Major Pelvic Trauma Evidence Based Management Guidelines

Dr Sashi Kumar MBBS DLO FACEM

Senior Staff Specialist Emergency Medicine

The Canberra Hospital AUSTRALIA

EMERGENCY DEPARTMENT

THE CANBERRA HOSPITAL

Major Pelvic Trauma

Major Pelvic Trauma

What is the problem ?

What is the problem ?

• Major source of Blood loss (BIG Bones, muscles and veins )

• Associated Intra abdominal bleeding is about 32 % (Level III- 3 )

• Needs Multi disciplinary approach for best results• (General Surgeon ,Emergency Physician

Orthopaedic Surgeon ,Interventional Radiologist ICU specialist , Nursing staff and

Blood Bank ) ( Level – IV )

ITIM

Evidence based –What is it ?

• Conscientious, explicit and judicious use of current best evidence in making decisions

Effectiveness and Efficiency -Random Reflections on Health Services -Cochrane 1972

Centre for Evidence based Medicine (www.cebm.net )

• Levels of evidence –varies from country to country Professor Archie Cochrane 1909-1988

Levels of Evidence – U.K.

• Level A –RCT ,cohort study, clinical decision rule• Level B –Retrospective cohort, Exploratory

cohort, case control, outcomes research• Level C- Case series • Level D – Expert opinion , critical appraisal,

bench research

- Oxford Centre for Evidence based Medicine

Levels of Evidence - USA

Source: Australian Bureau of Statistics

• Level I - at least 1 properly designed RCT• Level II - 1 well designed trials not randomised• Level II - 2 well designed cohort /case control• Level II - 3 multiple time series with or without

intervention

Level III - Opinions, clinical experience,

descriptive studies ,reports from expert

committees

-U.S. Preventive Services Task Force

Levels of Evidence -Australia

NHMRC Australia 1999

Level I - Systematic review of all RCT s

Level II - One properly designed RCT

Level III – 1- Well designed pseudo randomised controlled 2- Comparative studies with concurrent controls or case control studies not randomised3 – Comparative with historical control

Level IV -Case series , post test or pre and post test

YOUNG and BURGESS

Management of bleeding following major trauma –European guidelines -D. Spahn et al Critical Care 2007

• Urgent surgical bleeding control - Grade I

• Damage control surgical approach and packing of pelvis

• Pelvic ring disruptions should be closed and stabilised

• FAST /CT to identify bleeding

• Urgent angiogram and

embolisation if unstable

EAST Guidelines - USA

Level I - NIL

Level II –

Early external immobilisation for unstable pelvic fractures with hypotensionExternal immobilisation prior to LaparotomyEarly Angiography and Embolisation when bleeding cannot be controlled at laparotomy or when iv contrast arterial extravasation on CT

-Eastern Association for the Surgery in Trauma - 2001

EAST Guidelines

• Level III

• Early external stabilisation for Unstable pelvic fractures without hypotension but requiring steady and ongoing resuscitation

• No level III recommendations as to who requires urgent Angiography and Embolisation or urgent Laparotomy

Eastern Association for the Surgery in Trauma - 2001

Management of Exsanguinating pelvic injuries

• Do not test for pelvic stability – Do early x rays• Do not remove pelvic binders until permanent

fixation is applied• If Unstable after Pelvic Binder is applied must

have arterial bleeding and needs

operative / angiographic intervention

www.trauma.org - July 2008

Management trauma. org July 2008

Stable after pelvic binder can proceed to CT

Early CXR and ICC if required

Early FAST or DPA

minimal significant

Management

• IF Angiogram and embolisation not available within 30 mins - O.R. for haemorrhage control

• Pack external wounds• Extra peritoneal packing• Damage control laparotomy

Trauma. org July 2008

Angio - embolisation

• Major active bleeding is from branches of Internal Iliac artery

• Aggressive resuscitation with blood and blood products during the procedure

• Trauma team in attendance at the Angio suite

• Future - CT scans in Resuscitation Room and

Hybrid Operating Suites with Angiography facilities

Trauma. org July 2008

Trauma. org July 2008

Australian Guidelines• NSW Institute of Trauma and Injury

Management (ITIM ) and Liverpool Hospital Sydney (livtrauma.org )

• December 2009 updated every 5 years • Recommendations based on quality evidence

available right now from all over the world

How to determine source of Bleeding

• External bleeding/CXR /Pelvic radiograph within 10 mins of arrival – III - 3

• FAST /DPA within 30 mins - III - 3• DPA is reliable – III – 3• FAST especially RUQ is reliable – III -2 • When no other source is found go for Immediate angiography - III – 3

. If no FAST or DPA available assume

intra abdominal bleeding - Consensus ITIM

How to stabilise the Pelvis

• Rotational instability – Binding – III – 3• Vertical instability – skeletal traction – III – 3• Non invasive external stabilisation devices or a

bed sheet but allow access to laparotomy and femoral access for angiography – IV

• If Non invasive fails invasive anterior external fixation - IV

ITIM

Simple Pelvic Binder

1. Place folded bed sheet underneath the patient

between iliac crests and Greater Trochanters

2. With two trauma team members cross the sheet across the pubic symphysis and pull the sheet firmly so it tightly fits around and stabilises

the pelvis

3. A third person should clamp the sheet at the four points shown (away from Laparotomy / angiography access points).

SAM SLING

How to control bleeding• FAST/DPA to exclude intra abdominal bleed

• Angiography /embolisation within 45 mins – III-3

• Early Non –invasive External stabilisation and Traction for vertical shear to control venous and bony blood loss – III – 1

• Immediate Laparotomy for intra abdominal bleeding

–III-3

• If exsanguinating – Laparotomy ,ligation of arteries ,pelvic packing and stabilisation of fractures – IV

• ORIF contraindicated in unstable patient-IV

ITIM

NSW

GUIDELINES

NSW

GUIDELINES

SUMMARY• Very little good evidence

• Early External splint is the best evidence

• Look for another source of bleeding urgently

• Early DPA / FAST • Immediate Laparotomy if positive

SUMMARY• Fix pelvis at the same time as

laparotomy• Hypotensive after external splint

needs urgent angio /embolisation if available• A Multidisciplinary TEAM approach

Thank you

Thank You !