Hemodynamic Instability associated with pelvic fracture
Bill
Looked at Shock Trauma Protocol. It is OK but I would put angio before ex fix in the FAST neg side.
Also, it does not address what to do if to not have these resources like a community hospital in a rural area.
Jim
Jim
Do you have some references that we could post to support the contention that angio should precede ex fix in the FAST Neg hemodynamically unstable pelvis? We should have an angiographer's input on this as well. Who should that be?
As far as the resource-poor rural setting goes, your algorithm seems to suggest early transfer to a place where the Shock Trauma Protocol can be implemented.
Kyle Dickson has listed the AAOS transfer criteria for Pelvic Injury in his OTA Basic Fracture Conference talk . (Hit the "Refresh" or "Reload" button to get to the rest of that lecture). There is no mention of the hemodynamically unstable pelvic fx in this list. Would you suggest a transfer criteria and protocol that we can post?
Bill
Bill
Personally I think the Shock Trauma algorithm is useful, simple, and comprehensive. However, I would include slight modifications:
Dave
Dave
>1. The use of "non invasive pelvic stabilization" as per Kellam between "fast ---> pos" and laparotomy
A question arises as to whether this would interfere with the laparotomy.
>2. Footnote on which pelvic fx are amenable to external fixation
Please specify the list of pelvic fx's types ammenable to ex fix.
>3. I would change the term "observe" for the post-angio patient with ongoing blood loss and hemodynamic instability to "rewarm, correct coagulopathy, and fluid resuscitation".
Ken Mattox (see below) has been saying on the Trauma.org
list that cyclic hyperresuscitation is bad. Jacking up the BP forces
more blood loss. I wonder if anyone can suggest some specific physiologic
parameters/goals for fluid resuscitation.
Bill
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We are focusing on the WRONG thesis, the WRONG argument, and are bound to reach the WRONG conclusions. Remember the days of "flail" chest. The patients did not look bad until AFTER they arrived at the hospital and had a lot of fluids. The issue in pelvic fracture is similar. AGGRESSIVE cyclic hyperresuscitation results in a predictable coagulopathy and a rise in venous pressure. This leads to venous bleeding from the pelvic veins, requiring repeat cyclic hyperresuscitation and a viscous cycle requiring still other therapy. The studies of immediate external fixators are virtually ALL WAG data and a lot of "expert opinion" expressed.
k