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Pelvic Trauma. College of Emergency Medicine Southampton 29 th March 2011. Dr Gareth Davies Consultant in EM & PHC Medical Director London’s Air Ambulance. Aims. Review epidemiology Review types / classification of pelvic fracture & its importance Review various treatment modalities
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Pelvic Trauma College of Emergency Medicine Southampton 29th March 2011 Dr Gareth Davies Consultant in EM & PHC Medical Director London’s Air Ambulance
Aims • Review epidemiology • Review types / classification of pelvic fracture & its importance • Review various treatment modalities • Which are most pertinent to the ED clinician • Importance of patient handling • Review an example algorithm for ED management • Review a diagnostic dilemma
Epidemiology • Rare in context of all trauma • < 5% of ED fractures • Causes • Car RTA’s 50% • Pedestrian 20% • Motorcycle 10% • Falls 10% • Crush 5% • Misc 5%
Epidemiology • Disease associated with other injuries • 50% have head 50 % long bone • May have conflicting management strategies • Significant mortality rate 15 - 50% • Hypotension assd with higher mortality
Classifications • Tile, Toronto • Complex • Based on stability of post segment • ? benefit to ED clinician • Young and Burgess, Baltimore • Mechanism-based classification: Antero-posterior (AP) compression Lateral compression Vertical shear
In anyone patient multiple types Windswept pelvis
Importance of classification ? For ED physician debatable All can be unstable All can produce catastrophic bleeding Focus for ED - controlling bleeding
Pelvic Haemorrhage • Hyper acute • Road side • Acute • ED • Theatre • Angio • Subacute • ITU
Where does blood go? Retroperitoneal Intraperitoneal External
Retroperitoneal haematoma • Large volume - litres • Not picked up by FAST
Intraperitoneal bleeding • It’s a dilemma • Remember surgery is trauma • Positive FAST =/= theatre • Depending on clinical picture go to CT to assess intra-abdominal injuries • Move to angio • Caution mesenteric vessel bleed
Bleeding from the pelvis • Venous bleeding – around 90% • Sacral venous plexus • Arterial bleeding – around 10% • Branches of internal iliac artery • Bleeding from disrupted bones • Vertical shear > open book > lateral compression
Treatment Strategies External / Internal Fixation Pelvic packaging Angiography Patient handling Binders Blood pressure control Coagulation control Temperature control
Relationship between patient movement , handling and bleeding
ATLS “springing” of the pelvis Produced falls in BP
In resus characteristic times when BP fell Log rolling packaging for scanner spinal examination
? “Not an issue just top them up with some gelo”!!??
Dislodgement of clot Loss of tamponade Movement at Sacro iliac joint Fall in blood pressure Net effect
150o 90o 90o At hospital On Spinal Board 90o 90o RSI On Spinal Board Total = 330o Grand Total = 510o
150o 10o 10o On scoop Counter traction Left blade out Right blade out RSI Left blade in Right blade in At hospital Total = 170o 0o Total = 170o
Board and early roll 510 degrees 70% reduction in movement Scoop and delayed roll 170 degrees
Handling of pelvic fractures Should be based on patient need Recognises the whole of the patient pathway Not what suits individual practitioners Remember first clots are the best
Clinical Strategy Promote clots Promote clot stability
What do most trauma patients arrive on in your department? 50% RTA
Preferred Handling Device For Poly Trauma Patients? JRCALC - Scoop