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Fracture Pelvis

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)

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Fracture Pelvis

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  1. HKCEM College Tutorial Fracture Pelvis Author Dr. Chan Chun Man Oct., 2013

  2. You heard that a case will be transferred to your under primary trauma diversion. • Can you name the primary trauma diversion criteria?

  3. 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

  4. Activate Trauma Call?What are the criteria for Trauma Activation?

  5. Multi-disciplinary Polytrauma Management ATLS Pelvic Fracture call activated

  6. 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)

  7. X-ray of Trauma series Comminuted unstable pelvi-acetabular fracture Fracture ribs with pneumothorax

  8. What else would you apply in A&E? Chest drain was inserted and intubation commenced

  9. Early Use of Pelvic Binder “R” room

  10. 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

  11. Properly applied pelvic binder should NOT obscure the surgical field Pelvic binder should be centered at the level of greater trochanter

  12. 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

  13. 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.

  14. Hemostatic resuscitation • Consider early blood transfusion • Massive transfusion protocol MTP • What are the problems of massive transfusions?

  15. Massive transfusion problems Coagulopathy ,Hypothermia and Acidosis Thrombocytopenia Hypocalcaemia, Hyperkalaemia Blood Volume ReplacementAcute Respiratory Distress Syndrome (ARDS)

  16. Massive transfusion protocol & Tranexamic Acid( optimal blood product ratio ??1:1:1 plasma, platelet and FFP )

  17. 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    e.g. no allergy to transamin or DIC

  18. 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

  19. AFTER application of pelvic binder Pelvic volume is effectively controlled temporarily

  20. 3 in 1 Pelvic Damage Control Pelvic External Fixation + Packing + Embolization Pelvic Damage Control Persistent hemorrhagic shock BP: 80/40 To OT directly after CT

  21. 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 !

  22. Pelvic Damage Control3-Phase Approach Initial life saving procedures with control of bleeding ICU stabilization Definite treatment later

  23. Bony surface Retroperitoneal Venous plexus Arterial 15% 85% of # pelvis bleeding Is both Vascular and Bone Injury !!

  24. Any Fracture Patterncan Bleed to Death ! 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

  25. Pelvic binder • External fixation • Retro-peritoneal pelvic packing • Trans-catheter arterial embolization • Direct surgical hemostasis Control of Hemorrhage

  26. How to Control the Bleeding:3 in 1 Pelvic Damage Control Pelvic Packing  Venous Embolization  Arterial External Fixation  Bony OR ( Ext. Fix.  Packing ) IR Multi-disciplinary: each part plays a role

  27. 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 No Stable External Fixation Pelvic Packing +/- on table angiographic embolization No Yes ICU +/- CT scan Angiography Unstable or Ongoing Bleeding ICU Yes No Angiography ICU

  28. QEH ProtocolPersistent Shock  OT Pelvic binder Pelvic fracture ? Yes Responder ? MTP No OT Ex-Fix  Pelvic Packing (OR)  +/- Laparotomy On Table Angiogram & Embolization (IR)

  29. Our Protocol- A Three-in-one Approach In Order and In OT within same OT table Endovascular Operating Room (EVOR)

  30. The First Clot is the Best Clot Nurture the clot Protect the clot Pelvic binder at the level of greater trochanter Should apply pelvic binder before CT Massive Transfusion Protocol blood: FFP: Platelet conc in 1:1:1

  31. The Strength • External Fixation: - done before pelvic packing to re-establish a stable bony pelvic and to limit the pelvic volume • Angiographic Embolization : Set up during ex-fix & pelvic packing ~ 30mins, to minimal time wasting Indication depends on clinical condition after pelvic packing

  32. The Strength Address all 3 major bleeding sources • in one order consecutively • at the same theatre • within the Golden Hour • Minimal time wasted on prioritizing intervention procedures, doing unnecessary investigation and transferring patient • Flexibility of laparotomy or concomitant procedures for other associated injuries

  33. Thank You

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