The Hemodynamically Unstable Pelvic Fracture
Transcript of The Hemodynamically Unstable Pelvic Fracture
![Page 1: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/1.jpg)
The Hemodynamically Unstable Pelvic Fracture
Peter N Thompson MD Attending Trauma Surgeon Atlanticare
![Page 2: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/2.jpg)
Disclosures
• None financial
• I am not an orthopedic surgeon
• Emergency Department presentation
• Multidisciplinary approach and needs
![Page 3: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/3.jpg)
Pelvic Fractures • Common: e.g. 9% of blunt traumas possess,
6%of these associated with mortality—so 1/20 pelvic ring injuries are lethal
• Mortality due to hemorrhage—40%, or constellation of pelvic and associated injuries e.g. head trauma—30%
• Overall incidence increasing with aging population
![Page 4: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/4.jpg)
![Page 5: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/5.jpg)
![Page 6: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/6.jpg)
![Page 7: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/7.jpg)
ATLS• Advanced Trauma Life Support—American College of Surgeons
• “Audience”—providers engaging in care of the traumatically injured patient
• Systematic approach to trauma patient
• Increasing emphasis on pelvic injury/treatment
• Concept of “golden hour”
• Once again, touches on multiple disciplines
• Someone needs to “captain the ship”
![Page 8: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/8.jpg)
Overview/Objectives• Anatomy
• Fracture Anatomy/Injury Patterns
• Diagnosis
• Management modalities/options
• Suggested treatment algorithms
• Cases
![Page 9: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/9.jpg)
Anatomy• Three fused bones in the hemi-pelvis—pubic, ischium,
iliac—referred to as “innominate”
• Bony pelvis comprised of innominate (L and R) and sacrum
• These bones are not fused but held in place by strong ligaments at sacroiliac joints and the pubic symphysis as well as “bridging” ligaments
• Horizontal platform to accept spine and lower extremities
![Page 10: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/10.jpg)
![Page 11: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/11.jpg)
![Page 12: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/12.jpg)
![Page 13: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/13.jpg)
![Page 14: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/14.jpg)
![Page 15: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/15.jpg)
![Page 16: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/16.jpg)
![Page 17: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/17.jpg)
![Page 18: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/18.jpg)
![Page 19: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/19.jpg)
![Page 20: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/20.jpg)
Anatomy
• Arteries—external and internal iliac, branches including the superior and inferior gluteal
• Associated veins
• Major nerve trunks to pelvis and lower extremity
• Pelvic organs—genital, urinary, rectal/anal
![Page 21: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/21.jpg)
Fracture Anatomy
• To organize our professional conversations fracture classifications have been developed
• Consider (1)vectors of inciting force, (2)anatomic disruption, (3)stability/instability—vertical and rotational
• Tile and Young—Burgess Classifications
![Page 22: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/22.jpg)
Vector of Force Applied
• Lateral Compression—impact from side, “t-boned”
• Anterior-posterior Compression—frontal impact, straddle injury
• Vertical shear—fall from height, vertical vector
![Page 23: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/23.jpg)
![Page 24: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/24.jpg)
Stability
• Vertical
• Rotational
![Page 25: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/25.jpg)
![Page 26: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/26.jpg)
![Page 27: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/27.jpg)
![Page 28: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/28.jpg)
![Page 29: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/29.jpg)
![Page 30: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/30.jpg)
![Page 31: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/31.jpg)
Fracture Anatomy
• If one can correlate injury vector, degree of anatomic disruption, and issues of stability with an understanding of non-bony anatomy and associations one can approach the patient in the most logical way
![Page 32: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/32.jpg)
Diagnosis• Studies have shown that in an appropriate patient
physical exam is sensitive and specific in assessing for pelvic injury
• Physical exam—GENTLE medial compression, A-P compression, SI palpation, Perineal/Rectal assessment
• DO NOT manipulate in such a way to worsen bleeding
• Obviates need for imaging
![Page 33: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/33.jpg)
![Page 34: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/34.jpg)
![Page 35: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/35.jpg)
Diagnosis/Treatment• UNSTABLE PATIENT
• ATLS Primary Survey—ABCDE
• Assume C—circulation/cardiovascular
• Resuscitate—volume, blood—blood products
• Where??—field, chest, abdomen, pelvis, long bone fractures
• Assess in order while resuscitate
• Primary survey—CXR and Pelvic Films mandatory in blunt trauma
![Page 36: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/36.jpg)
Diagnostic Imaging• Plain A-P film
• Accept false negative rate in more subtle injuries
• One is looking for gross disruptions to guide management decisions in the UNSTABLE patient
• Inlet/outlet views not usually needed—we are not looking for subtleties
• CT Scan is not part of primary survey
![Page 37: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/37.jpg)
![Page 38: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/38.jpg)
CT Scan• Assumes the patient a “responder” in the
emergency setting, even if transiently
• Shows soft tissues, hematomas, other organs, active bleeding, bony relationships
• Now with 3-D reconstructions and formatting—clear understanding
• Sensitive and specific
![Page 39: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/39.jpg)
![Page 40: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/40.jpg)
![Page 41: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/41.jpg)
![Page 42: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/42.jpg)
![Page 43: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/43.jpg)
Treatment• ABCDE of ATLS Primary Survey
• If exam and X-rays indicate “significant” pelvic injury must rule in or rule out other contributing site(s) of hemorrhage—essentially the abdomen
• This will guide the treatment pathway—as per algorithms
• Prioritize what can be done and the order thereof
![Page 44: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/44.jpg)
Treatment—Initial• Bleeding sources—bones, arteries, veins
• The normal pelvis is a tight confined space/volume
• Displaced fractures cause loss of domain, increase volume, mobility of fragments thus contributing to ongoing blood loss—volume and mobility
• Restricting bony movement, reducing the volume, may help control bleeding from bony and venous sources
• Arterial bleeding (major) is high pressure, large vessel and will usually require more definitive intervention
![Page 45: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/45.jpg)
![Page 46: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/46.jpg)
YIKES!• ATLS
• HEMORRHAGE!
• RESUSCITATE!—WHILE YOU DIAGNOSE
• TEAM APPROACH
• BLOOD and BLOOD PRODUCTS 1:1:1 or 1:2:1
• MASSIVE TRANSFUSION PROTOCOL
• MINIMIZE CRYSTALLOID
• LARGE BORE IV ACCESS, LEVEL1TRANSFUSERS/WARMERS, PRESSURE BAGS
![Page 47: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/47.jpg)
![Page 48: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/48.jpg)
Initial Treatment—ER
• Decrease Pelvic Volume/Reduce Mobility
• Binders—sheet/manufactured device (t-pod)
• External fixation—C-clamp
• Aortic Occlusion—REBOA
![Page 49: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/49.jpg)
![Page 50: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/50.jpg)
Binders• Decrease movement and volume
• Most useful in “open-book” type fracture, less so in lateral compression (volume often reduced)
• Fracture type specific—may make worse—iliac wing
• Duration—can get skin necrosis, temporizing, <24 hours
• Simple sheet, T-pod
• Apply at trochanters—can cause abdominal compression if too high
• Moderate pressure
![Page 51: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/51.jpg)
![Page 52: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/52.jpg)
![Page 53: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/53.jpg)
![Page 54: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/54.jpg)
![Page 55: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/55.jpg)
![Page 56: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/56.jpg)
![Page 57: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/57.jpg)
C-clamp
• Placed in ED
• Posterior Stabilization
• Rotates
• Temporary
![Page 58: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/58.jpg)
![Page 59: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/59.jpg)
![Page 60: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/60.jpg)
![Page 61: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/61.jpg)
![Page 62: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/62.jpg)
Aortic Occlusion Balloon
• Aortic Occlusion Balloon placed percutaneously through introducer system via femoral artery
• Several deployment positions
• Lower to occlude distal aorta/major pelvic inflow
• Temporizing measure
![Page 63: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/63.jpg)
![Page 64: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/64.jpg)
![Page 65: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/65.jpg)
![Page 66: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/66.jpg)
![Page 67: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/67.jpg)
OPERATING ROOM MANAGEMENT
• Exploratory Laparotomy—damage control, stop hemorrhage
• Pelvis—does one plunge into pelvis, break into ?tamponade?
• Exercise caution—major shunts e.g. common or external iliac artery injury—rapidly expanding hematoma
• ?? Bilateral internal iliac artery ligation??
• Best to do as little as possible
![Page 68: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/68.jpg)
Pelvic Packing• Operative intervention
• One wants to maintain integrity of peritoneum and tamponade effect of pressure
• Packs placed extraperitoneally and need to be in the deep posterior pelvis/presacral area
• Incision can be vertical or transverse
• Can accompany a laparotomy yet kept anatomically separate
• Another temporizing measure
![Page 69: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/69.jpg)
![Page 70: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/70.jpg)
![Page 71: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/71.jpg)
![Page 72: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/72.jpg)
![Page 73: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/73.jpg)
![Page 74: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/74.jpg)
![Page 75: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/75.jpg)
Angiography/Embolization• No clear predictive factors guiding patient
selection for angiography for or against
• E. g. “25%” negative, +CT blush in stable patient may be clinically insignificant
• Hemodynamic instability, no other clear source, or “recognized unstable anatomy, higher grade, large hematoma, call IR
• Better negative than too late
![Page 76: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/76.jpg)
IR Caveats!• The “Captain” controls all but the procedure itself
• Must have ongoing complete resuscitative efforts and support—essentially a full OR team and capability
• Nurses, techs, equipment—infusers, monitors, ventilators, transfusion services
• Surgical team present throughout, directing and driving care
![Page 77: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/77.jpg)
Angiography
• Bilateral “damage control” internal iliac artery occlusion with temporizing gel foam--tolerated
• Selective angiography—more time consuming, more definitive
![Page 78: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/78.jpg)
![Page 79: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/79.jpg)
![Page 80: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/80.jpg)
![Page 81: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/81.jpg)
![Page 82: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/82.jpg)
External Fixation
• Realign anatomy controlling/decreasing bony movement and decreasing/restoring pelvic volume
• Usually temporizing—internal, definitive performed later
![Page 83: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/83.jpg)
![Page 84: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/84.jpg)
![Page 85: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/85.jpg)
Associated Injuries
• Genital/urinary injuries
• Ano/rectal injuries
![Page 86: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/86.jpg)
![Page 87: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/87.jpg)
Genital Urinary
• Male—perineal, meatal blood—retrograde urethagram
• Hematuria—cystogram (somewhat CT scan directed)
![Page 88: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/88.jpg)
![Page 89: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/89.jpg)
![Page 90: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/90.jpg)
![Page 91: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/91.jpg)
![Page 92: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/92.jpg)
![Page 93: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/93.jpg)
![Page 94: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/94.jpg)
![Page 95: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/95.jpg)
![Page 96: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/96.jpg)
![Page 97: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/97.jpg)
Ano-rectal
• “Open pelvic fracture”—high association with mortal outcome
• If perineal/anal/rectal injury—diversion of fecal stream
![Page 98: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/98.jpg)
![Page 99: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/99.jpg)
![Page 100: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/100.jpg)
![Page 101: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/101.jpg)
![Page 102: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/102.jpg)
![Page 103: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/103.jpg)
![Page 104: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/104.jpg)
![Page 105: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/105.jpg)
![Page 106: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/106.jpg)
Summary Treatment
• Algorithms
• Must know YOUR system, capabilities, and tailor your management accordingly
![Page 107: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/107.jpg)
![Page 108: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/108.jpg)
![Page 109: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/109.jpg)
Treatment “Summary” for Unstable Patient
• ATLS Protocol
• Assess chest, long bones—treat and splint as needed while continuing resuscitative efforts
• (+) Pelvic fracture
• (?) Abdomen—FAST, DPL or OR
• Call IR and prepare
• Binder
• REBOA
• If OR—add preperitoneal packing while there
• If IR—call Ortho preemptively
• After IR—Ortho, ex fix
![Page 110: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/110.jpg)
![Page 111: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/111.jpg)
![Page 112: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/112.jpg)
Clinical Case # 1• 57 yo male, pedestrian struck by motor vehicle
• Presents GCS 15, complaining of R shoulder, L LE pain
• PMH NIDDM, the rest unclear, no prior surgical history
• BP 99/60, P 83, RR 24
• PE consistent with hemorrhagic shock
![Page 113: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/113.jpg)
ATLS—lets go!!• Team approach!
• Anesthesia—RSI after getting quick verbal history
• Large bore IVs, R SCV Cordis catheter, transfuse blood in trauma bay via Level 1 transfuser
• All adjuncts in place and moving ahead—Foley catheter, OGT
• ABCDE
![Page 114: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/114.jpg)
Where is the blood?• No external bleeding
• CXR—no explanation for shock state
• No long bone fractures
• Abdomen—FAST unsatisfactory—DPL/OR or CT scan
• Pelvis—open book pelvic fracture
• Binder and STAT MASS
![Page 115: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/115.jpg)
![Page 116: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/116.jpg)
![Page 117: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/117.jpg)
Decision• Evaluate the abdomen as source—binder in place
• “Transient responder”
• Given all factors—CT scan and continue vigorous resuscitation
• DO NOT “abandon” patient
• Call IR—mobilize that team
• “Heads up” call to Orthopedics
![Page 118: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/118.jpg)
![Page 119: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/119.jpg)
![Page 120: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/120.jpg)
![Page 121: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/121.jpg)
![Page 122: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/122.jpg)
Hospital Course• Trauma Bay—evaluate, resuscitate
• CT scan—diagnose
• IR suite—arterial embolization
• OR—external fixation
• To ICU to further resuscitate
![Page 123: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/123.jpg)
Hospital Course 2• By morning…..35 units PRBC, 16 units FFP, 3 platelet packs
• HD #4 ORIF
• HD #6 compartment syndrome/fasciotomy
• HD #6 L LE DVT…complete to IVC, mechanical thrombectomy (limited), IVC filter
• HD #11 Debridement of L LE fasciotomy site tissue
• HD #12 Transferred to higher Level Center to advanced orthopedics/plastics
![Page 124: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/124.jpg)
![Page 125: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/125.jpg)
Hospital Course 3
• L LE with loss of motor sensory function
• Tissue loss—extent not defined
• ARF—dialysis dependent
• Continued transfusion requirements throughout.
![Page 126: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/126.jpg)
Clinical Case 2• 18 y o male head on MVC to tree
• L LE deformity
• Signs and symptoms of shock
• GCS 15
• No significant PMH, PSH
• 18 y o but morbidly obese
![Page 127: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/127.jpg)
ATLS• RSI after obtaining history
• Again—team approach
• IV Access—during Cordis attempts—suspect pelvic fracture—anatomy “off”
• CXR o k, no blood in field reported, L femur deformity
• Pelvic film—open book pelvic fracture
• PE—rectal blood and stool
![Page 128: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/128.jpg)
Decision• Evaluate abdomen—know there are two other causes of
blood loss, hypotension, but must evaluate abdomen
• FAST “seems” negative
• Too large to DPL
• Unstable
• Patient taken to OR to further assess abdomen—DP ”analysis”
• On way to OR, notify IR, Orthopedics
![Page 129: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/129.jpg)
Decision/Treatment 2• OR—limited peritoneal peek—enough to say NOT the source of
significant bleeding, instability
• Close only skin
• TO IR suite from OR
• Angioembolization performed R pelvis bleeding
• Patient taken to OR from IR suite
• External fixation L femur, pelvis
• Completion laparotomy, diverting loop ileostomy for rectal injury
![Page 130: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/130.jpg)
![Page 131: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/131.jpg)
![Page 132: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/132.jpg)
![Page 133: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/133.jpg)
![Page 134: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/134.jpg)
![Page 135: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/135.jpg)
![Page 136: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/136.jpg)
![Page 137: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/137.jpg)
![Page 138: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/138.jpg)
Hospital Course• HD #1—31 units PRBC, 24 units FFP, 5 platelet packs
• Urine initially grossly bloody, not intraperitoneal rupture as per OR
• Ultimately urethral injury diagnosed
• Pelvic infection/perineal infection
• Three month course, ICU/floor
• Ultimately transferred to rehab facility
![Page 139: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/139.jpg)
![Page 140: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/140.jpg)
![Page 141: The Hemodynamically Unstable Pelvic Fracture](https://reader031.fdocuments.in/reader031/viewer/2022012511/6189055684edfe7e3e505c8c/html5/thumbnails/141.jpg)
BUT
• In the end complex life threatening injuries
• Require team approach to get through the immediate period
• Even then extremely challenging to ultimately get the patient to recover to satisfactory level of function