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Predictors of laparotomy and mortality in polytrauma patients with pelvic fractures
Jameel Ali1, Khaled Al Ahmadi, Jack I Williams
1Department of Surgery, St. Michael's Hospital and the University of Toronto, Toronto, Ont.
Insights
In blunt trauma patients with pelvic fractures, laparotomy was associated with higher mortality. Predictors for needing surgery and death include low hemoglobin, hypotension, and severe injuries.
Area of Science:
- Trauma Surgery
- Emergency Medicine
- Surgical Critical Care
Background:
- Blunt trauma patients with pelvic fractures present a diagnostic challenge for determining the need for laparotomy.
- Timely surgical intervention is crucial, as delays can increase morbidity and mortality.
Purpose of the Study:
- To identify predictors of laparotomy and mortality in patients with severe blunt trauma and pelvic fractures.
- To analyze the impact of pelvic fractures on surgical decision-making and patient outcomes.
Main Methods:
- A retrospective analysis of 390 blunt polytrauma patients (Injury Severity Score [ISS] >/= 16) with pelvic fractures.
- Patients were divided into laparotomy (n=56) and nonlaparotomy (n=334) groups.
- Logistic regression analysis was used to assess predictors including age, hypotension, transfusion volumes, CT/FAST results, fracture severity, and ISS.
Main Results:
- Mortality was significantly higher in the laparotomy group (28.6%) compared to the nonlaparotomy group (12.9%).
- Predictors for laparotomy included low initial hemoglobin, positive FAST scans, and higher Abbreviated Injury Scores (AIS) for the abdomen and chest.
- Predictors for mortality included advanced age, higher ISS, higher AIS for head, chest, and abdomen, greater transfusion volumes, and initial hypotension.
Conclusions:
- Laparotomy in blunt trauma patients with pelvic fractures is associated with increased mortality.
- Key predictors for laparotomy and mortality in this cohort are similar to those observed in trauma patients without pelvic fractures.
- Early identification of these predictors can aid in timely and appropriate surgical management.
Abstract:
BACKGROUND: The decision to perform laparotomy in blunt trauma patients is often difficult owing to pelvic fractures; however, once the decision is made, delay or failure to perform laparotomy could affect morbidity and mortality. We sought to identify predictors of laparotomy and mortality in polytrauma patients with pelvic fractures. METHODS: We divided 390 blunt polytrauma patients (Injury Severity Score [ISS] >/= 16) with pelvic fractures into laparotomy (n = 56) and nonlaparotomy (n = 334) groups. We assessed the role of the following variables in predicting laparotomy and mortality: age, sex, hypotension, fluid and blood transfusions, positive abdominal computed tomography (CT) scans or focused assessment with sonography for trauma (FAST) examination, pelvic fracture severity and ISS. We analyzed the data using Student t and chi(2) tests, followed by logistic regression analysis. RESULTS: Mortality was higher in the laparotomy group than the nonlaparotomy group (28.6% v. 12.9%; overall mortality 15.1%). The laparotomy group had higher mean ISS (36.9 v. 24.9), higher mean abbreviated injury scores (AIS) for the abdomen (2.6 v. 0.9) and chest (3.4 v. 1.6), lower mean initial hemoglobin levels (105.2 v. 127.0 g/L), higher mean crystalloid (4249 v. 3436 mL) and blood transfusion volumes over 4 hours (12.1 v. 3.9 units), more frequent hypotension (44.6 v. 18.0%) and a higher percentage of positive CT scans (67.9% v. 28.4%) and FAST examination results (42.9% v. 3.3%) than the nonlaparotomy group. Age (mean 53.7 v. 41.5 yr); ISS (mean 39.0 v. 24.4); AIS for the head (mean 3.2 v. 1.7), abdomen (mean 1.6 v. 1.1), chest (mean 2.7 v. 1.8) and pelvis (mean 3.1 v. 2.6); crystalloid (mean 5157.3 v. 3266.4 mL) and blood transfusion volumes over 4 hours (mean 13.1 v. 3.7) and initial hypotension (61% v. 14.8%) were all greater among patients who died than those who survived. Mean initial hemoglobin levels were lower among patients who died than among those who survived (111.1 v. 126.2 g/L). Age, the AIS for the head, initial hypotension and low initial hemoglobin levels were highly predictive of mortality, whereas low initial hemoglobin levels, a positive FAST examination and high AIS for the abdomen and chest were all highly predictive of laparotomy. CONCLUSION: Among the polytrauma patients with pelvic fractures, 14.3% underwent laparotomy, and mortality was higher among these patients than among those who did not have the procedure. The predictors of laparotomy and mortality are similar to those anticipated in patients without pelvic fractures.