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excerpted from "Early Management of polytraumatized
patients with pelvic fracture"
Unfallchirurgische Klinik der Medizinischen Hochschule Hannover
T. Pohlemann, A. Gänsslen, T. Hüfner, H.Tscherne
Treatment protocol
In the cases were hemodynamic stability was not achieved within 10-15 minutes after admission, a surgical exploration of the pelvic retroperitoneum is performed. When the origin of bleeding can clearly be focused to the pelvic region, a midline incision of the lower abdomen is used, leaving the peritoneum intact. In the majority of cases all parapelvic fascias are already disrupted. After incision of the skin a large paravesical cavity filled with hematoma and blood clots is usually present. A direct manual access through the right or left paravesical space down to the presacral region is therefore possible without further dissection.
Primary orientation includes the check for any obvious arterial bleeding which can be readily accessed either by clamping, ligature or a vascular repair. If there is massive bleeding, a transient clamping of the infrarenal part of the aorta can be helpful. In the majority of cases a specific source of bleeding cannot be identified. The origin of hemorrhage is diffuse - either from the venous plexus or the fracture site. In external type injuries the sources of bleeding is generally located close to the anterior pelvic ring. In this region control of bleeding by surgical hemostases, closure of the pelvic ring and paravesical packing is relatively easy. With a higher degree of pelvc instability, especially in C-type injuries, the origin of bleeding is most frequently located in the prevesical region. With all compartment borders disrupted this space is generally easy to be manually accessed. The presacral and paravesical region is packed using standard surgical lap packs. An amount of 4-8 packs will be necessary for sufficient compression in the small pelvis. When the acute situation is under control, the integrity of the bladder and urethra is inspected. An urological repair should be adaequate to the patients general situation and is generally restricted to suprapubic urine drainage, insertion of a transurethral catheter and suture of the bladder.
The effectiveness of the tamponade is checked again and all now identifiable bleeding is controlled by direct surgical means. If the quality of reduction of the posterior ring is unsatisfactory, it is now adjusted to minimize bleeding from the fracture site. This is performed by a short loosening of the clamp, and the application of manual traction and internal rotation to the leg as well as control of the reduction by direct palpation of the easily accessible posterior pelvic ring. Then the definitive packing is applied and the fascia is closed.
When the abdomen has to be left open an at least partial closure of the extraperitoneal fascia in the pelvic region is recommeded for supporting the tamponade effect. Then the patient is transferred to the intensive care unit for further stabilization.
With persistant bleeding an angiography combined with embolization can now be performed. If there is still active bleeding and need for blood transfusion, first, the body temperature has to be normalized as soon as possible for stabilization of the intrinsic hemostatic system. With normal body temperature a second attempt for hemorrhage control by changing the packing is performed.
With stabilized hemodynamics the packing is left in place for 24-48 hours. During the "second look" operation the local overview is usually significantly improved and the bleeding has completely stopped or can be controlled by local surgical hemostases. With a persitent bleeding new tamponades are inserted and a "third look" is planned 24-48 hours later.