Modifiability of surgical timing in postinjury multiple organ failure patients.

BACKGROUND: Postinjury multiple organ failure (MOF) is the leading cause of late trauma deaths, with primarily non-modifiable risk factors. Timing of surgery as a potentially modifiable risk factor is frequently proposed, but has not been quantified. We aimed to compare mortality, hospital length of stay (LOS), and ICU LOS between MOF patients who had surgery that preceded MOF with modifiable timings versus those with non-modifiable timings. METHODS: Retrospective analysis of an ongoing 17-year prospective cohort study of ICU polytrauma patients at-risk of MOF. Among MOF patients (Denver score>3), we identified patients who had surgery that preceded MOF, determined whether the timing of these operation(s) were modifiable(M) or non-modifiable (non-M), and evaluated the change in physiological parameters as a result of surgery. RESULTS: Of 716 polytrauma patients at-risk of MOF, 205/716 (29%) developed MOF, and 161/205 (79%) had surgery during their ICU admission. Of the surgical MOF patients, 147/161 (91%) had one or more operation(s) that preceded MOF, and 65/161 (40%) of them had operation(s) with modifiable timings. There were no differences in age (mean (SD) 52 (19) vs 53 (21)years), injury severity score (median (IQR) 34 (26-41)vs34 (25-44)), admission physiological and resuscitation parameters, between M and non-M-patients. M patients had longer ICU LOS (median (IQR) 18 (12-28)versus 11 (8-16)days, p < 0.0001) than non-M-patients, without difference in mortality (14%vs16%, p = 0.7347), or hospital LOS (median (IQR) 32 (18-52)vs27 (17-47)days, p = 0.3418). M-patients had less fluids and transfusions intraoperatively. Surgery did not compromise patient physiology. CONCLUSION: Operations preceding MOF are common in polytrauma and seem to be safe in maintaining physiology. The margin for improvement from optimizing surgical timing is modest, contrary to historical assumptions.

Postinjury multiple organ failure in polytrauma: more frequent and potentially less deadly with less crystalloid.

BACKGROUND: Recently, retrospective registry-based studies have reported the decreasing incidence and increasing mortality of postinjury multiple organ failure (MOF). We aimed to describe the current epidemiology of MOF following the introduction of haemostatic resuscitation. METHODS: A 10-year prospective cohort study was undertaken at a Level-1 Trauma Centre-based ending in December 2015. Inclusion criteria age ≥ 16 years, Injury Severity Score (ISS) > 15, Abbreviated Injury Scale (AIS) Head < 3 and survived > 48 h. Demographics, physiological and shock resuscitation parameters were collected. The primary outcome was MOF defined by a Denver Score > 3. SECONDARY OUTCOMES: intensive care unit length of stay (ICU LOS), ventilation days and mortality. RESULTS: Three hundred and forty-seven patients met inclusion criteria (age 48 ± 20; ISS 30 ± 11, 248 (71%) were males and 23 (6.6%) patients died. The 74 (21%) MOF patients (maximum Denver Score: 5.5 ± 1.8; Duration; 5.6 ± 5.8 days) had higher ISS (32 ± 11 versus 29 ± 11) and were older (54 ± 19 versus 46 ± 20 years) than non-MOF patients. Mean daily Denver scores adjusted for age, sex, MOF and ISS did not change over time. Crystalloid usage decreased over the 10-year period (p value < 0.01) and PRBC increased (p value < 0.01). Baseline cumulative incidence of MOF at 28 days was 9% and competing risk analyses showed that incidence of MOF increased over time (subdistribution hazard ratio 1.14, 95% CI 1.04 to 1.23, p value < 0.01). Mortality risk showed no temporal change. ICU LOS increased over time (subdistribution hazard ratio 0.95, 95% CI 0.92 to 0.98, p value < 0.01). Ventilator days increased over time (subdistribution hazard ratio 0.94, 95% CI 0.9 to 0.97, p value < 0.01). CONCLUSION: The epidemiology of MOF continues to evolve. Our prospective cohort suggests an ageing population with increasing incidence of MOF, particularly in males, with little changes in injury or shock parameters, who are being resuscitated with less crystalloids, stay longer on ICU without improvement in survival.

Major Pelvic Ring Injuries: Fewer Transfusions Without Deaths from Bleeding During the Last Decade.

BACKGROUND: Pelvic fracture-associated bleeding can be difficult to control with historically high mortality rates. The impact of resuscitation advancements for trauma patients with unstable pelvic ring injuries is unknown. We hypothesized that the time elapsed since introduction of our protocol would be associated with decreased blood transfusion requirements. METHODS: A level 1 trauma center's prospective pelvic fracture database was reviewed from 01/01/2009-31/12/2018. All patients with unstable pelvic ring injuries initially presenting to our institution were included. Adjusted regression analysis was performed on the overall cohort and separately for patients in traumatic shock (TS). The primary outcome was 24 h packed red blood cell (PRBC) requirements. Secondary outcomes were 24 h plasma, cryoprecipitate, platelet and intravenous fluid (IVF) requirements, length of stay and mortality. RESULTS: Patients with mechanically unstable pelvic ring injuries (n = 144, median [Q1-Q3] age 44 [28-55] years, 74% male) received a median (Q1-Q3) of 0 (0-4) units PRBC within 24 h, with TS patients (n = 47, 42 [28-60] years, 74% male) receiving 6 (4-9) units PRBC. There was no decrease in 24 h PRBC requirements for the overall cohort (years; IRR = 0.91, 95% CI 0.83-1.01; p = 0.07). TS patients had decreases in 24 h PRBC (years; IRR = 0.90, 95%CI 0.84-0.96; p = 0.002), plasma (IRR = 0.92, 95%CI 0.85-0.99; p = 0.019), cryoprecipitate (IRR = 0.88, 95%CI 0.81-0.95; p = 0.001) and IVF (IRR = 0.94, 95%CI 0.90-0.98; p = 0.004). There were 5 deaths (5/144, 3.5%) with no deaths due to acute hemorrhage. CONCLUSIONS: Over this 10-year period, there was no hemorrhage-related mortality among patients presenting with pelvic fractures. Crystalloid and transfusion requirements decreased for patients presenting with traumatic shock.

Association Between Blood Donor Demographics and Post-injury Multiple Organ Failure after Polytrauma.

OBJECTIVE: To test the hypothesis that blood donor demographics are associated with transfused polytrauma patients' post-injury multiple organ failure (MOF) status. SUMMARY OF BACKGROUND DATA: Traumatic shock and MOF are preventable causes of death and post-traumatic hemorrhage is a frequent indication for transfusion. The role of blood donor demographics on transfusion recipients is not well known. METHODS: A log-linear analysis accounting for the correlated structure of the data based on our prospective MOF database was utilized. Tests for trend and interaction were computed using a likelihood ratio procedure. RESULTS: A total of 229 critically injured transfused trauma patients were included, with 68% of them being males and a mean age of 45 years. On average 10 units of blood components were transfused per patient. A total of 4379 units of blood components were donated by donors aged 46 years on average, 74% of whom were males. Blood components used were red blood cells (47%), cryoprecipitate (29%), fresh frozen plasma (24%), and platelets (less than 1%). Donor-recipient sex mismatched red blood cells transfusions were more likely to be associated with MOF ( P = 0.0012); fresh frozen plasma and cryoprecipitate recipients were more likely to experience MOF when transfused with a male (vs female) component ( P = 0.0014 and <0.0001, respectively). Donor age was not significantly associated with MOF for all blood components. CONCLUSIONS: Blood components donor sex, but not age, may be an important factor associated with post-injury MOF. Further validation of our findings will help guide future risk mitigation strategies specific to blood donor demographics.

NOT ALL CELL-FREE MITOCHONDRIAL DNA IS EQUAL IN TRAUMA PATIENTS.

ABSTRACT: Mitochondrial DNA (mtDNA) acts as a proinflammatory damage-associated molecular pattern that stimulates innate immune activation via Toll-like receptor 9, similarly to bacterial DNA. A number of clinical studies have measured elevated cell-free mtDNA in the plasma of trauma patients, thought to originate from tissue injury and inflammatory processes; however, the magnitude of this increase, the absolute concentration, and the association with poor outcomes varies considerably across studies. Measurements of cell-free mtDNA in healthy individuals have shown that the majority of "cell-free" mtDNA (>95%) can be centrifuged/filtered from plasma in the size range of 0.45 to 5 µm, suggesting that there are larger forms of mtDNA-containing complexes in the plasma that could be considered cell-free. Whether this is true for trauma patients (and other relevant disease states) and the clinical relevance of the larger forms of mtDNA is unknown. These findings from healthy individuals also suggest that the centrifugation speeds used to generate cell-free plasma (which are rarely consistent among studies) could result in mixed populations of cell-free mtDNA that could confound associations with outcomes. We demonstrate in this study of 25 major trauma patients that the majority of the cell-free mtDNA in trauma patient plasma (>95%) is removed after centrifugation at 16,000g. Despite the larger forms of mtDNA being predominant, they do not correlate with outcomes or expected parameters such as injury/shock severity, multiple organ failure, and markers of inflammation, whereas low-molecular-weight cell-free mtDNA correlates strongly with these variables.

The epidemiology of overtransfusion of red cells in trauma resuscitation patients in the context of a mature massive transfusion protocol.

PURPOSE: Packed red blood cell (PRBC) transfusion remains an integral part of trauma resuscitation and an independent predictor of unfavourable outcomes. It is often administered urgently based on clinical judgement. These facts put trauma patients at high risk of potentially dangerous overtransfusion. We hypothesised that trauma patients are frequently overtransfused and overtransfusion is associated with worse outcomes. METHODS: Trauma patients who received PRBCs within 24 h of admission were identified from the trauma registry during the period January 1 2011-December 31 2018. Overtransfusion was defined as haemoglobin concentration of greater than or equal to 110 g/L at 24 h post ED arrival (± 12 h). Demographics, injury severity, injury pattern, shock severity, blood gas values and outcomes were compared between overtransfused and non-overtransfused patients. RESULTS: From the 211 patients (mean age 45 years, 71% male, ISS 27, mortality 12%) who met inclusion criteria 27% (56/211) were overtransfused. Patients with a higher pre-hospital systolic blood pressure (112 vs 99 mmHg p < 0.01) and a higher initial haemoglobin concentration (132 vs 124 p = 0.02) were more likely to be overtransfused. Overtransfused patients received smaller volumes of packed red blood cells (5 vs 7 units p = 0.049), fresh frozen plasma (4 vs 6 units p < 0.01) and cryoprecipitate (6 vs 9 units p = 0.01) than non-overtransfused patients. CONCLUSION: More than a quarter of patients in our cohort were potentially given more blood products than required without obvious clinical consequences. There were no clinically relevant associations with overtransfusion.

Time to definitive fixation of pelvic and acetabular fractures.

BACKGROUND: The timing of definitive surgical stabilization is a controversial topic of pelvic and acetabular fracture (PAF) management. Historically, staged care with delayed definitive fixation was recommended; however, more recently, some centers have shown early definitive fixation to be feasible in most patients. We hypothesized that time to definitive fixation of PAF decreased without adverse outcomes. METHODS: A level 1 trauma center's prospective pelvic fracture database was retrospectively analyzed. A total of 341 of the 1,270 consecutive PAF patients had surgery between January 2009 and December 2018. Demographics, polytrauma status, hemodynamic stability, time to definitive operation, length of intensive care unit stay, hospital length of stay, mortality were recorded. Data is presented as mean ± SD, percentages. Statistical significance was determined at p < 0.05. RESULTS: There were 34 ± 8 per year operatively treated PAF patients during the study period. The demographics (age, 44.1 ± 18 years; 74.5% males) and injury severity (Injury Severity Score, 20; interquartile range, 16-29) did not change. Time to definitive fixation on average was 85 ± 113 hours (range, 0.8-1286 hours). Linear regression analysis demonstrated a decrease in time to definitive fixation considering all patients (ß = -0.186, p = 0.003). pelvic ring fractures with polytrauma (ß = -1.404, p = 0.03). and hemodynamically unstable patients (ß = -1.428, p = 0.037). There was no significant change in mortality, length of stay, or intensive care unit length of stay for the overall cohort or any subgroup. CONCLUSION: Time to definitive fixation in PAF has decreased during the last decade, with the largest decrease in time to fixation occurring in the hemodynamically unstable and pelvic fracture with polytrauma cohorts. The timely definitive internal fixation is achievable without increased length of stay. LEVEL OF EVIDENCE: Therapeutic/care management, level IV.

A tale of two cities: prehospital intubation with or without paralysing agents for traumatic brain injury.

BACKGROUND: The role of prehospital endotracheal intubation (PETI) for traumatic brain injury is unclear. In Victoria, paramedics use rapid sequence induction (RSI) drugs to facilitate PETI, while in New South Wales (NSW) they do not have access to paralysing agents. We hypothesized that RSI would both increase PETI rates and improve mortality. METHODS: Retrospective comparison of adult primary admissions (Glasgow Coma Scale <9 and abbreviated injury scale head and neck >2) to either Victorian or NSW trauma centre, which were compared with univariate and logistic regression analysis to estimate odds ratio for mortality and intensive care unit (ICU) length of stay. RESULTS: One hundred and ninety-two Victorian and 91 NSW patients did not differ in: demographics (males: 77% versus 79%; P = 0.7 and age: 34 (18-88) versus 33 (18-85); P = 0.7), Glasgow Coma Scale (3 (3-8) versus 5 (3-8); P = 0.07), and injury severity score (38 (26-75) versus 35 (18-75); P = 0.09), prehospital hypotension (15.4% versus 11.7%; P = 0.5) and desaturation (14.6% versus 17.5%; P = 0.5). Victorians had higher abbreviated injury scale head and neck (5 (4-5) versus 5 (3-6); P = 0.04) and more often successful PETI (85% versus 22%; P < 0.05). On logistic regression analysis, mortality did not differ among groups (31.7% versus 26.3%; P = 0.34; OR = 0.84; 95% CI: 0.38-1.86; P = 0.67). Among survivors, Victorians had longer stay in ICU (364 (231-486) versus 144 (60-336) h), a difference that persisted on gamma regression (effect = 1.58; 95% CI: 1.30-1.92; P < 0.05). CONCLUSION: Paramedics using RSI to obtain PETI in patients with traumatic brain injury had a higher success rate. This increase in successful PETI rate was not associated with an improvement in either mortality rate or ICU length of stay.

Comparison of postinjury multiple-organ failure scoring systems: Denver versus Sequential Organ Failure Assessment.

BACKGROUND: The Denver and Sequential Organ Failure Assessment (SOFA) scores have been used widely to describe the epidemiology of postinjury multiple-organ failure; however, differences in these scores make it difficult to compare incidence, duration, and mortality of multiple-organ failure. The study aim was to compare the performance of the Denver and SOFA scores with respect to the outcomes of mortality, intensive care unit length of stay (ICU LOS), and ventilator days. METHODS: A 60-month prospective epidemiologic study was undertaken at an Australian Level I trauma center. Data were collected on trauma patients that met inclusion criteria (ICU admission, Injury Severity Score [ISS] > 15, age > 18 years, head Abbreviated Injury Scale [AIS] score < 3, survival for >48 hours). Demographics, ISS, physiologic parameters, SOFA and Denver scores, and outcome data were prospectively collected. Sensitivity/specificity and receiver operating characteristic curve were calculated for both scores. Analysis was also completed for a Day 3 postinjury SOFA and Denver score. RESULTS: A total of 140 patients met the inclusion criteria (mean [SD] age, 47 [21] years; ISS, 30; male, 69%; mortality rate, 6%; mean [SD] ICU LOS, 9 [7] days; mean [SD] ventilation period, 6 [7] days). There was no difference in the score performance predicting mortality. Day 3 SOFA score of 4 or greater outperformed the Denver score of greater than 3 when predicting ICU LOS and ventilator days (area under the curve, 0.83 vs. 0.69, 0.86 vs. 0.73, respectively). The SOFA score was more sensitive and the Denver score was more specific when predicting mortality, ICU LOS, and ventilator days. CONCLUSION: Both scores had similar performance predicting mortality; however, the Day 3 SOFA score outperforms the Denver score when predicting ICU LOS and ventilator days. Either score could be superior based on whether one is seeking to optimize specificity or sensitivity. It is important to note that these findings are in a non-head-injured population and that there are practical difficulties using the SOFA in head-injured patients. LEVEL OF EVIDENCE: Diagnostic study, level II.

Factors associated with pelvic fracture-related arterial bleeding during trauma resuscitation: a prospective clinical study.

OBJECTIVES: To determine predictors of pelvic fracture-related arterial bleeding (PFRAB) from the information available in the Emergency Department (ED). DESIGN: Prospective cohort study. SETTING: Single level-1 Trauma Center. PATIENTS: In a 3-year period ending in December 2008, consecutive high-energy pelvic fracture patients older than 18 years were included. Patients who arrived >4 hours after injury or dead on arrival were excluded. Patient management followed advanced trauma life support and institutional guidelines. Collected data included patient demographics, mechanism of injury, vital signs, acid-base status, fluid resuscitation, trauma scores, fracture patterns, procedures, and outcomes. Potential predictors were identified using standard statistical tests: Univariate analysis, Pearson correlation (r), receiver operator characteristic, and decision tree analysis. INTERVENTION: Observational study. OUTCOME MEASURES: PFRAB was determined based on angiography or computed tomography angiogram or laparotomy findings. RESULTS: Of the 143 study patients, 15 (10%) had PFRAB. They were significantly older, more severely injured, more hypotensive, more acidotic, more likely to require transfusions in the ED, and had higher mortality rate than non-PFRAB patients. No single variable proved to be a strong predictor but some had a significant correlation with PFRAB. Useful predictors identified were worst base deficit (BD), receiver operator characteristic (0.77, cutoff: 6 mmol/L, r = 0.37), difference between any 2 measures of BD within 4 hours (ΔBD) >2 mmol/L, transfusion in ED (yes/no), and worst systolic blood pressure <104 mm Hg. Demographics, injury mechanism, fracture pattern, temperature, and pH had poor predictive value. CONCLUSIONS: BD <6 mmol/L, ΔBD >2 mmol/L, systolic blood pressure <104 mm Hg, and the need for transfusion in ED are independent predictors of PFRAB in the ED. These predictors can be valuable to triage blunt trauma victims for pelvic hemorrhage control with angiography. LEVEL OF EVIDENCE: Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence.

Changes in the epidemiology and prediction of multiple-organ failure after injury.

BACKGROUND: The epidemiology of multiple-organ failure (MOF) after injury has been changing, questioning the validity of previously described prediction models. This study aimed to describe the current epidemiology of MOF. The secondary aim was development of a prediction model that could be used for early identification of patients at risk of MOF. METHODS: A 60-month prospective epidemiologic study was undertaken at an Australian Level I trauma center. Data were collected on trauma patients that met inclusion criteria (intensive care unit [ICU] admission; Injury Severity Score [ISS] > 15; age > 18 years, head Abbreviated Injury Scale [AIS] score < 3; and survival for >48 hours). Demographics, injury severity (ISS), physiologic parameters, MOF status based on the Denver score, and outcome data were prospectively collected. Univariate analysis and multivariate logistic modeling were performed; p < 0.05 was considered significant. Data are presented as percentage or mean (SD). RESULTS: A total of 140 patients met the inclusion criteria (age, 47 [21] years; ISS, 30 [11]; male, 69%), 21 patients (15%) developed MOF, and MOF associated mortality was 24% versus non-MOF mortality rate of 3%. Patients who developed MOF had longer ICU stays (19 [7] vs. 7 [5], p < 0.01) and had more ventilator days (18 [9] vs. 4 [4], p < 0.01). Prediction models were generated at two time points as follows: admission and 24 hours after injury. At admission, age (>65 years) and admission platelet count (<150 × 10(9)/L) were significant predictors of MOF; at 24 hours after injury, MOF was predicted by age more than 65 years, admission platelet count less than 150 × 10(9)/L, maximum creatinine of greater than 150 × 10(9)/L and minimum bilirubin of greater than 10 × 10(9)/L. Shock parameters and injury severity did not predict MOF. CONCLUSION: The incidence of MOF (15%) is lower than reported 15 years ago; MOF remains a major cause of ICU resource use and late mortality after injury. The independent predictors of MOF have fundamentally changed, likely owing to improvements in resuscitation and critical care. Current predictors are universally available at admission and 24 hours. LEVEL OF EVIDENCE: Epidemiologic/prognostic study, level III.

Efficacy and safety of emergency non-invasive pelvic ring stabilisation.

BACKGROUND: Urgent non-invasive pelvic ring stabilisation (pelvic binding, PB) in shocked patients is recommended by state and institutional guidelines regardless of the fracture pattern. The purpose of this study was to determine the adherence to the guidelines, efficacy of the technique and identification of potential adverse effects associated with PB. PATIENTS AND METHODS: A 41-month retrospective analysis of the prospective pelvic fracture database was undertaken at a level 1 trauma centre. High-energy pelvic fractures were included in the analysis with exclusion of the A type injuries (AO/OTA classification) and patients who were dead on arrival. Collected data included patient demographics, injury severity score, fracture classification, application and timing of PB, associated injuries, physiological parameters, resuscitation fluids and outcomes. Pre and post-PB radiographs were reviewed. The potential effects of the PB on soft tissue (femoral vessel, bladder and rectal injury) complications were assessed by independent experts. RESULTS: 115 patients with high-energy B and C type pelvic ring injuries were included. Thirty-six (31%) patients presented in haemorrhagic shock on arrival. A total of 43 pelvic bindings were performed, 18 of them on shocked patients. The adherence to the guidelines was 50% (18/36) overall. Analysing fracture types of shocked patients the adherence was: B1 80%, B2 20%, B3 20%, C1 66%, C2 86%, C3 33%. The alignment of the pelvis was improved or perfect on post-PB radiographs in 68% and had not changed in 21%. In some cases of B2 and B3 type injuries the PB increased the deformity after application (11%). There were 10 deaths (8.7%) in the study group, with 4 deaths attributed to acute pelvic bleeding. Two of these had PB applied and two were identified as potential for improvement. One femoral artery injury, four bladder injuries and three rectum injuries were identified in patients who had PB applied. Association between the PB and these injuries is unlikely. CONCLUSION: The adherence to the guidelines should be improved with further education and system development. The good effect of the technique was evident on radiographs. Although in some lateral compression fracture patterns the deformity increased, no hazards were associated with the use of PB.

Mission to eliminate postinjury abdominal compartment syndrome.

OBJECTIVES: To determine the current incidence of postinjury abdominal compartment syndrome (ACS), the effect of intra-abdominal hypertension (IAH) on trauma outcomes, and the independent predictors of postinjury IAH. DESIGN: Prospective cohort study. SETTING: University-affiliated level 1 trauma center. PATIENTS: Eighty-one consecutive shock/trauma patients admitted to the intensive care unit (mean [SD] values: age, 41 [2] years; 70% male; injury severity score, 29 [1]; base deficit, 6 [0.5] mmol/L; lactate level, 29.73 [4.5] mg/dL; transfusions of packed red blood cells, 5 [0.5] U in first 24 hours; mortality rate, 2.5%; and multiple organ failure [MOF], 6%) had second hourly intra-abdominal pressure (IAP) monitoring. MAIN OUTCOME MEASURES: Intensive care unit length of stay, ACS, IAH, MOF, mortality. RESULTS: The mean (SD) IAP was 14 (1) mm Hg. No patients developed ACS. Sixty-one patients (75%) had sustained IAH. Both patients with IAH and those without had similar demographics and injury severity. Patients with IAH had worse metabolic acidosis (P = .02), received more crystalloids (P = .03), and underwent laparotomy more frequently (P = .005). One patient with IAH and one without died. MOF occurred in 1 patient without IAH (5%) vs 4 with IAH (7%). The mean (SD) intensive care unit length of stay was 11 (3) days in patients without IAH vs 8 (1) days in those with IAH. Intra-abdominal hypertension was poorly predictive of MOF (odds ratio, 1.17; 95% confidence interval, 0.96-1.43; P = .13). Of the 30 variables in multiple logistic regression analysis, only base deficit, laparotomy, and emergency department crystalloids were identified as weak predictors of IAP greater than 12 mm Hg. No predictors were found for the clinically more relevant IAP greater than 15 mm Hg and IAP greater than 18 mm Hg. CONCLUSIONS: Most of the severe shock/trauma patients developed sustained IAH. Based on univariate and multivariate analyses, there was no difference in outcomes between the trauma patients with IAH and those without. Multiple logistic regression analysis failed to show IAH as a predictor of MOF. The attenuation of the deadly ACS to a less deleterious IAH could be considered a success of the last decade in trauma and critical care.

Acute definitive internal fixation of pelvic ring fractures in polytrauma patients: a feasible option.

BACKGROUND: Staged surgery is recommended for the management of multiple injuries-associated high-energy pelvic ring fractures (acute temporary skeletal stabilization is followed by definitive internal fixation [ORIF]). Acute definitive internal fixation is a controversial topic. The purpose of this study was to evaluate the safety and efficiency of acute pelvic ORIF by comparing its short-term outcomes with those who had staged surgery. METHODS: A 43-month retrospective review of the prospective pelvic fracture database of a level-1 trauma center was performed. Consecutive high-energy trauma patients who sustained a fracture that was suitable for minimally invasive internal fixation (iliosacral screw fixation and symphyseal plating) were included. Patients were categorized as acute ORIF (<24 hours) or staged late ORIF (>24 hours). Demographics, Injury Severity Score, pelvic Abbreviated Injury Score, first 24-hour transfusions, physiologic parameters, time to operating room (OR), angiography requirement, length of stay (LOS), and mortality were recorded. Data are presented as mean +/- SD or percentages. Statistical significance was determined at p < 0.05 based on univariate analysis. RESULTS: Forty-five patients met inclusion criteria, 18 patients had acute definitive ORIF (5.5 hours to OR) and 27 had late definitive ORIF (5 days to OR). Acute and late ORIF patients had comparable demographics (age: 48 +/- 22 years vs. 40 +/- 14 years, gender: 82% vs. 79% men) and injury severity (Injury Severity Score: 30 +/- 18 vs. 24.5 +/- 13, pelvic Abbreviated Injury Score: 3.7 +/- 1 vs. 3.4 +/- 1.1). Initial shock parameters were significantly worse in the acute ORIF group (systolic blood pressure, 69.7 +/- 17 mm Hg vs. 108 +/- 21 mm Hg; BD, -7.4 +/- 4 vs. -4.9 +/- 2 mEq/L, lactate 6.67 +/- 7 mmol/L vs. 2.51 +/- 1.3 mmol/L). Angiography was used in 18% (3/18) vs. 21% (6 of 27) of the cases. All early ORIF patients survived and one (3%) of the late ORIF patients died. There was a trend to shorter hospital LOS (25 +/- 24 days vs. 37 +/- 32 days) and a decreased 24-hour red cell transfusion rate (4.7 +/- 5 U vs. 6.6 +/- 4 U) in the early ORIF group. The intensive care unit admission rate (12 of 18 vs. 15 of 27) and LOS was comparable (2.9 +/- 2.5 days vs. 3.7 +/- 3.6 days). CONCLUSION: Acute ORIF of unstable pelvic ring fractures within 6 hours could be safely performed even in severely shocked patients with multiple injuries. The procedure did not lead to increased rates of transfusion, mortality, intensive care unit LOS, or overall LOS. Furthermore, all these parameters showed a trend toward benefit compared with a staged approach.