The Case Presentation

On Impact: A 28 year old male motorcyclist traveling approx 60 mph intercepts an automobile which ignores a stoplight.

Image from DEKRA and the Winterthur Insurance Company

On Scene: pulse 120, systolic blood pressure 90, Resp 16, GCS 8.

PreHospital Questions:

• The BP is 90 systolic. All pelvic injury algorithms selected for this discussion are acivated by "hemodynamic instability". Adam Starr has called for a definition of this term. Is this patient "hemodynamically unstable"?
• Most algorithms (e.g. Agolini ) - with the exception of Brohi - call for fluid resuscitation. How much fluid should this patient receive? Can Ken Mattox help answer this?
• As a diagnostic measure, the ATLS Manual recommends "Downward pressure with the heels of the hands on both anterior superior iliac spines". Tim Coats warns against disturbance of clot formation. What should be done in the field to recognize a pelvic injury in this patient? Both in the field and in the hospital, should such movements as log-rolling to check for spinal injury be deferred?
• The Rt iliac wing is mobile to exam and the nearest hospital is 30 minutes away. What (if any) sort of provisional pelvic stabilization (e.g. Dallas binder, G-Suit, Kendrick extrication device, Geneva belt, London splint, etc) should be applied to this patient?
• The nearest community hospital is 30 minutes away. The nearest Level II Trauma Center (Surgery and Orthopaedics on call - volume = 2-3 major pelvic fractures/month) is 60 minutes away. The nearest Level I Trauma Center (Surgery and Orthopaedic residents in house, Inverventional Radiologist on call - volume = 8-10 major pelvic fractures/month) is 90 minutes away. Both the Kellam and the Routt algorithms address the transfer question. To which hospital should this patient be transported? What should the minimum hospital staffing, infrastructural and utilization requirements be to ensure adequate care for this patient?

On Arrival - Level I: pulse 160, blood pressure 70/40, patient saran wrapped to backboard, intubated and Ambu bag ventilated, saturations 99%, 2 large bore iv's running LR. Chest Xray - Lt hemopneumothorax. Lt Chest tube placed. AP pelvic Xray obtained.

Image courtesy of Kenneth Johnson, MD, Vanderbilt Univ Med Ctr, Nashville

Emergency Room Questions:

• The Agolini and Brohi algorithms immediately determine pelvic mechanical stability. Others (e.g. Scalea) focus FAST or DPL. What should be ordered first in this patient? FAST /DPL for the determination of intra-abdominal hemorrhage or AP Pelvic xray for a determination of pelvic stability?
• How is pelvic "mechanical instability" defined?
• Are routine Pelvic AP xrays required for all hemodynamically unstable trauma patients - or only those patients with positive physical findings?
• Are the orthopaedic Tile and Burgess-Young pelvic injury classifications well enough understood and accepted to drive an interdisciplinary approach to this hemodynamically and mechanically unstable pelvic injury ?
• Can pelvic pathomechanics be as neatly categorized as the Burgess-Young pelvic injury classification suggests or are most combined mechanical injuries ?

Image courtesy of Karim Brohi, FRCS, London Hospital, Trauma.Org

A sheet was immediately wrapped around the pelvis in the emergency room. Blood pressure improved to 90/60 with tachycardia of 130/min.

Image courtesy of Paul Tornetta III, MD, Boston Univ Med Ctr

More Emergency Room Questions:

• The Kellam, Brohi and Routt algorithms call for "non-invasive" pelvic stabilization. Can noninvasive stabilization be used as a predictor for the need for immediate external fixation vs. laparotomy vs. angiography?
• What is the most likely source of ongoing pelvic bleeding in this patient - broad fracture surfaces, posterior venous plexus or arterial?
• The blood bank is calling about anticipated transfusion requirements. Based on the AP Pelvic Xrays, can an estimation of blood loss be made for this patient?
• While it has been shown that pelvic fractures are "skeletal markers" for major associated injury (e.g. aortic injury), some studies show the specificity of such markers to be poor. Should pelvic injury algorithms address specific unstable pelvic injury types?
• At this point, Evers and Pohlemann have already taken the patient to the OR. Is this overutilization of hospital resources?

The patient has received 3000 cc crystalloid, the 4th of 10 units of PRBC's and 1 unit of FFP is ordered. Abdominal ultrasound shows hypoechoic stripe in Rt upper quadrant Morrison's pouch (positive for free intraperitoneal blood).

Image courtesy of Karim Brohi, FRCS, London Hospital, Trauma.Org

FAST vs DPL Questions:

• Despite conclusive evidence that focused abdominal ultrasound for trauma (FAST) is as reliable, faster than and more readily repeatable than diagnostic peritoneal lavage (DPL), why does only the Scalea algorithm calls exclusively for a FAST determination of hemoperitoneum?
• Given the accuracy of FAST, when the patient becomes hemodynamically unstable after negative FAST examination, why does the Scalea algorithm call for an open diagnostic peritoneal lavage instead of a repeat FAST?
• Laparotomy can significantly diminish tamponade of a retroperitoneal hematoma. If the diagnostic accuracy of DPL and FAST are similar, won't the significant incidence of DPL false positves resulting from intraperitoneal diapedesis of the retroperitoneal hematoma similarly predispose the patient to an unnecessary laparotomy?
• What is the accuracy of FAST in the presence of a large retroperitoneal haematoma?
• Should portable FAST ultrasonography be performed earlier on pelvic injury patients by EMS flight nurses?
• What if this patient were FAST Negative? What would be the next step?

To maintain closure of the open book pelvis while providing full abdominal access, the sheet & towel clip were replaced with a pelvic clamp. The fluoroscopically assisted application time was 35 minutes.

Image courtesy of Kenneth Johnson, MD, Vanderbilt Univ Med Ctr, Nashville

Ex Fix Questions:

• The surgeons (e.g. Scalea, Brohi, Agolini) want to perform an immediate laparotomy. The orthopaedists (e.g. Kellam, Routt) want an immediate Ex Fix. What should be done first in this case?
• It appears that fluoroscopy is increasingly recommended for pelvic external fixation and that this is causing angst amongst general surgical colleagues who feel it may be over-extending an unnecessary procedure. How long should pelvic external fixation take and what are the minimum requirements to perform it properly?
• It appears that pelvic external fixation
  • does not significantly tamponade retroperitoneal hemorrhage,
  • does not significantly reduce intrapelvic volume,
  • cannot control suprapelvic Zone 1 and 2 retroperitoneal hematoma extension and
  • frequently increases posterior pelvic displacement - in the vicinity of major sources of venous and arterial hemorrhage.
    
    Is there any evidence to support the use of the external fixator?
    
    
• C-Clamp vs. Pelvic Stabilizer vs. Anterior External Fixation. Which one is the best for this patient?

On OR Arrival: 45 minutes after arrival in the ER, 10 Units of PRBC's, 1 Unit FFP, 6000 cc crystalloid, the patient arrives in the operating room for laparotomy with BP 90/50 pulse 140. An extensive liver laceration is found and is controlled with packing. A large pelvic retroperitoneal haematoma is present. A symphysis pubis 4 hole 4.5 mm pelvic reconstruction plate closes the anterior diastasis and bilateral extraperitoneal paravesicular pelvic packing is performed after the evacuation of approximately 3000 cc of clot from this region. The abdomen is closed with running suture. The pelvic C-Clamp is removed. After the 70 minute operative procedure and 6 more units of PRBC's, 2500 cc of crystalloid, the BP has been maintained at 90/60, pulse 140, urine output since admission 300 cc. Post op labs: Hct 24, Plt 64K, PH 7.12, pO2 312, pCO2 56.

The patient is transferred to the angiography suite. Within 30 minutes, hemorrhage from the left obturator artery is identified and embolized. BP 100/70, pulse 100, Lab: Hct 17, Plt 91K, INR 1.26, PTT 44.3

Image courtesy of Steven Olson, MD, UC Davis, Sacramento

Angiography Questions:

• In retrospect should angiography have been performed first?
• In what percentage of hemodynamically unstable pelvic injuries can angiography achieve hemostasis?
• Are there specific patterns of pelvic fracture which have a higher incidence of significant arterial vs. venous and fracture surface bleeding?
• Does the presence of orthopaedic hardware complicate angiographic visualization and treatment of hemorrhage?
• Bladder necrosis has been reported with embolization. What are the complications of angiographic hemostasis?

After sustained hemodynamic improvement in angiography and in anticipation of a prolonged and difficult ICU course, the orthogonal fluoroscopy is utilized to guide percutaneous Rt iliosacral screws to supplement the pelvic internal fixation. After a total of 90 minutes in the angiography suite patient is transferred to the intensive care unit where he was warmed and his acidosis and coagulopathy corrected.

Image courtesy of Kenneth Johnson, MD, Vanderbilt Univ Med Ctr, Nashville

Percutaneous Iliosacral Screw Questions:

• Is there any place for iliosacral screw fixation in the haemodynamically unstable patient?
• What is percentage of complete posterior pelvic disruptions (Tile type C injuries) can be reduced closed?
• What is the neural and vascular complication rate of percutaneous iliosacral screw fixation?
• What is the fixation failure rate of of percutaneous iliosacral screw fixation?
• Is it safe/advisable to proceed with percutaneous iliosacral screw fixation prior to obtaining a CT scan of the posterior pelvis?
• What is the average percutaneous iliosacral screw placement time?

The patient subsequently underwent a CT scan of his head which revealed tight cisterns, a left subdural hematoma and a mass effect of the left ventricles. Intracranial pressure monitoring was established via a right frontal burr hole. Initial intracranial pressures of approximately 35 mm Hg increased relentlessly over the ensuing 48 hours despite Mannitol and further aggressive support. Eventually ICP topped 100 mm Hg pressure. Pupils became fixed and dilated. A day later life support was withdrawn.

Image courtesy of Eric Frykberg, MD, Shands, UF Jacksonville