Transcript Pelvic Fracture

LOGO
Hemorrhage in Pelvic
Fractures…Where To Go
Dr. Dora Tai
Introduction
Introduction
Bleeding from Pelvic Fractures
 Three bleeding sources:
1. Arteries (10-15%)
2. Low-pressure venous plexus (80-90%)
3. Fractured cancellous bone surfaces
Giannoudis PV, Pape HC. Damage control orthopaedics in unstable pelvic ring injuries. Injury, Int. J.Care Injured 2004;35:671-677.
Geeraerts T, Chhor V, Cheisson G, Martin L, Bessoud B, Ozanne A, Duranteau J. Clinical review : Initial management of blunt pelvic
trauma patients with haemodynamic instability. Critical Care 2007; 11:204-212.
White CE, Hsu JR, Holcomb JB. Haemodynamically unstable pelvic fractures. Injury, Int. J.Care Injured 2009; 40: 1023-1030.
External Pelvic Stabilization
1
2
Reduce pelvic
volume
↓
↓ blood loss
promotes
tamponade effect
Return bony pelvic
components back into
apposition
↓
Haemostatic pathways
to control venous
bleeding
3
↓ clot dislodgement
↓ elimination of
thrombotic process
↓ consumption of
clotting factors
Miller PR, Moore PS, Mansell E, Meredith W, Chang MC. External fixation or arteriogram in bleeding pelvic fracture : Initial
therapy guided by markers of haemorrhage. J Trauma 2003; 54(3):437-443.
DiGiacomo JC, Bonadies JA, Cole FJ, Diebel L, Hoff WS, Holevar M, Malcynski J, Scalea T. Practice management guidelines for
haemorrhage in pelvic fracture. Eastern Association for the Surgery of Trauma 2001; 1-15.
Pelvic Binder
Non-invasive, inexpensive
Easy to apply
Access to abdomen
White CE, Hsu JR, Holcomb JB. Haemodynamically unstable pelvic fractures. Injury, Int. J.Care Injured 2009; 40: 1023-1030.
External Fixator
Mohanty K, Musso D, Powell JM, Kortbeek JB, Kirpatrick AW. Emergent management of pelvic ring injuries: An update. Can J Surg
2005; 48(1):49-55.
DiGiacomo JC, Bonadies JA, Cole FJ, Diebel L, Hoff WS, Holevar M, Malcynski J, Scalea T. Practice management guidelines for
haemorrhage in pelvic fracture. Eastern Association for the Surgery of Trauma 2001; 1-15.
Posterior C clamp
Mohanty K, Musso D, Powell JM, Kortbeek JB, Kirpatrick AW. Emergent management of pelvic ring injuries: An update. Can J Surg
2005; 48(1):49-55.
DiGiacomo JC, Bonadies JA, Cole FJ, Diebel L, Hoff WS, Holevar M, Malcynski J, Scalea T. Practice management guidelines for
haemorrhage in pelvic fracture. Eastern Association for the Surgery of Trauma 2001; 1-15.
External Fixator
Indications:
 If laparotomy or packing is needed for
unstable pelvic fracture
Heetveld MJ, Harris I, Schlaphoff G, Sugrue M. Guidelines for the management of haemodynamically unstable pelvic
fracture patients. ANZ J.Surg 2004; 74: 520-529.
Suzuki T, Smith WR, Moore EE. Pelvic packing or angiography : Competitive or complementary? Injury, Int. J.Care
Injured 2009; 40: 343-353.
Arterial Bleeding
White CE, Hsu JR, Holcomb JB. Haemodynamically unstable pelvic fractures. Injury, Int. J.Care Injured 2009; 40: 1023-1030.
Arterial Bleeding
Indicators of significant arterial
bleeding:
1. Lack of response to initial resuscitation
2. Contrast material extravasation (blush)
on CT scan
 Sensitivity 80-84%
 Specificity 85-98%
Yoon W, Kim JK, Jeong YY, Seo JJ, Park JG, Keun HK. Pelvic arterial hemorrhage in patients with pelvic fractures : Detection with
contrast-enhanced CT. RadioGraphics 2004;24:1591-1606.
Miller PR, Moore PS, Mansell E, Meredith W, Chang MC. External fixation or arteriogram in bleeding pelvic fracture : Initial therapy
guided by markers of haemorrhage. J Trauma 2003; 54(3):437-443.
CT Scan
Axial CT scan shows pelvic haematoma (white arrows) with extravasation
of contrast medium (arrowhead).
Angiography and Embolization
Digital angiography of the left internal iliac artery with extravasation of contrast
Geeraerts T, Chhor V, Cheisson G, Martin L, Bessoud B, Ozanne A, Duranteau J. Clinical review : Initial management of blunt pelvic
trauma patients with haemodynamic instability. Critical Care 2007; 11:204-212.
Heetveld MJ, Harris I, Schlaphoff G, Sugrue M. Guidelines for the management of haemodynamically unstable pelvic fracture patients.
ANZ J.Surg 2004; 74: 520-529.
Angiography and Embolization
Indications:
1.Persistent haemodynamic instability
2.Ongoing bleed despite pelvic
packing
3.Arterial extravasation of contrast
Heetveld MJ, Harris I, Schlaphoff G, Sugrue M. Guidelines for the management of haemodynamically unstable pelvic
fracture patients. ANZ J.Surg 2004; 74: 520-529.
Balogh Z, Caldwell E, Heetveld M, Amours SD, Schlaphoff G, Harris I, Sugrue M. Institutional practice guidelines on
management of pelvic fracture-related haemodynamic instability : Do they make a difference ? J Trauma 2005; 58:778-782.
Suzuki T, Smith WR, Moore EE. Pelvic packing or angiography : Competitive or complementary? Injury, Int. J.Care Injured
2009; 40: 343-353.
Pelvic Packing
Preperitoneal
space
White CE, Hsu JR, Holcomb JB. Haemodynamically unstable pelvic fractures. Injury, Int. J.Care Injured 2009; 40: 1023-1030.
Giannoudis PV, Pape HC. Damage control orthopaedics in unstable pelvic ring injuries. Injury, Int. J.Care Injured 2004;35:671-677.
Gansslen A, Giannoudis P, Pape HC. Haemorrhage in pelvic fracture: Who needs angiography ? Curr Opin Crit Care 2003; 9:515-523.
Pelvic Packing
White CE, Hsu JR, Holcomb JB. Haemodynamically unstable pelvic fractures. Injury, Int. J.Care Injured 2009; 40: 1023-1030.
Giannoudis PV, Pape HC. Damage control orthopaedics in unstable pelvic ring injuries. Injury, Int. J.Care Injured 2004;35:671-677.
Gansslen A, Giannoudis P, Pape HC. Haemorrhage in pelvic fracture: Who needs angiography ? Curr Opin Crit Care 2003; 9:515-523.
Pelvic Packing
Indications:
 Ruptured pelvic haematoma at
laparotomy (transperitoneal)
 Unresponsive to embolization/initial
resuscitation
 No angiography facilities available
Heetveld MJ, Harris I, Schlaphoff G, Sugrue M. Guidelines for the management of haemodynamically unstable pelvic
fracture patients. ANZ J.Surg 2004; 74: 520-529.
White CE, Hsu JR, Holcomb JB. Haemodynamically unstable pelvic fractures. Injury, Int. J.Care Injured 2009; 40: 1023-1030.
CROSS-ROAD SITUATION: ANGIO or PACKING
Comparison of Interventions
Angiography +/embolisation
Advantages
Pelvic Packing
• Less invasive
• Quick to perform
• High success rate
• Does not limit access to • Does not require special
abdomen
technology
• Can stop arterial
bleeding
Disadvantages/
Complications
External fixation
• Quick to perform
• Can be placed in the
AED
• Stabilize patient for
angiography
• Time consuming
• Pin site infection
• Invasive
• Requires interventional
radiologist
• Nerve and vascular
injuries (C-clamp)
• Intrapelvic infection
• Haematoma
• May not be effective for
treatment of arterial
bleeding
• Removal required
Suzuki T, Smith WR, Moore EE. Pelvic packing or angiography : Competitive or complementary? Injury, Int. J.Care Injured 2009; 40: 343353.
Papakostidis C, Giannoudis PV. Pelvic ring injuries with haemodynamic instability : Efficacy of pelvic packing, a systematic review. Injury,
Int. J.Care Injured 2009; 40S4: S53-S61.
Time to intervention: PACKING group vs ANGIO group (45mins vs 130mins)(p=0.01)
Blood transfusion in the first 24 hours: ,less in the PACKING group
(6.9 unit vs 10.1 units ; p=0.01)
Mortality: PACKING group 4/20 vs ANGIO group 6/20 (p = 0.48)
Early mortality rate: 10% (95% CI: 3−18%)
Late mortality rate: 13% (95% CI: 5−22%)
Overall mortality: 28% (95% CI: 16.8−39.4%)
Increase in SBP after EPP (p=0.002)
Mortality : 28%
QEH Data
2005 2006 2007 2008 2009
(8 mth)
Total no. of
trauma cases
No of pelvic
injury cases (%)
401
351
371
447
402
27
38
36
45
27
(7%) (11%) (10%) (10%) (7%)
QEH Protocol 2004-2008
Pelvic Fracture
Hypotension
Wrap Pelvis with
Sheet/Binder
FAST Scan/ Diagnostic Peritoneal Lavage
Grossly Positive
Laparotomy
+ External Fixation
Grossly Negative
Sustained Response to
Initial Resuscitation?
No
Stable
Yes
ICU
No
Angiography
+ Embolization
Angiography
+ Embolization
Yes
Amenable to External
Fixation
No
ICU+CT
Yes
External
Fixation
QEH Protocol 2008-2009
Pelvic Fracture
Shock
Wrap Pelvis with Sheet/Binder
FAST Scan/ Diagnostic Peritoneal Lavage
Grossly Positive
Grossly Negative
Sustained Response to
Initial Resuscitation?
Pelvic Fixation
Pelvic Packing
Laparotomy
Yes
Stable
No
No
External Fixation
Pelvic Packing
Yes
ICU +/- CT scan
Angiography
Unstable or Ongoing
Bleeding
ICU
Yes
Angiography
No
ICU
Retrospective Review for
Unstable Pelvic Fractures
 Study period : June 2007- End of 2009
 Number of patients: 24
 Aim: To compare the mortality rate between the 2
protocols
 Previous protocol :
(Angiogram +/- Embolization) Feb 2004 – June 08
 Current protocol :
(Packing +/- Angiogram +/- Embolization) Jun 08
onward
Retrospective Review for
Unstable Pelvic Fractures
 Male : Female 15:9
 Age: mean 47.7yrs, median 45yrs, range:18-84yrs
 Mechanism of injury: Blunt trauma
 Road traffic accident: 13
 Fell from height: 11
 Trauma score (Median / Mean) : ISS 41.2/ 43
 Overall mortality : 58.3% (14/24)
QEH Data
N= 24
ANGIO
N= 13
PACKING
N=11
P value
Age
44.8 (+/- 23.7)
51.2 (+/- 19.6)
0.464
Blood transfusion in
AED (units)
3.3 (+/-4.4)
2.7 (3.37)
0.338
Combination of
treatment
0/13
5/11
0.002
Time spent in AED
(mins)
61.9 (+/- 33.5)
69.7 (+/- 15.6)
0.711
Systolic pressure on
arrival (mmHg)
61.2 (+/- 15.5)
99.0 (+/- 32.6)
0.060
ISS
40.0 (+/- 12.7)
42.3 (+/- 18.1)
0.724
RTS
5.52 (+/- 2.4)
6.92 (+/- 2.0)
0.139
TRISS
0.45 ( +/- 0.3)
0.73 (+/- 0.2)
0.050
Mortality
10/13 (77% )
4/11 (36%)
0.095
The Golden Hour…every second counts!
Acknowledgements
 Dr. Li Wing Hong
 Dr. Lee Kin Bong
 Dr. Lee Kin Yan
 Dr. Tang Lap Fai
 Dr. Ho Hiu Fai
 Ms Annice Chang