Transcript 13.05 Pelvis Fracture

HKCEM College Tutorial
Fracture
Pelvis
AUTHOR
DR. CHAN CHUN MAN
OCT., 2013
▪ You heard that a case will
be transferred to your under
primary trauma diversion.
▪ Can you name the primary
trauma diversion criteria?
Arrive A&E at 16:12
BP:90/50, P:150
SaO2 100 % (100 % O2)
GCS: 15/15 (E4V5M6)
Severe pelvic pain &
deformity
Left LL deformed
Multiple crush marks and
abrasions over both LL
Scalp haematoma
Activate Trauma Call?
What are the criteria for Trauma
Activation?
Multi-disciplinary
Polytrauma
Management
ATLS
Pelvic Fracture call
activated
Physical examination
• GCS 15/15 in agony
• PEAR
• Chest : AE fair due to pain
• Abdomen:
• Soft, mild distension and tender over lower abdomen
• PR: tone and perianal sensation intact, prostate not high riding , no
blood at meatus( what does this imply?)
• Fast scan –ve
• Hb 15 ( ?good sign)
X-ray of Trauma series
Comminuted unstable pelvi-acetabular fracture
Fracture ribs with pneumothorax
What else would you apply in A&E?
Chest drain was inserted and intubation commenced
Early Use of Pelvic Binder “R” room
Pelvic Binder
• Name the pelvic binder you are currently using.
• e.g. SAM sling or T –POD
• How to apply?
•
•
http://www.youtube.com/watch?v=KVOk1WB2yhM
http://www.youtube.com/watch?v=PO-gLZXxZ_E
Properly applied pelvic binder should
NOT obscure the surgical field
Pelvic binder
should be
centered at
the level of
greater
trochanter
Damage control resuscitation (DCR)
• Permissive hypotension ?
• What is the Target SBP
• What is the reason behind?
• Hemostatic resuscitation ? MTP
• Damage control operation or surgery (DCO/DCS)
e.g. bleeding control ,decontamination , quick body
cavity closure to rewarm patient ,planned reoperation for
definite repair when physiology normalized
Permissive hypotension
• What is the target SBP in permissive hypotension?
• SBP around 80 to 90mmHg
• To minimize the risk of hydrostatic dislodgement of
the temporary clot in bleeding vessels prior to
operation to stop internal bleeding.
Hemostatic resuscitation
• Consider early blood transfusion
• Massive transfusion protocol MTP
• What are the problems of massive
transfusions?
Massive transfusion problems
Coagulopathy ,Hypothermia and Acidosis
Thrombocytopenia
Hypocalcaemia, Hyperkalaemia
Blood Volume Replacement Acute Respiratory Distress
Syndrome (ARDS)
Massive transfusion protocol & Tranexamic Acid
( optimal blood product ratio ??1:1:1 plasma, platelet and FFP )
Transamin (Tranexamic Acid)
▪ There are increasing evidences to support use of transamin
▪ Some recommend
▪ Tranexamic acid (transamin) is to be administered to all trauma
patients (age>18 years old) fulfilling the following 3 criteria:
▪ 1)
within 3 hours of injury
▪2
with significant hemorrhage or considered to be at risk of
significant hemorrhage with compensated shock e.g. in #
pelvis, massive hemothorax, +ve FAST/hemoperitoneum
▪ 3)
with no contraindication to tranexamic acid
to transamin or DIC
e.g. no allergy
Whole Body CT at
16:46
Haemoperitoneum in pelvis
Brain: no ICH
Extensive haematoma and active contrast
extravasation at pelvic cavity
Beware CT as tunnel to death in unstable
patient
Irradiation ALARA ( as low as reasonably
achievable)
Short AED duration saves life, consider
resuscitation procedure and XR at same time
by wearing lead apron
AFTER
application
of pelvic
binder
Pelvic volume
is effectively
controlled
temporarily
Pelvic External Fixation
+ Packing + Embolization
Pelvic Damage Control
Persistent hemorrhagic shock
BP: 80/40
To OT directly after CT
Haemodynamically Unstable (Exsanguinating) Pelvic Fracture
Extremely high mortality (40-60%)
Associated with polytrauma with multiple concomitant
injuries
(up to 90%)
Survival mainly depends on timely bleeding control
Bleed to
death !
Pelvic Damage Control
3-Phase Approach
• Initial life saving procedures with control of
bleeding
• ICU stabilization
• Definite treatment later
1. Bony surface
2. Retroperitoneal Venous plexus
85% of # pelvis bleeding
3. Arterial  15%
Is both Vascular and Bone Injury !!
Concomitant injuries make the
situation even more complicated !!!
Massive bleeding can happen in any type
of fracture
 difficult to differentiate the sources in
the golden hour
1. Pelvic binder
2. External fixation
3. Retro-peritoneal pelvic packing
4. Trans-catheter arterial
embolization
5. Direct surgical hemostasis
Control of
Hemorrhage
Embolization  Arterial
Pelvic Packing 
Venous
How to Control the Bleeding:
3 in 1 Pelvic Damage Control
External Fixation  Bony
Exsanguinating Pelvic Fracture since July 2008
Pelvic Fracture
Shock
Pelvic binder
FAST Scan/ Diagnostic Peritoneal Lavage
Grossly Positive
Grossly Negative
Sustained Response to
Initial Resuscitation?
External Fixation
Pelvic Packing
Laparotomy
Yes
Stable
No
External Fixation
Pelvic Packing
+/- on table angiographic embolization
Yes
ICU +/- CT scan
Angiography
Unstable or Ongoing
Bleeding
ICU
Yes
Angiography
No
No
ICU
QEH Protocol
Persistent Shock  OT
Pelvic fracture ?
Pelvic binder
Yes
Responder ?
MTP
No
OT
Ex-Fix  Pelvic Packing (OR)  +/- Laparotomy
 On Table Angiogram & Embolization (IR)
Our Protocol- A Threein-one Approach In
Order and In OT within
same OT table
Endovascular Operating Room (EVOR)
The First Clot is the Best Clot
Protect the clot
Nurture the clot
The Strength
The Strength

Minimal time wasted on prioritizing intervention procedures, doing
unnecessary investigation and transferring patient

Flexibility of laparotomy or concomitant procedures for other
associated injuries
Thank You