic process and options for hemorrhage control after pelvic fracture have changed. We retrospectively reviewed the procedures we performed and their outcomes. Methods The CTCARM was installed in our trauma resuscitation room in April 2020. Patients who were diagnosed as having pelvic fracture and underwent interventional radiology for hemorrhage control within 2.5 hours after arrival were compared before and after CTCARM installation. We reviewed the time process for hemorrhage control, treatment options performed, blood products used and their outcomes. Results Included in this study were 56 patients treated between 2016 and 2022, of whom 36 patients were treated before (original group) and 20 patients after CTCARM installation (CTCARM group). Patient characteristics and vital signs at admission were not statistically different. Preperitoneal pelvic packing was performed significantly more frequently in the original group (p<0.01), whereas resuscitative endovascular balloon occlusion of the aorta use was much more frequent in the CTCARM group (p=0.02). Although the times from admission to first angiography (p=0.014) and to complete hemostasis (p=0.02) were significantly shorter in the CTCARM group, mortality was not statistically different. Four preventable trauma deaths occurred in the original group, but there were none in the CTCARM group. Six unexpected survivors were observed in the original group and four in the CTCARM group. Conclusions Although the CTCARM had no direct effects on patient mortality for now, it has allowed us to accelerate the treatment time process, shorten preperitoneal pelvic packing procedural time, and potentially avoid subsequent preventable trauma deaths. Level of evidence Level IV.

[1]  A. Kirkpatrick,et al.  Simultaneous versus rapid serial interventions in a hybrid operating suite for severely injured patients: a prospective evaluation of differences in RAPTOR techniques and outcomes , 2022, Canadian journal of surgery. Journal canadien de chirurgie.

[2]  C. Mauffrey,et al.  Inflate and pack! Pelvic packing combined with REBOA deployment prevents hemorrhage related deaths in unstable pelvic fractures. , 2022, Injury.

[3]  Hiroaki Watanabe,et al.  Hybrid emergency rooms reduce the requirement of blood transfusion in patients with severe trauma , 2021, World Journal of Emergency Surgery.

[4]  T. Kitamura,et al.  Cost-effectiveness of a hybrid emergency room system for severe trauma: a health technology assessment from the perspective of the third-party payer in Japan , 2020, World Journal of Emergency Surgery.

[5]  E. Moore,et al.  Resuscitative endovascular balloon occlusion of the aorta in pelvic ring fractures: The Denver Health protocol. , 2020, Injury.

[6]  S. Inui,et al.  Hybrid Emergency Room System (HERS) improves timeliness of angioembolization for pelvic fracture. , 2019, The journal of trauma and acute care surgery.

[7]  P. Rhee,et al.  Nationwide Analysis of Resuscitative Endovascular Balloon Occlusion of the Aorta in Civilian Trauma. , 2019, JAMA surgery.

[8]  K. Inaba,et al.  Effect of door-to-angioembolization time on mortality in pelvic fracture: Every hour of delay counts , 2018, The journal of trauma and acute care surgery.

[9]  T. Rasmussen,et al.  Military-civilian partnership in device innovation: development, commercialization and application of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA). , 2017, The journal of trauma and acute care surgery.

[10]  Daiki Wada,et al.  The Survival Benefit of a Novel Trauma Workflow that Includes Immediate Whole-body Computed Tomography, Surgery, and Interventional Radiology, All in One Trauma Resuscitation Room , 2017, Annals of surgery.

[11]  Paul D. White,et al.  How to compare the means of two samples that include paired observations and independent observations: A companion to Derrick, Russ, Toher and White (2017) , 2017 .

[12]  E. Moore,et al.  Preperitoneal pelvic packing reduces mortality in patients with life-threatening hemorrhage due to unstable pelvic fractures , 2017, The journal of trauma and acute care surgery.

[13]  A. Peitzman,et al.  Pelvic trauma: WSES classification and guidelines , 2017, World Journal of Emergency Surgery.

[14]  R. Karmy-Jones,et al.  Western Trauma Association Critical Decisions in Trauma: Management of pelvic fracture with hemodynamic instability-2016 updates. , 2016, The journal of trauma and acute care surgery.

[15]  J. Minei,et al.  Current management of hemorrhage from severe pelvic fractures: Results of an American Association for the Surgery of Trauma multi-institutional trial , 2016, The journal of trauma and acute care surgery.

[16]  J. Minei,et al.  Current management of hemorrhage from severe pelvic fractures: Results of an American Association for the Surgery of Trauma multi-institutional trial , 2016, The journal of trauma and acute care surgery.

[17]  R. Vaidya,et al.  Patients with pelvic fractures from blunt trauma. What is the cause of mortality and when? , 2016, American journal of surgery.

[18]  H. Yoshihara,et al.  Demographic epidemiology of unstable pelvic fracture in the United States from 2000 to 2009: Trends and in-hospital mortality , 2014, The journal of trauma and acute care surgery.

[19]  P. Giannoudis,et al.  Pelvic fractures presenting with haemodynamic instability: treatment options and outcomes. , 2013, The surgeon : journal of the Royal Colleges of Surgeons of Edinburgh and Ireland.

[20]  P. Whiting,et al.  Systematic review and meta-analysis of the current evidence on the duration of protection by bacillus Calmette-Guérin vaccination against tuberculosis. , 2013, Health technology assessment.

[21]  C. Guerriero,et al.  The CRASH-2 trial: a randomised controlled trial and economic evaluation of the effects of tranexamic acid on death, vascular occlusive events and transfusion requirement in bleeding trauma patients. , 2013, Health technology assessment.

[22]  T. Rasmussen,et al.  Noncompressible torso hemorrhage: a review with contemporary definitions and management strategies. , 2012, The Surgical clinics of North America.

[23]  T. Scalea,et al.  Trauma mortality in mature trauma systems: are we doing better? An analysis of trauma mortality patterns, 1997-2008. , 2010, The Journal of trauma.

[24]  R. McIntyre,et al.  Western trauma association critical decisions in trauma: management of pelvic fracture with hemodynamic instability. , 2008, The Journal of trauma.

[25]  Lloyd G. Greenwald,et al.  Time to laparotomy for intra-abdominal bleeding from trauma does affect survival for delays up to 90 minutes. , 2002, The Journal of trauma.

[26]  G. Velmahos,et al.  "Insignificant" mechanism of injury: not to be taken lightly. , 2001, Journal of the American College of Surgeons.

[27]  T A Gennarelli,et al.  A revision of the Trauma Score. , 1989, The Journal of trauma.

[28]  R. Brumback,et al.  Pelvic fractures: value of plain radiography in early assessment and management. , 1986, Radiology.

[29]  W. Copes,et al.  Evaluating trauma care: the TRISS method. Trauma Score and the Injury Severity Score. , 1987, The Journal of trauma.