Management of Bleeding Pelvic Fractures
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1 Management of Bleeding Pelvic Fractures Clay Cothren Burlew, MD FACS Professor of Surgery Program Director, SCC and TACS Fellowships Director, Surgical Intensive Care Unit Denver Health Medical Center/University of Colorado
2 No Disclosures.
3 Pelvic Fractures & Mortality Majority of pelvic fractures are stable / low energy mechanism. Subgroup of 8-10% with HD instability Mortality rates 30-50% in modern series Costantini et al. J Trauma 2016 Tesoriero et al. J Trauma 2017 Gaski et al. J Trauma 2016
4 KEY POINT Stop the bleeding..
5 Stop the Bleeding. Despite prompt angiography Despite hemostatic resuscitation Despite protocol driven management Patients were still dying due to pelvic fracture related hemorrhage.
6 In Pelvic Packing Described in Europe rapid transport to OR external bony fixation packing of retroperitoneum Rationale: addresses venous/bony bleeding additional procedures as indicated Pohlemann et al. OTA A Mtg 2000 Ertel et al. J Orthop Trauma 2001
7 Pelvic Packing Pelvic fixation first:
8 KEY POINT Be aware of bar location during ex-fix placement.
9 Pelvic Packing Modified European technique: 6-8 cm suprapubic incision divide midline fascia Smith et al. J Trauma 2005 Cothren et al. J Trauma 2007
10 KEY POINT Incision should be away from a laparotomy incision keep the spaces separate!
11 Pelvic Packing You will encounter the hematoma!
12 Pelvic Packing Packing the pelvis: 3 lap pads on either side of bladder 1 st one is all the way down to presacral space Use a ringed forceps or Cobb elevator Done blindly (at unpacking)
13 Pelvic Packing Typically 6 packs for adults, 4 for children. Inverted U around the bladder. (at unpacking)
14 Pelvic Packing Suprapubic catheters must be placed at first operation.
15 PITFALLS Separate incision for SP tube.
16 Pelvic Packing Close fascia and skin
17 KEY POINT Pelvic packing may be used in children. Burlew et al. J Trauma Acute Care Surg 2017 Chao et al. J Pediatr Surg 2012
18 Unstable Pelvic Fracture Algorithm FAST Exam Positive Negative Operating Room: Exploratory Laparotomy 2 units RBCs/ED trauma bay HD Unstable If Pelvic Hematoma Evident Pelvic Fixation and Pelvic Packing HD Stable HD Stable HD Unstable HD Stable Resuscitate in the SICU + CT scans Operating Room: Pelvic Fixation and Pelvic Packing Re-ultrasound Abdomen
19 Pelvic Packing 11 years 2293 pelvic fx patients 128 (6%) patients = PPP/EF 70% men Age = 44 ± 2 yrs ISS = 48 ± 1 ED vitals: SBP 74 ± 2 HR 120 ± 2 Pelvic fx classification: APC III (29) LC II (26) LC III (20) APC II (20) LC I (13) APC I (4) vertical shear (14) CM (2) Burlew et al. J Trauma Acute Care Surg 2017
20 Packing: Hemorrhage Control Time to OR: 44 minutes RBCs: 4 ± 0.4 units in ED Pre-SICU vs. subsequent 24 8 units vs. 3 units FFP:RBC ratio was 1:2
21 Packing and Concurrent Procedures 85% of pts underwent 3 ± 0.2 procedures Laparotomy Urologic procedures Extremity vascular Neurosurgical/spine Thoracotomy Ex fix of fractures I&D wounds/fasciotomy
22 Open Pelvic Fractures Packing doesn t work for open fractures.
23 Unstable Pelvic Fracture Algorithm FAST Exam Positive Negative Operating Room: Exploratory Laparotomy 2 units RBCs/ED trauma bay HD Unstable If Pelvic Hematoma Evident Pelvic Fixation and Pelvic Packing HD Stable HD Stable HD Unstable HD Stable Resuscitate in the SICU + CT scans Operating Room: Pelvic Fixation and Pelvic Packing Re-ultrasound Abdomen
24 Unstable Pelvic Fracture Algorithm Operating Room: Pelvic Fixation and Pelvic Packing Re-ultrasound Abdomen Remain HD Unstable Arterial Bleeding from Pelvis? Hemoperitoneum? Abdominal Compartment Syndrome?
25 Unstable Pelvic Fracture Algorithm What is the role of angio??
26 Angiography After Packing Minority required AE 13% of patients pelvic packs Time to resuscitate/transfer need for angio = avg of 10 hrs Fx classification: LC I (4) LC II (4) APC III (2) APC II (2) LC III (2) VS (2)
27 Who Needs Angiography? Can t predict by: age, ISS, presenting SBP, presenting base deficit, ED blood tx, or fracture pattern Patients with AE after packing: lower HR (105 8 vs 121 3) more RBC pre-sicu (15 3 vs 9 1) more FFP pre-sicu (9 2 vs 4 1) more RBC in SICU (7 2 vs 3 1) more FFP in SICU (6 2 vs 2 0.4)
28 Who Needs Angiography? FAST Exam Positive Negative Operating Room: Exploratory Laparotomy 2 units RBCs/ED trauma bay HD Unstable HD Stable HD Unstable If Pelvic Hematoma Evident Pelvic Fixation and Pelvic Packing HD Stable HD Unstable HD Stable Resuscitate in the SICU + CT scans Operating Room: Pelvic Fixation and Pelvic Packing Re-ultrasound Abdomen Ongoing Transfusion Requirements after Pelvic Packing? (>4 units RBCs from pelvic source with normal coags in 12 hours) Yes Angiography No SICU
29 PITFALLS Caution: Empiric Embolization. B anterior divisions embo d You can send the patient for just a diagnostic angio
30 Hybrid OR If you have hybrid OR capabilities, the algorithm may change flush angiogram of the pelvis after pelvic packing.
31 Pelvic Packing: Mortality All pelvic fx = 8% Mortality in high risk = 21% traumatic brain injury (9) multiple organ failure (4) withdrawal of support (4) pulmonary failure (3) cardiac failure (3) adverse physiology (3) invasive mucormycosis (1) Death after arrival: 89 min 100 min 9 hours
32 Modern Day Comparison 21% mortality (all cause) in our study of PP 32% mortality in AAST multicenter study 1 shock defined as SBP < 90, HR > 120, BD >6 41% mortality in angio only study 2 comparison group >10u RBCs in first 24 hrs 37% mortality in hemostatic resusc study 3 comparison group >5u RBCs in first 24 hrs 1 Costantini et al. J Trauma Acute Care Surg Tesoriero et al. J Trauma Acute Care Surg Gaski et al. J Trauma Acute Care Surg 2016
33 Unstable Pelvic Fracture Algorithm Refractory Profound Shock (SBP < 80 mmhg) FAST Exam REBOA if available Positive Negative Operating Room: Exploratory Laparotomy 2 units RBCs/ED trauma bay HD Unstable HD Stable HD Unstable If Pelvic Hematoma Evident Pelvic Fixation and Pelvic Packing HD Stable HD Unstable HD Stable Resuscitate in the SICU + CT scans Operating Room: Pelvic Fixation and Pelvic Packing Re-ultrasound Abdomen Ongoing Transfusion Requirements after Pelvic Packing? (>4 units RBCs from pelvic source with normal coags in 12 hours) Yes Angiography No SICU
34 REBOA, Ex Fix, Pelvic Packing 31 yo man, run over by a cement truck Large wound/open pelvic fx SBP 80mmHg on arrival, CXR/FAST negative sheet the pelvis Terumo sheath in CFA MT protocol Despite RBCs, SBP = 50mmHg REBOA, transport to OR
35 REBOA, Ex Fix, Pelvic Packing Ex-fix Pelvic packing REBOA deflated Catheter out = 61 min Patient stable Transfer to SICU CT scans
36 KEY POINT You have to be ready!
37 PITFALLS Avoid re-opening the pelvis exacerbates the bleeding. Look at the perineum significant external blood loss.
38 Pelvic Trauma: Summary Mortality rates remain high in complex fx. Have an algorithm. Use all techniques at your disposal Binders External fixation Pelvic packing Angioembo REBOA
39 Questions?
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