Hemodynamic Instability associated with pelvic fracture
Date: Thu, 24 Aug 2000 07:57:41 -0700
From: Chip Routt
here's my ideal management scenario assuming ongoing troubles throughout:
adult patient with pelvic ring disruption associated with hemodynamic instability-
in field volume resuscitation/airway control/circumferential pelvic sheeting or vacuum beanbag or mast application/pack open wounds/splint obvious extremity injuries-
the patient should be warmed and kept warm-
rapid transport to an appropriate facility-
adequate medications/familiar clinical & screening radiographic assessments and resuscitation simultaneously using general trauma surgeon "director/facilitator" and appropriate subspecialty consultants including experienced radiologist-sonographer-angiographer/orthopedics/urology/pulmonary... dpl/sonogram-
single, experienced pelvic mechanical evaluation, perineal and regional skin/soft tissue/urological/rectal assessments, and analysis of plain pelvic radiograph-
if sonogram and/or dpl is positive then on to operation at the quarterback's direction (use an operating table which is radiolucent and accomadates traction, and please allow the orthopedist to aid with patient positioning and wide draping) for laparotomy and appropriate pelvic stabilization (external-percutaneous-internal) according to specific pelvic injury pattern and associated injuries...specific timing of orthopedic intervention depends on clinical scenario...perhaps the simple anterior pelvic external frame can be applied while the circumferential sheet is still in place and just before laparotomy, and should be positioned to allow adequate abdominal access...after laparotomy, additional fixation is possible at same anesthetic. open wounds are washed and debrided.
if dpl/sonogram is negative then on to angiography which can be accomplished with the circumferential sheet in place...additional pelvic orthoganol imaging is easily completed just before or after angiography/embolization using their technologically advanced equiptment...this can also include simple urological radiographic evaluations such as retrograde urethrogram/cystogram...similarly external frames and even percutaneous posterior pelvic stabilization can be done in the angio suite, if necessary.
the subsequent management strategies are dependant on the patient's clinical response to the above...hopefully, complete clinical and radiographic evaluations, and appropriate treatments can proceed.
wrap/warm/fill/fix/squirt/divert. keep it simple. be available. communicate with your colleagues. get experience, or get help. be quick. keep doing something. do what's right.
that's about it-
chip