Improvised explosive device related pelvi-perineal trauma: anatomic injuries and surgical management

Pelviperineal injuries, primarily due to blast mechanisms, are becoming the signature injury pattern on operations in Afghanistan. This study set out to define these injuries and to refine our team-based surgical resuscitation strategies to provide a resuscitation-debridement-diversion didactic on our Military Operational Surgical Training predeployment course to optimize our field care of these injuries.

A retrospective study of the UK Joint Theatre Trauma Registry was performed looking at consecutive data from January 2003 to December 2010, identifying patients with perineal injuries. Data abstracted included patient demographics, mechanism of injury, Injury Severity Score (ISS), management, and outcomes.

Of 2204 UK military trauma patients, 118 (5.4%) had a recorded perineal injury and 56 (47%) died . Pelvic fractures were identified in 63 (53%) of 118 patients of which only 17 (27%) of 63 survived. Mortality rates were significantly different between the combined perineal and pelvic fracture group compared with the pelvic fractures or perineal injuries alone (107 [41%] of 261 and 11 [18%] of 56, respectively, p < 0.001). The median (interquartile range) ISS for all patients was 38 (29-57). The ISS for those with pelvic fractures were significantly higher than those with perineal injuries alone, 50 (38-71) versus 30 (15-35) (p < 0.001).

Improvised explosive device-related perineal injuries with pelvic fractures had the highest rate of mortality compared with perineal injuries alone. Early aggressive resuscitation (activation of the massive hemorrhage protocol) is essential to survival in this cohort. Our recommendations are uncompromising initial debridement, immediate fecal diversion, and early enteral feeding.