Pelvic packing or endovascular interventions: which should be given priority in managing hemodynamically unstable pelvic fractures? A systematic review and a meta-analysis
Authors: Zhang Dong , Zhang Gong-zi , Peng Ye , Zhang Shu-wei , Li Meng , Jiang Yv , Zhang Li-hai 
Published: February 2022

Abstract
Background: Pelvic fractures in trauma patients can be associated with substantial massive hemorrhage. Mainly hemostasis interventions consist of pelvic packing (PP) and endovascular intervention (EI), such as angiography-embolization (AE) and resuscitative endovascular balloon occlusion of the aorta (REBOA). Whether PP or EI should be given priority for the management of hemodynamic unstable patients with pelvic fractures is still under debate. This meta-analysis aims to find out the evidence-based recommendations to fill the gap in literature. Materials and Methods: PubMed, CENTRAL, and EMBASE was searched for articles published from Jan 1st, 2000 to Jan 31st, 2022. Eligible studies, such as retrospective cohort study, propensity score matching studies, prospective cohort study, observational cohort study, quasi-randomized clinical trial evaluating PP and EI (AE or REBOA) managing patients with hemodynamically unstable pelvic fractures, were included. Mean Difference (MD), relative risk (RR), and 95% confidence intervals (CI) were calculated employing fixed- or random-effects models depending on the heterogeneity of included trials. This meta-analysis was performed to compare the effectiveness of the two methods in terms of mortality, unstable fracture pattens, Injury Severity Score (ISS), systolic blood pressure (SBP), lactate (LA), base deficiency (-BE), hemoglobin preoperatively, blood transfusion requirement, the time to and of operation, the complications.Results: 15 trials enrolling 1,136 patients were analyzed with the total mortality of 28.4% (323/1136). In our study, there was no effect of PP preference on the ISS (PP 36.4±10.4 vs. EI 34.5±12.7,), SBP (PP 81.1± 24.3 mmHg vs. EI 94.2±32.4 mmHg), LA (PP 4.66±2.72 mmol/L vs. 4.85±3.45 mmol/L), BE (PP 8.14±5.64 mmol/L vs. 6.66±5.68 mmol/L), unstable fracture pattens (RR=1.10, 95% CI [0.63, 1.92]). The application of PP was associated with lower preoperative hemoglobin level(PP 8.11±2.28 g/dl vs. EI 8.43±2.43 g/dl, p<0.05), more preoperative transfusion(MD=2.53, 95% CI [0.01, 5.06]), less postoperative transfusion within first 24 hours(MD=-1.09, 95% CI [-1.96, -0.22]), shorter waiting time to intervention(MD=-0.93, 95% CI [-1.54, -0.31]), shorter operation time of intervention(MD=-0.41, 95% CI [-0.52, -0.30]). PP has lower mortality rate due to uncontrolled hemorrhage in the acute phase (RR= 0.41, 95% CI [0.22, 0.79]). There is neither difference on mortality due to other complications (RR=1.60, 95% CI [0.79, 3.24]), nor total mortality (RR=0.92, 95%CI [0.49, 1.74]) (p>0.05).Conclusions: We firstly reached a conclusion that PP, a reliable hemostatic method, had advantages of reducing the amount of postoperative transfusion, shortening the time of waiting and operating and decreasing the mortality due to uncontrolled hemorrhage in the acute phase, without raising the odds of mortality due to complications. PP should be given a high priority in resuscitating the most pelvic fractures with hemodynamically unstable, especially in case of bleeding from veins and fracture sites, as well as inadequate EI. Sometimes AE should be regarded as a complementary treatment in case of the relative stable branch artery injury, the recurrent hypotension and ongoing hypotension after PP. REBOA is recommended in temporally transporting the hemorrhagic shock patients and stopping fatal bleeding from the main artery or multiple-sources.