Management of Pelvic Fracture
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1 Management of Pelvis Fracture with Hemodynamic Instability James W. Davis MD Professor of Clinical Surgery, UCSF/Fresno Chief of Trauma Management of Pelvic Fracture How NOT to do it The basics Evaluation for abdominal hemorrhage External pelvic stabilization Angiography with embolization Pelvic packing Western Trauma Association Algorithm
2 Case: Pelvic Fracture Hemodynamic Instability 49 yo woman, MCC versus car Arrival 0030 hrs Field hypotension, A, A OR x 3 BP on arrival: 80/50 FAST: Negative x 3 Resuscitation 7 liters crystalloid 6 units PRBC Case: Pelvic Fracture, Unstable AP Pelvis CXR: RUL contusion Repeat FAST NEGATIVE To Angio at 0230
3 Case: Pelvic Fracture, still unstable In angio, BP 120/56 to 80/49 Ongoing IV, PRBC Angio: NEGATIVE Bilateral internal iliac arteries embolized Back to Trauma Bay Pelvic Fracture: still really unstable IN Trauma Bay: Hypotensive FAST: now positive Urgently to OR In extremis, near code on arrival Ex lap: ml, thin blood Pelvic hematoma moderate non-expanding Empiric chest tubes
4 Pelvic Fracture: in OR Right Chest Tube 1700 over ~ 30 minutes Right thoracotomy: bleeding from rib fractures, no definable vessel Chest: temporary closure Abdomen: temporary closure PACU: on levo, epi, death at 0730 PRBC 26, FFP 10, cryo 10, Plates 10 Unstable Pelvic Fracture: Lessons Learned ATLS: ABC s Not intubated until in extremis in OR BEFORE angio far more prudent Negative Angio To OR for exploration Consider pelvic packing Early use of Massive Transfusion Protocol to avoid lethal triad
5 Pelvic Fracture with Instability Management of patients with hemodynamic instability from pelvis fracture is challenging and controversial. Mortality rates have ranged from % Death within the first 24 hours of injury was most often a result of acute blood loss Significant decreases in mortality rates have been shown with adoption of algorithms for management of these injuries The key issues in management are identifying the site(s) of hemorrhage and then controlling the bleeding. Pelvic Fracture Management The Basics ATLS resuscitation principles CXR AP pelvis Fracture type Evaluation for abdominal bleeding FAST Diagnostic Peritoneal Aspiration (DPA)
6 Pelvic Fracture and Intra- abdominal Injury Force severe enough to fracture the pelvic ring can cause abdominal injuries. Frequency of abdominal injury ranges from 16-55% Appropriate evaluation of the abdomen for associated intra-abdominal abdominal injuries cannot be over-stressed. Management of Pelvic Fracture: External Stabilization pelvic binder Decreases pelvic volume, in right fracture type (Class II) Widened symphysis Vertical shear Not useful for lateral compression, rami fxs Improves hemodynamics (Class III)
7 Use of External Pelvic Stabilization 36 year old Male, Auto vs Pedestrian at Freeway speed Pelvic Fracture Blee ding 3 major sources; arterial, venous cancellous bone. Autopsy study (1973): extravasation of contrast from the hypogastric arteries in 85%. Bleeding sources were bilateral in 63%, 61% had more than one bleeding site identified. Careful dissection revealed lesions to main arteries in only 3 specimens, bleeding from bone and adjacent soft tissue hampered identification stressed the significance of hemorrhage from the fracture sites A more recent study reported that over 70% of unstable patients with pelvic fractures will have arterial bleeding
8 Pelvic Blush on CT Scan Pelvic Fracture: Angio-embolization Selective angiography of both iliacs Gelfoam or coils for extravasation Reported as 87%-95% effective Re-angiography and embolization as salvage procedure in selected patients Complications of gluteal necrosis, death from sepsis RARE but do occur.
9 Pelvic Angio with Extravasation Pelvic Fracture: Pre-Peritoneal Peritoneal Pelvic Packing Initially described in Europe Experience in USA mixed Denver: 100% successful Mass Gen: 66% mortality (not published) Other centers: 50% mortality (not published) Caveats: Appropriate knowledge and experience Institutional capabilities
10 Pelvic Fracture: Pelvic Packing Unstable patient, expanding hematoma Open hematoma, evacuate clot Retract bladder, 3 lap pads on each side Below the SI joint, posteriorly Middle pelvic brim Deep in retro-pubic spce Continued hemorrhage; to angiography Removal or exchange of packs in hours WTA Pelvic Fracture Algorithm Negative Pelvic stabilization Unstable Trauma Evaluation AP Pelvis FAST or DPA? Positive Preperitoneal Packing Hemodynamically Stable? No Massive Transfusion Protocol Yes Pelvic blush? OR for Exploration, + ex fix No Yes Angio / Embolization Yes Positive Abd/Pelvic CTS? No ICU, finish evaluation & resuscitation
11 UCSF
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