Predicting the need for abdominal hemorrhage control in major pelvic fracture patients: the importance of quantifying the amount of free fluid.

BACKGROUND: In our institution, the computed tomographic (CT) scan has largely replaced the ultrasound for the rapid detection of intraperitoneal free fluid (FF) and abdominal injuries in severely injured patients.We hypothesized that in major pelvic fracture patients, quantifying the size of FF on CT improves the predictive value for the need for abdominal hemorrhage control (AHC).

METHODS: The CT scans of major pelvic fracture (pelvic ring disruption) patients (January 1, 2004, to June 31, 2012) were reviewed for the presence of FF (small, moderate, or large amount) and abdominal injuries. AHC was defined as requiring a surgical intervention for active abdominal bleeding or angiographic embolization for an abdominal arterial injury.Positive predictive value (PPV) and negative predictive value (NPV) (95% confidence interval [CI]) were calculated for all patients and in a subgroup of patients with a high risk for significant hemorrhage (base deficit ≥ 6 mEq/L).

RESULTS: Overall, 160 patients were included in the study. Of the 62 FF patients, 26 required AHC (PPV, 42%, 95% CI, 30-55%). Of the 98 patients without FF, none required AHC (NPV, 100%; 95% CI, 95-100%). For a moderate-to-large amount of FF, the PPV and NPV in all patients were 81% (95% CI, 60-93%) and 96% (95% CI, 91-99%), respectively.In the subgroup of 49 high-risk patients (31%), 17 of 26 FF patients required AHC (PPV, 65%; 95% CI, 44-82%), and none of the 23 patients without FF required AHC (NPV, 100%; 95% CI, 82-100%). For a moderate-to-large amount, the PPV and NPV in high-risk patients were 93% (95% CI, 64-100%) and 89% (95% CI, 72-96%), respectively.

CONCLUSION: In major pelvic fracture patients, the predictive value of FF on CT for the need for AHC is closely related to the amount present. A moderate-to-large amount of FF is highly predictive for the presence of abdominal bleeding that requires hemorrhage control.

LEVEL OF EVIDENCE: Therapeutic study, level IV; prognostic study, level III.