Pelvic Fracture Bleeing: Packing or Angio-Embolize?

Transcription

1 Talk Overview Pelvic Fracture Bleeig: Packig or Agio-Embolize? Gregory J Jurkovich, MD FACS Doat Professor of Trauma Surgery Vice-Chair for Cliical Affairs ad Quality Departmet of Surgery, UC Davis Health Sacrameto, Califoria Pelvic Fractures & Mortality Majority of pelvic fractures are stable or low eergy mechaism. Defiitio of the problem Iitial maagemet Agioembolizatio Ratioale for pelvic packig Operative techique Results of pelvic packig Pelvic Aatomy Pelvic rig, ligamets, ad vasculature Always a subgroup that does poorly à high mortality, high complicatio rates At risk: older age shock (SBP < 90) high eergy patter Trauma. EE Moore (ed) Figs 37-1, 3 Vectors of Ijury Lateral Compressio T-Boe MVC Auto vs. Pedestria from side Fall from height lad o side AP Compressio Head-o MVC MCC with spread legs Direct cotact or trasmitted via femur Ca be ligametous oly Vertical Shear Fall from height ad lad o oe leg Lateral Compressio Fracture Acute shorteig of pelvic diameter Does t ope the pelvis Lowest likelihood of sigificat hemorrhage More likely solid orga, thoracic, or c-spie ijury Itra-pelvic orga damage Graded by: Degree of posterior wideig Associated cotra-lateral AP compressio (widswept pelvis) 1

2 Lateral Compressio Fracture AP Compressio Wides pelvic diameter Opes the pelvis May ot have a fracture o x-ray Highest likelihood of arterial hemorrhage Iteral (or commo) iliac Graded by: Symphyseal diastasis Posterior SI disruptio Vertical Shear Usually affects oly oe hemipelvis Iteral hemipelvectomy Disrupt all ligamets Sigificat risk of hemorrhage Superior gluteal Classificatio of Fracture Patters Stable Fracture Patters Ustable Fracture Patters AP Compressio Type 1 AP Compressio Type 2 Lateral Compressio AP Compressio Type 3 Type 1 Lateral Compressio Type 2 Lateral Compressio Type 3 Vertical Shear Youg JWR, Burgess AR, Brumback RJ, Poka A: Pelvic Fractures: Value of plai radiography i early assessmet ad maagemet. Radiology 160: Youg Burgess (WJES 2017; 12:5) Why does fracture patter matter?

3 Why does fracture patter matter? 231 hypotesive pelvic fractur patiets Youg-Burgess Classificaio AP Compressio, Lat Compressioi, VS Ustable fracture patters: APC II, III, LC II, III ad VS 38 died i ED, 193 survivors to ICU UPC patter: hemorrhage from pelvis i 60% Stable patter: hemorrhage from abdome 85% 2002 Why does fracture patter matter? Ustable fracture patter: 52% died Stable fracture patter: 25% died Recall all were hypotesive. Ustable fracture patter 14 had both agio ad celiotomy Agio first % mortality Celiotomy first 60% mortality 2002 What is the practice orm? 11 ceters 163 patiets with pelvic fracture shock Overall mortality 30% 83% of patiets with APC III eeded agio embolizatio Predictors of eed for hemorrhage cotrol: APC III, Ope Pelvic Fracture No Cosesus o treatmet But.. Havig a pla i place essetial (Biffl, A Surg, 2001) 11 ceters 1,339 patiets Overall mortality 9.0% 178 preseted i shock Mortality i this group: 32% No Cosesus o treatmet priorities 1,339 patiets, 11 ceters, Agio % (129) Embolizatio for pelvic bleedig--5.9% (79) Exteral Fixatio % (97) Pelvic Packig 2.3% (31) REBOA % (5) Costatii ad AAST Pelvic Fx Study Group, J TACS 2016; 80(5)

4 Pelvic Fracture Hemorrhage Cotrol 11 ceters, AAST, Pelvic Fractures & Mortality Source of mortality: Head Ijury 31% Bleedig 39% MOF 30% Scalea et al. J Trauma 2003 Pelvic Fractures & Mortality Pelvic Fracture Bleedig Head Ijury 31% Bleedig 39% MOF 30% Impact of RBC trasfusio: mechaical stabilizatio 1u RBCs = 9% mortality 6u RBCs = 43% mortality resuscitatio Startig blood products -Activate the massive trasfusio protocol. Stop the bleedig. Smith et al. J Orthop Trauma 2007 Pelvis Fx + HD Ustable Pelvic Fracture Patiet resuscitatio Source of bleedig? Does the patiet eed to go to the OR? The Agio Suite? Hybrid Room? ICU? Pelvis Fx + HD Ustable What is the sour of hemorrhage? 1. Itra-abdomial: liver, splee, mesetery, whatever GO TO THE OR 2. Chest GO TO THE OR 3. Extremity Touriquet, OR 4. Retroperitoeal Upper ANGIO 5. Retroperitoeal Lower (Pelvis) OR or ANGIO? 4

5 PITFALL If persistet or recurret hypotesio, remember FAST is t accurate! (15-20% False Negative) World Society of Emergecy Surgery pelvic fracture maagemet algorithm (WJES 2017) WSES icludes surgeos from whole world. This Classificatio ad Guidelies statemets aim to direct the maagemet of pelvic trauma, ackowledgig that there are acceptable alterative maagemet optios. I reality, as already cosidered for other positio papers ad guidelies, ot all trauma surgeos work i the same coditios ad have the same facilities ad techologies available [8]. Report based o 59 articles reviewed by 30 surgeos, (Dever, USA) Eve high-volume, well-respected trauma ceters care for those patiets differetly. Why ca we ot fid the aswer?... A radomized, prospective trial would be exceedigly difficult, but would provide the best iformatio. I the absece of that, a large, multi-istitutioal, prospective observatioal trial would be a good first step. We could the stop debatig the subject, come to some cosesus, ad save more ad more lives. Chia ad Swede ulikely combiatio but maybe the best data Tom Scalea, U Marylad/RA Cowley Shock Trauma, March 2017 Commetig o Burlew et al, J TACS Feb

6 Quasi-Radomized (?? time of day) 29 patiet PACK -- ight 27 patiet ANGIO -- day Pelvic PACK: quicker to accomplish 77 mi vs. 102 mi time to start 60 mi vs 84 mi operative/agio procedure time Pelvic PACK: less blood loss 5.2 utis vs. 6.4 uits (s) Both Fail 9 of 27 ANGIOI eeded packig 6 of PACK eeded agio Ijury, 2016, 45: How log does it take to get agiography ad embolizatio? R.Adams Coley Shock-Trauma Ceter Log-time leader of agio-embolizatio for treatmet of hemorrhage 10 year iteral review of time to agio-embolizatio Time to agio 10 year review, sigle ceter 4712 total pelvic fracture patiets 344 (7.3%) uderwet pelvic agiography ISS 29 5 uits blood; 6 u FFP/24 hours (media) 44% i shock (of the 344) 30% Massive trasfusio protocol Oe year later... Dever says pack them, it is faster.... Time to Agio: mi, media 286 mi 3.5 to 6.3 HOURS Shock: Media time 4 hours Tesoriero et al, J TACS (1):18-25 Dever pre-peritoeal pelvic packig (PPP) experiece Packig pelvic fractures sice ,293 pelvic fracture patiets over 11 years 128 (6%) PACK? Now may agio? Time to OR: 44 mi Failure: 16 patiets (13%) uderwet agioembolizatio with documeted blush AFTER PPP. So.... Helpful, or simply idetifyig AE cadidates Pelvic Packig rage Burlew et al, J TACS (2):

7 Maybe it is just better resuscitatio? Oslo, Norway AAST 2015 Pelvic packig sice 1994 Massive trasfusio protocol started study Era 2 : after 2007 Similar patiets, ijury severity, etc PACKig rate fell % to 10% AE rate fell -- 15% to 9% Deaths fell 10% to 5% More FFP, more platelets (1:1:1) Oslo Algo DCL damage cotrol laparotomy EPP = PPP EAST Guidelies J TACS 2011 (77(6): EAST Guidelies Level 1 Patiets with pelvic fracture associated hemorrhage should be cosidered for AE Extravasatio should udergo AE FAST is useless 7

8 EAST Guidelies Level 2 Repeat pelvic AE if bleedig persists Elderly with certai fracture patters should be cosidered for AE regardless of hemodyamic status DPL/A is the best test to exclude itraperitoeal bleedig i the ustable pt. CT the STABLE patiet regardless of FAST EAST Guidelies Level 3 Retroperitoeal pelvic packig is effective as a salvage procedure after AE RPP cotrols hemorrhage whe used as part of a multidiscipliary cliical pathway Pelvic Fracture Protocol Pelvic Fracture Protocol Yes CT sca of abdome/pelvis Hemodyamically Stable? Hemodyamically Stable? Yes CT sca of abdome/pelvis No Massive Trasfusio Protocol FAST Exam / DPA Pelvic Fracture Protocol Pelvic Fracture Protocol Hemodyamically Stable? Yes CT sca of abdome/pelvis No Yes CT sca of abdome/pelvis Hemodyamically Stable? No Massive Trasfusio Protocol Operatig Room Positive Massive Trasfusio Protocol FAST Exam / DPA Operatig Room Positive FAST Exam / DPA Negative cotrol of pelvic fracture bleedig 8

9 Pelvic Fracture Protocol Pelvic Packig for Hemorrhage Cotrol Hemodyamically Stable? Yes No CT sca of abdome/pelvis Massive Trasfusio Protocol FAST Exam / DPA Positive Negative agioembolizatio or pelvic packig Operatig Room Maagemet of Hemorrhage Operative packig 85% of bleedig is veous Sigificat egative agio rate 2007 Pelvic Packig Really? Ca this possibly work? Ratioale for Pelvic Packig Mortality for hemodyamically ustable pelvic fractures remais 40-60%. Associated with multiple other ijuries Agiographic embolizatio is successful performed less tha 50% of the time. 85% of hemorrhage from pelvic fractures is boy/veous i origi. IR vs OR? Simplifies decisio makig. Usually performed i <30 miutes (media time from admissio to IR of 301 miutes durig the ight i oe study). Able to maage other ijuries simultaeously. KEY POINT Modified Europea techique: Icisio should be away from a laparotomy icisio keep the spaces separate! 6-8 cm suprapubic icisio divide midlie fascia Smith et al. J Trauma 2005 Cothre et al. J Trauma

10 Pelvic Packig You will ecouter the hematoma! Pelvic Packig Packig the pelvis: 3 lap pads o either side of bladder 1st oe is all the way dow to presacral space Pelvic Packig Typically 6 packs for adults, 4 for childre Pelvic Packig Video Pelvic Packig Suprapubic catheters Close fascia ad ski Pelvis Fx + HD Ustable Curret commo maagemet: USA resuscitatio mechaical stabilizatio embolizatio Importace of maagemet protocols: 20% decrease i mortality Biffl et al. A Surg

11 Agioembolizatio Agio-Embolizatiop for Hemorrhage Cotrol Established techique for over 30 years Addresses arterial bleedig Safe ad efficacious Proposed idicatios: How fast ca you really get this doe? How ofte is it really eeded? hemodyamic istability despite RBCs large retroperitoeal hematoma o CT sca active cotrast extravasatio o CT sca hematoma size ad locatio o CT Margolies et al. NEJM 1972; Blackmore & Jurkovich, Arch Surg 2003 ; Paetta et al. J Trauma 1985 Maagemet of Hemorrhage Arterial Agiography / embolizatio Braches of iteral iliac 1 iliolumbar 2 lateral sacral 3 superior gluteal 4 obturator 5 iteral pudedal 6 iferior gluteal 7 vescicle Radiographics: The olie joural of CME i radiology. Agioembolizatio Evaluate all pelvic vessels Selective embolizatio with Gelfoam Proximal embolizatio of iteral iliac gluteal claudicatio pelvic ecrosis Maagemet of Hemorrhage Arterial Agiography / embolizatio Braches of iteral iliac 1 iliolumbar 2 lateral sacral 3 superior gluteal 4 obturator 5 iteral pudedal 6 iferior gluteal 7 vescicle Radiographics: The olie joural of CME i radiology. Agio Critical Care o the Road Multi-discipliary persoel OR = Aesthesia Team Agio = Trauma Team ad Stat RN IR focuses o vascular cotrol Active resuscitatio Blood Coagulopathy Acidosis Vet maagemet 11

12 Problems with Agio-embolizatio Complicatios of Agio-Embolizatio Abdomial compartmet sydrome Bladder pressure ureliable Gluteal ecrosis after agioembolizatio Pelvic sepsis Veous Thromboembolism Pelvic Pai u 85% of bleedig is veous/boy i origi u Takes time to set up Why is it loger tha cardiac cath? u Not available at all ceters at all times u Other life threateig ijuries Role of hybrid suites Sexual dysfuctio, dysparuia, uriary ad fecal dysfuctio Huittie ad Slatis. Surgery 1973 Extraperitoeal pelvic packig It is pro-active you are doig somethig Gives you somethig to do i that hour while you re waitig for IR to come i ad get set up Appears to effectively address veous bleedig Ucertai if it affects arterial bleedig, but might slow it dow Coclusio Pelvic fracture ad shock remais lethal Packig Faster cotrol veous of blood loss may slow arterial bleedig or stop it. Earlier itervetio o cocurret ijuries. Simplifies decisio makig o stop --- the OR. Agio-embolizatio seems to take loger tha we thik (or loger tha it should) QA this! AE works, but may eed repeatig. Expect this. FAST is useless i this settig REBOA has a role Thak You! Questios? 12