Hemodynamic Instability associated with pelvic fracture
1. Hemodynamic instability includes not only hypotension, but also tachycardia, significant base deficit, unexplained fall in hemoglobin and high intravenous fluid infusion rates and volumes to maintain blood pressure. If any of these adverse indicators are present in the pelvic fracture patient, immediate consultation should be obtained from General Surgery and Orthopaedics Surgery, while aggressive resuscitative efforts are directed at stabilizing the patient's airway, breathing and circulation. Interventional Radiology, if available, should be notified in advance in the event that pelvic angiography and embolization are required.
2. Common causes of hemodynamic instability in the trauma patient include tension pneumothorax, and hemorrhagic shock secondary to intra-thoracic, intra-abdominal, and externalcutaneous sources. Bleeding from the face and scalp, in particular, can be quite profuse and is oftentimes underestimated in terms of its significance. Hemorrhage control may require packing and occasionally direct suture ligation (particularly in the case of scalp bleeding) to effect hemostatic control. In patients with pelvic fractures, external bleeding from the pelvic region should alert the physician to the possibility of an open pelvic fracture. External bleeding in association with an open pelvic fracture can be torrential and immediately life-threatening and requires immediate attention. Under these circumstances bleeding is most efficiently controlled with vigorous gauze packing of the bleeding site and non definitive stabilization of the pelvis with traction and external compressive devices (see footnote #3), such as a sheet,while other means of definitive hemorrhage control (i.e., angiography and/or external fixation) areis pursued. The diagnosis and management of life-threatening intra-abdominal hemorrhage in the context of the pelvic fracture patient is discussed in footnote # 5 below, while material related to life-threatening thoracic injuries can be found in Chapter ___.
3. Non-Invasive Pelvic Stabilization (NIPS) is indicated in those patients whose pelvic fractures are either clinically unstable (bony pelvis is unstable to pelvic compressionclinical examination), and/or radiologically unstable (any widening of the posterior pelvic ring on the AP pelvic radiograph). Under these circumstances, NIPS can be achieved by application of any of a number of stabilizing garments. These include the MAST (Military Anti-Shock Trouser), a vacuum beanbag, or even a standard bedsheet wrapped around the pelvis and secured anteriorly sufficiently to limit movement of the bony pelvis. These techniques should be supplemented by longitudinal skeletal traction of 20 to 30 lbs. on the invovled extremity (either femoral or tibial). If the MAST is employed, both lower extremity compartments and abdominal compartment should be inflated to 30 to 40 mmHg pressure. Thorough inspection of the abdomen, pelvis and lower extremities should be carried out prior to NIPS application to identify any sites of significant hemorrhage which must be controlled prior to patient transfer. This information must be relayed to the accepting physician, and these areas immediately re-inspected upon arrival to the accepting institution, to ensure adequate and on-going hemorrhage control.
4. The prompt availability of experienced general surgeons, orthopedic surgeons, and interventional radiologists is mandatory to achieve optimal salvage of these critically injured patients. Ideally, the general surgeon and orthopedic surgeon should be present upon patient arrival but certainlyat a minimum should be present within 15 minutes of patient arrival. Interventional angiography should be available within 30 minutes of patient arrival. If none of these resources can be brought to bear in this time frame, the patient should be transferred to an institution of higher capability. However, if life-threatening intra-abdominal hemorrhage is present (see footnote # 5 below), and an experienced general surgeon is promptly available, emergent laparotomy should be carried out to control abdominal cavitary hemorrhage. Following emergent laparotomy, which may require intra-abdominal packing, If packing is necessary to control pelvic hemorrhage , it must be placed in the extraperitoneal space of the true pelvis. NIPS can be applied and the patient transferred to an institution where experienced trauma, orthopedicstssurgeons and angiographers are available.
5. "Life-Threatening Intra-Abdominal Hemorrhage" refers to a magnitude of hemoperitoneum sufficient to be the sole cause of, or contribute significantly to, the patient's on-going hemodynamic instability. Given the inadvisability of Abdominal CT in hemodynamically unstable patients, and the well-documented inaccuracy of DPL (Diagnostic Peritoneal Lavage) in patients with pelvic fracture, the diagnostic test of choice in this situation is the performance of a DPT (Diagnostic Peritoneal Tap). This test should be performed using an open supra-umbilical approach to reduce the chances of a false-positive aspirate. Aspiration of 5-10cc of gross blood is considered a positive tap, and an indication for emergent laparotomy. An alternative to DPT is Abdominal Ultrasonography, performed by the radiologist, surgeon or emergency physician at the patient's bedside in the Emergency Department, but only if it is immediately available, and reliably interpreted. { what is a positive U/S result] If the results of the abdominal ultrasound are in any way equivocal, a DPT must be done. Please refer to related material on the evaluation of abdominal injury in Chapter ______.
6. Refers to the initial skeletal stabilization of the bony pelvis. Not all patients with pelvic fractures will benefit from such fixation, and the various fixation techniques do have their own complications. Therefore, early involvement of an experienced orthopaedic surgeon is critical in determining whether skeletal stabilization should be employed, as well as which particular type of stabilization (external fixator, internal fixation, skeletal traction) will be used.
7. Radiology should be notified as soon as the need for angiography is identified in order to ensure their prompt availability. Likewise, angiography should not be delayed by the performance of non-life-threatening diagnostic and therapeutic procedures. Contrast studies of the genito-urinary tract should be delayed until after angiography has been completed, as these may obscure the angiographic field and delay/prevent angiographic control of pelvic hemorrhage. As far as possible, the patient should remain in a monitored environment (ED or ICU) while awaiting angiography. In the setting of pelvic fracture-related hemorrhage, pelvic angiography should be carried out with a flush aortogram with bilateral runoff, followed by bilateral selective injections into the iliac vessels. If arterial hemorrhage is documented, control of such should be obtained via conventional embolization techniques using non resorbable emboli. Under certain circumstances (vessel spasm or abrupt cutoff of a named vessel without frank extravasation), pre-emptive embolization should be considered is done to reduce the likelihood of recurrent arterial hemorrhage.
8. The timing of the initial skeletal stabilization (if indicated) relative to the laparotomy (simultaneous vs before/after) should be mutually agreed upon by the Attending Traumatologist and Orthopedicstsurgeon. There is, however, some evidence to suggest that laparotomy may cause further destabilization of the pelvic retroperitoneal compartment, resulting in a significant increase in the space into which retroperitoneal hemorrhage can occur. Thus, in those situations where both emergent laparotomy and external pelvic fixation are required, some consideration should be given to applying the external fixation device prior to proceeding with laparotomy, if this can be accomplished without undue delay. If not, then the orthopedic surgeon must be in attendance in the operating room and the patient prepared sterily so a frame can be applied immediately should the patient become hemodymamically abnormal.
9. In the hemodynamically unstable patient, laparotomy should be directed towards life-saving maneuvers, i.e. the Damage Control Laparotomy. Hemorrhage should be controlled rapidly by organ resection if possible (i.e. spleen, kidney) or by other means of hemostasis, including packing, if resection is not feasible (i.e. liver). Enteric spillage is controlled grossly by ligation, over-sewing or stapling with no attempt to re-establish bowel continuity. Definitive organ injury repair is accomplished at subsequent laparotomy once control of pelvic-related hemorrhage has been achieved, and the patient is no longer acidotic, coagulopathic or hypothermic. If hemodynamic stability is rapidly restored during laparotomy, definitive repair of organ injury (including diverting colostomy for selected patients with open pelvic fractures [see # __ below]), may be undertaken provided other extra-abdominal life-threatening conditions (including expanding retroperitoneal hematoma [see # 10 below]) are not present.
10. RPH = retroperitoneal hematoma. A large and/or expanding retroperitoneal hematoma seen at the time of laparotomy is an indication for pelvic angiography immediately following completion of the laparotomy, regardless of the hemodynamic stability of the patient. It maybe useful to consider packing the true pelvis by placing large sponges posterior to the pubic rami and in front of the bladder. This will control the bleeding in the true pelvis. If the patient is in extremis, opening the retroperitoneum and cross clamping the aorta maybe lifesaving. Following this, a controlled look for minor arterial hemorrhage is possible and when controlled, it maybe possible to internally stabilize the pelvic fracture.
11. Radiology should be notified as soon as the need for angiography is identified in order to ensure its immediate availability at the completion of the laparotomy. Under these circumstances, laparotomy should be limited to the treatment of life-saving procedures, reserving definitive repair of non-life-threatening injuries until angiography has been completed and the patient fully resuscitated. In patients with evidence of severe closed head injury, rapid CT scanning of the head, if not already performed, should precede pelvic angiography in order to ensure a non-contrasted head CT. In the setting of pelvic fracture-related hemorrhage, pelvic angiography should be carried out with a flush aortogram with bilateral runoff, followed by bilateral selective injections into the iliac vessels. If arterial hemorrhage is documented, control of such should be obtained via conventional embolization techniques. Under certain circumstances (vessel spasm or abrupt cutoff of a named vessel without frank extravasation), pre-emptive embolization should be considered to reduce the likelihood of recurrent arterial hemorrhage.
12. All hemodynamically unstable patients with pelvic fracture should be admitted to the ICU for ongoing resuscitation and evaluation. It is particularly important to correct any abnormalities involving the "lethal triad" (coagulopathy, hypothermia, and acidosis).
13. Hemodynamic instability is determined utilizing those clinical parameters listed in # 1 above. Transfusion requirements in excess of 5 units within 24 hours or 8 units within 48 hours of admission have been recommended as indications for angiography. .Must make sure that coagulation parameters are normalized.
14. Although persistent hemodynamic instability and /or excessive transfusion requirements may be due to extra-pelvic hemorrhagic sources, angiography, if not previously performed, is mandatory. If angiography has been previously performed, repeat pelvic angiography may reveal embolizable sources that may have been missed at the initial angiogram secondary to arterial spasm or hypotension.
15. Open pelvic fracture refers to a pelvic fracture in which the fracture site communicates directly with the external skin or with an adjacent mucosal surface (i.e., vagina, bladder or rectum).
16. In patients with open pelvic fractures, it is imperative to determine the exact site of communication between the fracture site and the skin or mucosal surface. Patients whose fracture sites communicate with cutaneous openings of the anterior abdominal wall or flank will not require such diversion.
17. In patients whose open pelvic fractures communicate with buttock or perineal wounds or where the open wound maybe potential soiled with fecal contents, a completely diverting colostomy should be performed as soon as possible but no later thanwithin 48 hours from the of injury. as tThe incidence of pelvic-related sepsis increases dramatically beyond this point. These wounds should also be subjected to serial irrigation and debridement (sometimes as frequently as daily), until a clean and granulating surface is obtained. Prior to performing the colostomy, the general surgeon should consult with the orthopedic surgeon so as not to place the colostomy in a site which would preclude the orthopedic surgeon from obtaining optimal exposure for open reduction and internal fixation (ORIF) of the pelvic fracture if required.
18. Definitive pelvic fracture fixation should be accomplished when the
patient is hemodynamically stable, pelvic fracture-related hemorrhage has
been controlled, and the nature of the instability of the pelvic ring has
been ascertained.