Evolution of a multidisciplinary clinical pathway for the management of unstable patients with pelvic fractures

Objective To determine whether the evolution of the authors' clinical pathway for the treatment of hemodynamically compromised patients with pelvic fractures wa s associated with improved patient outcome. Summary Background Data Hemodynamically compromised patients with pelvic fractures present a comple x challenge. The multidisciplinary trauma team must control hemorrhage, res tore hemodynamics, and rapidly identify and treat associated life-threateni ng injuries. The authors developed a clinical pathway consisting of five pr imary elements: immediate trauma attending surgeon's presence in the emerge ncy department, early simultaneous transfusion of blood and coagulation fac tors, prompt diagnosis and management of associated life-threatening injuri es, stabilization of the pelvic girdle, and timely insinuation of pelvic an giography and embolization. The addition of two orthopedic pelvic fracture specialists led to a revision of the pathway, emphasizing immediate emergen cy department presence of the orthopedic trauma attending to provide joint decision making with the trauma surgeon, closing the pelvic volume in the e mergency department, and using alternatives to traditional external fixatio n devices. Methods Using trauma registry and blood bank records, the authors identified pelvic fracture patients receiving blood transfusions in the emergency department . They analyzed patients treated before versus after the May 1998 revision of the clinical pathway. Results A higher proportion of patients in the late period had blood pressure less than 90 mmHg (52% vs. 35%). in the late period, diagnostic peritoneal lavag e was phased out in favor of torso ultrasound as a primary triage tool, and pelvic binding and C-clamp application largely replaced traditional extern al fixation devices. The overall death rate decreased from 31% in the early period to 15% in the later period, as did the rate of deaths from exsangui nation (9% to 1%), multiple organ failure (12% to 1%), and death within 24 hours (16% to 5%). Conclusions The evolution of a multidisciplinary clinical pathway, coordinating the res ources of a level 1 trauma center and directed by joint decision making bet ween trauma surgeons and orthopedic traumatologists, has resulted in improv ed patient survival. The primary benefits appear to be in reducing early de aths from exsanguination and late deaths from multiple organ failure.