Post on 21-Jun-2020
10/2/2018
1
Acute Management of Pelvic Injuries
David Volgas, MD
CoxHealth
University of Missouri
17 yo male ped struck by truck
• HD unstable
• Open pelvic wound superior gluteal fold through rectum to scrotum
• Open rami
• Intubated at scene
Learning Objectives
1. Understand who the ‘at risk patient’ with pelvic disruption
2. Recognize response to resuscitation and how this guides management
3. Understand treatment algorithm with regards to orthopaedic and non orthopaedic intervention
Learning Objectives
1. Understand who the ‘at risk patient’ with pelvic disruption
2. Recognize response to resuscitation and how this guides management
3. Understand treatment algorithm with regards to orthopaedic and non orthopaedic intervention
Learning Objectives
1. Understand who the ‘at risk patient’ with pelvic disruption
2. Recognize response to resuscitation and how this guides management
3. Understand treatment algorithm with regards to orthopaedic and non orthopaedic intervention
Learning Objectives
1. Understand who the ‘at risk patient’ with pelvic disruption
2. Recognize response to resuscitation and how this guides management
3. Understand treatment algorithm with regards to orthopaedic and non orthopaedic intervention
10/2/2018
2
What’s the big deal?
• Hemorrhagic shock ‐‐‐ Death!!!!
What’s the big deal?
• Associated injuries
– Blunt chest injury 60%
– Long bone fractures 50%
– Head and abdominal 40% (liver, spleen, bladder)
– Spine fractures 25%
Pelvic Vascular Anatomy Pelvic Ligamentous Anatomy
Young – Burgess Classification Less Worrisome Types
10/2/2018
3
Less Worrisome TypesMortality
APC III
APC II
VS
LC III 14%
25%
25%
37%
Transfusion Requirements
Young Burgess Manson
LC 2 2.8 4
LC 3 5.7 5.6
VS 7.8 1.7
APC 2 6.4 4.5
APC 3 20.4 8
Pattern Recognition!
• Expansile
• Tensile
• Increased volume
• Increased bleeding
Pelvic Related Bleeding• Venous
‐ 80‐90%
• Fracture surface
• Open wounds
• Arterial
‐ Superior gluteal (APC)
‐ Obturator (LC)
‐ Internal pudendal (LC)
• Others
Mechanically Unstable Pelvis
YES NOHemodynamic Instability
Finish Course Elective Stabilization
pRBC and products per resuscitation protocol
Reduction and provisional stabilization of pelvis‐Sheet‐Binder‐Frame
Hemodynamic Reassessment
10/2/2018
4
Chip Rout’s Algorithm
• Wrap ‘em
• Warm ‘em
• Fill ‘em
• Squirt ‘em
• Divert ‘em
• Fix ‘em
In English for the rest of us
• Pelvic Containment
• Thermoregulation
• Fluid Resuscitation
• Pelvic Angiography
• Colonic Diversion
• Operative Fixation
Chip Rout’s Algorithm
• Wrap ‘em
• Warm ‘em
• Fill ‘em
• Squirt ‘em
• Divert ‘em
• Fix ‘em
Pelvic Containment
• Taping
• Circumferential sheet
• External fixation
Gardner et al. JOT 2009
Circumferential Pelvic Sheeting
10/2/2018
5
‐Traction‐Open wounds‐Check reduction
Presentation Post binder Comment about binder application
• Non ortho providers may or may not recognize increased pelvic volume
• No down side to have binder on LC pattern or acetabular fracture
• Can always remove if not needed
• Guess wrong DEATH
Comment about binder application
• Non ortho providers may or may not recognize increased pelvic volume
• No down side to have binder on LC pattern or acetabular fracture
• Can always remove if not needed
• Guess wrong DEATH
Comment about binder application
• Non ortho providers may or may not recognize increased pelvic volume
• No down side to have binder on LC pattern or acetabular fracture
• Can always remove if not needed
• Guess wrong DEATH
Garder et al. JOT 2009
Working Portals
10/2/2018
6
Pelvic Binders? Anterior Pelvic External Fixation•2nd phase•Transition from binder/sheet
• Improve and maintain reduction
•Stability•Time
Anterior Pelvic External Fixation
•AIIS
•Iliac crest
•Combo
Anterior Pelvic External Fixation
Disadvantages
•Pin site infection
•Not for all injuries
•Lack of posterior control
Chip Rout’s Algorithm
• Wrap ‘em
• Warm ‘em
• Fill ‘em
• Squirt ‘em
• Divert ‘em
• Fix ‘em
Thermoregulation
• Injury
• Hemorrhage
• Hypothermia
• Acidosis
• Coagulopathy
10/2/2018
7
Chip Rout’s Algorithm
• Wrap ‘em
• Warm ‘em
• Fill ‘em
• Squirt ‘em
• Divert ‘em
• Fix ‘em
Appropriate Resuscitation
• Controversial
• 1:1:1 vs whole blood?
• Minimal crystalloid
Chip Rout’s Algorithm
• Wrap ‘em
• Warm ‘em
• Fill ‘em
• Squirt ‘em
• Divert ‘em
• Fix ‘em
Angiography
• Indications:- Transfusion non-responder
- High risk patterns
- Age > 60
- Contrast extravasation
- Bladder displacement
• Be present!
• Resuscitative
Endovascular
Balloon
Occlusion of the
Aorta
REBOA Pelvic Packing
• Be present!
• Pelvic containment
needed
10/2/2018
8
Chip Rout’s Algorithm
• Wrap ‘em
• Warm ‘em
• Fill ‘em
• Squirt ‘em
• Divert ‘em
• Fix ‘em
Diverting colostomy
• Indicated in open pelvic fractures, especially with rectal tear
Diverting Colostomy
• Be present!
• Assist in location
• Future surgical
incisions
Chip Rout’s Algorithm
• Wrap ‘em
• Warm ‘em
• Fill ‘em
• Squirt ‘em
• Divert ‘em
• Fix ‘em
Gardner et al. JOT 2009
• Screw reduction • Select patients• Pure distraction pattern• Limited associated reduction
• Efficient technique mandatory
• Temporary or definitive
Gardner et al. JOT 2009
10/2/2018
9
Our Patient
• 75 yo female
• Auto vs. ped
• BP: 80/40
• Resuscitating
Open Pelvic Fractures
• 50% mortality!!!!
• Rectal tears / vaginal tears
• Good physical exam in mandatory in all cases
– Supplement with speculum or proctoscope exam
Open wound management
• Inspect
• Plug hole
• Reduce pelvis
• Recognize debridement needed, possible diversion
Summary
• Emergency providers should recognize at risk fracture patterns
• Pelvic sheet is always appropriate but must be done correctly
• Remember to warm and fluid resuscitate patient at all times
• 80% of pelvic bleeding is venous and will respond to closing the pelvic volume
Words of Wisdom
• Remain calm & consistent
• Resist chaos• ATLS!• ABCDE