10/2/2018. Acute Management of Pelvic Injuries. Learning Objectives. 17 yo male ped struck by truck

Transcription

1 17 yo male ped struck by truck Acute Management of Pelvic Injuries David Volgas, MD CoxHealth University of Missouri HD unstable Open pelvic wound superior gluteal fold through rectum to scrotum Open rami Intubated at scene Learning Objectives 1. Understand who the at risk patient with pelvic disruption 2. Recognize response to resuscitation and how this guides management 3. Understand treatment algorithm with regards to orthopaedic and non orthopaedic intervention Learning Objectives 1. Understand who the at risk patient with pelvic disruption 2. Recognize response to resuscitation and how this guides management 3. Understand treatment algorithm with regards to orthopaedic and non orthopaedic intervention Learning Objectives 1. Understand who the at risk patient with pelvic disruption 2. Recognize response to resuscitation and how this guides management 3. Understand treatment algorithm with regards to orthopaedic and non orthopaedic intervention Learning Objectives 1. Understand who the at risk patient with pelvic disruption 2. Recognize response to resuscitation and how this guides management 3. Understand treatment algorithm with regards to orthopaedic and non orthopaedic intervention 1

2 What s the big deal? Hemorrhagic shock Death!!!! What s the big deal? Associated injuries Blunt chest injury 60% Long bone fractures 50% Head and abdominal 40% (liver, spleen, bladder) Spine fractures 25% Pelvic Vascular Anatomy Pelvic Ligamentous Anatomy Young Burgess Classification Less Worrisome Types 2

3 Less Worrisome Types Mortality LC III 14% VS APC II APC III 25% 25% 37% Transfusion Requirements Young Burgess Manson LC LC VS APC Expansile Tensile Increased volume Increased bleeding Pattern Recognition! APC Venous 80 90% Fracture surface Open wounds Arterial Pelvic Related Bleeding Superior gluteal (APC) Obturator (LC) Internal pudendal (LC) Others YES prbc and products per resuscitation protocol Mechanically Unstable Pelvis Hemodynamic Instability Reduction and provisional stabilization of pelvis Sheet Binder Frame Hemodynamic Reassessment NO Finish Course Elective Stabilization 3

4 In English for the rest of us Pelvic Containment Thermoregulation Fluid Resuscitation Pelvic Angiography Colonic Diversion Operative Fixation Pelvic Containment Taping Circumferential sheet External fixation Circumferential Pelvic Sheeting Gardner et al. JOT

5 Presentation Post binder Comment about binder application Non ortho providers may or may not recognize increased pelvic volume No down side to have binder on LC pattern or acetabular fracture Can always remove if not needed Guess wrong DEATH Traction Open wounds Check reduction Comment about binder application Non ortho providers may or may not recognize increased pelvic volume No down side to have binder on LC pattern or acetabular fracture Can always remove if not needed Guess wrong DEATH Comment about binder application Non ortho providers may or may not recognize increased pelvic volume No down side to have binder on LC pattern or acetabular fracture Can always remove if not needed Guess wrong DEATH Working Portals Garder et al. JOT

6 Pelvic Binders? Anterior Pelvic External Fixation 2 nd phase Transition from binder/sheet Improve and maintain reduction Stability Time Anterior Pelvic External Fixation AIIS Iliac crest Combo Anterior Pelvic External Fixation Disadvantages Pin site infection Not for all injuries Lack of posterior control Thermoregulation Injury Hemorrhage Hypothermia Acidosis Coagulopathy 6

7 Appropriate Resuscitation Controversial 1:1:1 vs whole blood? Minimal crystalloid Angiography Indications: - Transfusion non-responder - High risk patterns - Age > 60 - Contrast extravasation - Bladder displacement Be present! REBOA Pelvic Packing Resuscitative Endovascular Balloon Occlusion of the Aorta Be present! Pelvic containment needed 7

8 Diverting colostomy Indicated in open pelvic fractures, especially with rectal tear Be present! Assist in location Future surgical incisions Diverting Colostomy Screw reduction Select patients Pure distraction pattern Limited associated reduction Efficient technique mandatory Temporary or definitive Gardner et al. JOT 2009 Gardner et al. JOT

9 75 yo female Auto vs. ped BP: 80/40 Resuscitating Our Patient 50% mortality!!!! Rectal tears / vaginal tears Open Pelvic Fractures Good physical exam in mandatory in all cases Supplement with speculum or proctoscope exam Inspect Plug hole Reduce pelvis Open wound management Summary Emergency providers should recognize at risk fracture patterns Pelvic sheet is always appropriate but must be done correctly Remember to warm and fluid resuscitate patient at all times 80% of pelvic bleeding is venous and will respond to closing the pelvic volume Recognize debridement needed, possible diversion Words of Wisdom Remain calm & consistent Resist chaos ATLS! ABCDE 9