From: Michael Sugrue
Date: Sun, 12 Nov 2000 08:21:10 +1000
Is there any evidence to show a towel works? and on a second issue what is the scientific Level 1 and 2 supported evidence that orthopaedic fixation works.
Tie a towel around the pelvis is 100% successful - an easily acheived and an outcome that can be measured ie. one secure knot! Where is the evidence however that is stops the bleeing or the lesser outcome that it helps fix the pelvis.
From: McSwain, Norman
Date: Mon, 13 Nov 2000 11:55:17 -0600
PASG is supported in the literature and practical experience as working well for controlling hemorrhage associated with pelvic fractures (adults & peds). It has been shown to close the pelvis in isolated cases but I have not seen a large study of radiographs before and after to prove how well that it works for the bony component. However, it certainly does not take the "10-12" minutes to apply in the field that was objected to. It takes about one minute by an experienced EMT. My experience is that it works much better than towels & sheets. Not sure why we are looking for other things when we already have something that works.
Date: Sun, 12 Nov 2000 18:24:16 -0500
From: Bill Burman
>Michael.Sugrue: Is there any evidence to show a towel works?
To close the pelvic ring - it seems to work in cadavers -
Pelvic Ring Disruptions: Reduction by Means of Circumferential Compression
Using A Sling - A Poster from OTA 2000 by James C. Krieg et al, Oregon Health
Science University, Portland,
http://www.hwbf.org/ota/am/ota00/otapo/OTP00002.htm
and there are reports that it does the same thing in vivo.
Vermeulen B, Peter R, Hoffmeyer P, Unger PF, Swiss Surgery. 5(2):43-6, 1999. http://www.hwbf.org/ota/s2k/abstracts/gbelt.htm
images from Parkland - http://www.hwbf.org/ota/s2k/abstracts/binder.htm - with a reminder that this device and idea is not new.
To control pelvic bleeding - basically anecdotal -
http://www.hwbf.org/ota/s2k/cases/erf1.htm
http://www.hwbf.org/ota/s2k/cases/torn2.htm
and from the recent OTA-AAST symposium transcript
http://www.hwbf.org/ota/s2k/panel/pfset.htm
:
>on a second issue what is the scientific Level 1 and 2 supported evidence that orthopaedic fixation works.
None as stated by Ken Mattox: http://www.hwbf.org/ota/s2k/mail/mattox1.htm
Probably the best citation of ex-fix proponents have to offer is Barry
Riemer J Trauma 1993 Nov;35(5):671-5
http://www.hwbf.org/ota/s2k/abstracts/exfix1.htm
but it suffers from the use of historical controls.
Bill Burman, MD
HWB Foundation
Date: Mon, 13 Nov 2000 10:31:11 -0500
From: carl hauser
Yeah, right ...it works in cadavers. And if it's your 1' mode of dealing with pelvic hemorrhage that's what your patients will be, too.
The rationale for 'closing the pelvic ring' comes from "The effect of laparotomy and external fixator stabilization on pelvic volume in an unstable pelvic injury." Ghanayem et al, J Trauma 1995. The idea was that if you diminished the volume of the pelvis there'd be less space to bleed into and tamponade would be achieved earlier. This data is the only basis for the use of ex-fix, bedsheets, towels, expensive corsettes etc. Please show me anything other data worthy of the name that shows it's good for anything. Actually, it's crappy fixation, too.
Yet subsequent to that logic the ex-fix has become an article of religious faith and fervor among orthopods. The logic of the cadaver study is intuitively obvious but it's wrong. The problem (as anybody who's been there a few times knows) is that pelvic hemorrhage isn't limited to the true pelvis. The 1.5 vs 2.5 liters that can bleed into the fixed / unfixed pelvis aren't what kills the patient. It's the 40 liters that will bleed up the retroperitoneum and into the buttock and flanks, ex-fixed or not.
Closure of the pelvis for control of hemorrhage (with a very few exceptions) is a contradiction in terms. Hemodynamically significant pelvic hemorrhage is arterial. So, go to angio, go directly to angio, do not pass go and do not collect $200.
Yeah, I know ... but how do I really feel...
CJH
Date: Mon, 13 Nov 2000 16:04:40 -0500
From: Bill Burman
> Yeah, right ...it works in cadavers. And if it's your 1' mode of dealing with pelvic hemorrhage that's what your patients will be, too.
Carl
Don't get so upset about the use of cadavers. If you really want to debunk the theory of control of pelvic hemorrhage by tamponade secondary to closing down the pelvic ring consider these cadaveric references:
http://www.hwbf.org/ota/s2k/abstracts/vrahas1.htm
Grimm MR; Vrahas MS; LSU, New Orleans J Trauma 1998 Mar;44(3) "there
was no significant (tamponade) difference between the disrupted specimens
without or with external fixation"
http://www.hwbf.org/ota/s2k/abstracts/moss.htm
Moss MC; Bircher, Department of Orthopaedic Surgery, St. George's Hospital,
London, England. Injury 1996;27 Suppl 1:S-A21 "Our finding was that
the increase in the volume of the true pelvis which occurs in a fracture
with massive diastasis is much smaller than previously assumed."
>So, go to angio, go directly to angio, do not pass go and do not collect $200.
But what about this case?
http://www.hwbf.org/ota/s2k/cases/ertl1.htm
Autopsy reportedly showed no arterial injury as have a number of other autopsies
http://www.hwbf.org/ota/s2k/abstracts/huit.htm
as reported by Huittinen V, Slatis P, Helsinki, Finland; Postmortem angiography
and dissection of the hypogastric artery in pelvic fractures; Surgery 73:3
pp. 454-462, 1978
Looks like deadly bleeding can come from a number of sources all at once and perhaps Dr. McSwain has a point when he says:
"Not sure why we are looking for other things when we already have something that works (the G-Suit)."
In fact it works so well that it can be difficult to recognize a severe
pelvic injury when the patient arrives with such a device on.
See: http://www.hwbf.org/ota/s2k/abstracts/gsuit.htm
Connolly B; Gerlinger T; Pitcher JD, J Trauma 1999 Feb;46(2):340-2 Complete
masking of a severe open-book pelvic fracture by a pneumatic antishock garment.
If there is no ruptured diaphragm or other contrainidcations, it seems
to be pretty good at controlling leaking arteries (Triple A), holding the
bones where they belong, and even perhaps - with its abdominal segment -
tamponading retroperitoneal zones 1 & 2
(http://www.hwbf.org/ota/s2k/abstracts/ards.htm)
which appears to be the conduit for the exsanguinating blood loss out the
chest tube in the aforementioned case with no arterial injury.
Bill Burman, MD
HWB Foundation
Date: Mon, 13 Nov 2000 16:37:56 -0500
From: carl hauser
Bill:
That's some awesome detective work digging up those old papers, and there's nothing in any of these references which I would take issue with ..including the difficulty the Finns have finding bleeding points after the heart has stopped pumping. By the way, I never said there was no evidence against the use of ex-fix, just that there was none supporting it.
There's no question that pelvic hemorrhage comes from many sources, but it's my experience (and that of many authors) that the rate of finding arterial bleeders in hemodynamically unstable pelvic fracture patients without other sources is very high - probably 80% or so in good hands, and that angio is therefore "where the money is". I have no problem at all with control of venous and bony bleeding sometimes being helpful, but the big stuff is almost always arterial, and time is our enemy. So if the emphasis is put on early angio, perhaps other modalities will find appropriate secondary roles. But doctors tend to be creatures of habit, and as long as a whole bunch of people think that slapping an ex-fix (or a MAST suit) on every hypotensive pelvic fracture should be our first move we will continue to lose patients unnecessarily. So from the scietific and educational perspective this whole story needs to be debunked, and the emphasis put the other way around.
CJH
Date: Tue, 14 Nov 2000 00:17:11 -0500
From: Bill Burman
Carl
>if the emphasis is put on early angio, perhaps other modalities will find appropriate secondary roles.
Angio has been reported as being effective in stopping ongoing pelvic bleeding.
http://www.hwbf.org/ota/s2k/abstracts/rhodang.htm
Agolini, Shah, Jaffe, Newcomb, Rhodes, Reed, J Trauma 1997 Sep;43(3):395-9
http://www.hwbf.org/ota/s2k/abstracts/proangio2.htm
Segina, Agnew, Swischuck,Northrup, Booth, Clevenger, University of Florida-Jacksonville,
OTA 2000
But it isn't 100% successful for everybody -
http://www.hwbf.org/ota/s2k/abstracts/angfxclass1.htm
Perhaps this is related to what Andy Burgess said at OTA-AAST 2000:
http://www.hwbf.org/ota/s2k/panel/pfset.htm
"not everybody has a Sal (Sclafani) nearby, or a Yoram Ben-Menachem."
And also, as stated previously, deadly pelvic bleeding might not always come from an artery.
>the difficulty the Finns have finding bleeding points after the heart has stopped pumping
According to their report, Huittinen and Slatis performed selective bilateral
hypogastric arteriography combined with xray and dissection. Their methodology
which is described under "further excerpts" at:
http://www.hwbf.org/ota/s2k/abstracts/huit.htm
was probably imperfect. In only 8/27 cases was the pelvic injury considered
to be the main cause of death. But in only 3 cases could they identify an
arterial injury.
The main clinical, logistical and cost problem seems to be figuring out
who needs immediate angio. It has been suggested that the G-Suit might help
decide.
http://www.hwbf.org/ota/s2k/abstracts/gsuit1.htm
Flint; Brown; Richardson; Polk; Ann Surg 1979 Jun;189(6):709-16 "Failure
of patients to respond promptly to the G-suit strongly suggests arterial
bleeding amenable to selective catheterization and embolic occlusion."
Bill Burman, MD
HWB Foundation
From: GDDMD
Date: Mon, 13 Nov 2000 21:23:28 EST
Carl,
I agree that hemodynamically important bleeding in pelvic fractures is usually arterial and should be managed with emblolization. However, pelvic stabilization does have some value. An unstable and thereby easily movable pelvic ring can can exacerbate pelvic vascular injuries by causing new vascular trauma and dislodging clot prior to it's organization. Pelvic fixation and stabilization is an adjunctive treatment for hemorhage from pelvic trauma to limit further injury.
By the way before anyone asks, there is to my knowledge no randomized data to support this view. It does "make sense", however we all know that what makes sense may not be true in the long term.
From: Frykberg, Eric
Date: Mon, 13 Nov 2000 11:44:12 -0500
Carl--
But--this method clearly WORKS in the properly selected patient (i.e. one with an open-book type injury--not in most other forms of injury)--by working, I mean it rapidly--viurtually immediately stabilizes the hypotensive patient, even those with arterial bleeding. It does not definitively treat the bleeding-no. But it does clearly buy you time for the next step of angio-embolization, and clearly does not substitute for the latter.
ERF
Date: Mon, 13 Nov 2000 15:08:08 -0500
From: carl hauser
>But--this method clearly WORKS in the properly selected..."
Sorry, Rick:
Show me the data!
Ex fix doesn't "clearly work" in any subgroup of fractures in my experience or in published data, and I've essentially completely abandoned it.
Open book fractures are the only ones the ex-fix would be expected even to reduce orthopedically, but I still defy you to show me any proof that they achieve more hemostasis than that produced by time. I'm sorry, but arterial bleeders don't care about the volume of the pelvis. They'll dissect through any available tissue plane. Sure, some will stop on their own, but then "all bleeding stops" ...doesn't it? I agree that venous bleeding can be reduced by 'closing the book', but venous bleeding is rarely life threatening in closed fractures.
The rare time I'll wrap the pelvis with a bed sheet is to help control veins after packing an open pelvic fracture while on the way to angio to control the arteries. This is always a desperation move, based more on the "baci di tuti baci" Michael gave to Fredo Corleone in the nightclub in Havana than on any data.
CJH
From: Frykberg, Eric
Date: Mon, 13 Nov 2000 15:19:49 -0500
Carl--
Sorry I wasn't clear--what I meant was, I have seen this method clearly improve blood pressure and reduce pulse rate almost immediately after placement in hypotensive patients with actively bleeding pelvic fractures, in our case using the wrapped sheet, in getting the patient ready for angio after excluding intraperitoneal bleeding--who at angio did have arterial bleeding that was emoblized. This again applies to only a select minority of pelvic fracture patients who have disruption and expansion of the pelvic ring, and this is not a useful approach in the routine fracture Yes--only anecdotal, but compelling nonetheless, as a method worth trying for yourself to see. I too would be interested in seeing some objective data helping to define its role. But on the other hand--seeing is believing.
ERF
Date: Mon, 13 Nov 2000 15:57:40 -0500
From: carl hauser
Rick
Yeah, yeah, it worked no doubt at the same time you were pouring fluids in a mile a minute, whip stitching the scalp and putting in a chest tube in a patient who was later shown to have a pelvic arterial bleed that needed embolization. So, how was this different than putting on a MAST and increasing SVR etc??
And as for this "seeing is believing" stuff, surely one has to consider the source... Since when do you believe in "anecdolts" ?
CJH
From: Frykberg, Eric
Date: Mon, 13 Nov 2000 16:05:32 -0500
Carl--
All true--still, experience tends to influence our actions--even yours--when data is lacking.
We all know how effective is placing a finger over a bleeding femoral artery at the groin, but I doubt any of us could find published data to support doing it. Not to disparage the need for hard data, but --as I've affirmed before--the place of clinical experience, tho potentially flawed in and of itself, is important. Especially when we are not dealing with a major intervention or time or resource consumption.
ERF
Date: Tue, 14 Nov 2000 11:08:17 -0500
From: carl hauser
Eric:
Much of what we accept as fact in surgery is actually "grandfathered" into our knowledge base, and that's OK. I'd agree that maneuvers like digital compression of external arterial hemorrhage, closure of hollow visceral injuries, resection of dead bowel and evacuation of expanding epidural hematomas are clearly justified on the basis of such historic experience. They don't require further scientific validation, but if you're saying that pelvic ex-fix should be put into that group of time-tested interventions I don't buy it.
Moreover, no matter how fast the orthopods say they can "slap one on", it still takes valuable time. And as for resource consumption, have you looked recently at what orthopedic hardware costs? One titanium screw can be a couple of hundred bucks! (talk about getting screwed!) And just how much do the Orthopods charge for this unproven 1/2 hour procedure? I'll bet it's 10 times the $535 Medicaid once paid me for a nephrectomy plus a Whipple plus 2 weeks of post op care...
CJH
From: Robert F. Smith
Date: Tue, 14 Nov 2000 12:13:37 -0500
Carl,
I don't think that's what Eric was saying. Sometimes using some method to reapproximate the posterior elements in open book fractures seems to provide immediate improvement. The method need not be Ex Fix. Could be towels or MAST which as you say are much quicker. We also put on a MAST to transport the unstable patients to angio and tend to prophylactically intubate as well.
Rob Smith
From: Frykberg, Eric
Date: Tue, 14 Nov 2000 12:26:09 -0500
Carl--
You continue to follow your own path of conversation without listening or reading what I am saying--I never said a thing about Orthopods putting on ex-fixes in an unstable patient--I agree that's not a good idea--but compression of a pelvis can be done very rapidly in the trauma center with a C-clamp or just wrapping a sheet--I've done it, and been successful WHEN volume was not working. And again, only as an adjunct to going to angio or the OR, whatever. Don't knock something you haven't tried!
ERF
From: ECThompson
Date: Tue, 14 Nov 2000 10:13:02 -0600
One of the problems, Carl, is that you probably see your patients with 30-60 minutes after injury. In East Texas and Louisiana it is not uncommon for us to see patients 2-6 hours after injury. Most of the patients with serious arterial bleeding have died. Therefore, it is not uncommon for us to see patients with significant hypotension that respond to fluids and fixation.
Date: Tue, 14 Nov 2000 11:11:12 -0500
From: carl hauser
Exactly.
And those same patients might well have responded to the fluids without the ex-fix, or perhaps to nothing at all.
CJH
From: Michael Sugrue
Date: Wed, 7 Nov 2001 12:06:12 +1100
Could I have any pointers to new or old work showing that Ext Fixators of the Pelvis effect pelvic bleeding
Date: Wed, 7 Nov 2001 08:00:05 -0500
From: Bill Burman
This subject was addressed in the 2000 OTA-AAST Pelvic Injury Symposium.
See: http://www.hwbf.org/ota/s2k/s2k.htm
Date: Thu, 08 Nov 2001 18:48:36 +0100
From: Hans-Christoph Pape
according to the protocol that is currently used at Hannover, Germany, external fixation usually is accompanied by internal packing via a small anterior approach as a damage control procedure. We have experienced that pelvic mass bleeding is attenuated, but not controlled, if external fixation is performed alone. One overview is published in Clin Orth 305, 69, 1994, another one is a study that was published in German language (Unfallchirurg 1996, 99:734-743), but contains an english abstract.
Date: Thu, 08 Nov 2001 18:18:44 -0500
From: carl hauser
Hans-Christian:
The idea of internal packing of the true pelvis for bleeding makes somewhat more sense to me than does external fixation, but as I see it, all true pelvic bleeding is insignificant. That's because bleeding into the true pelvis can only account for the loss of a couple of units of blood. So neither packing it nor reducing its' bony volume is of value. The really dangerous bleeding is the 40, 50, 60, 100 units of blood that can go into the retroperitoneum and the parietal soft tissues after a pelvic fracture lacerates a major pelvic artery. Neither external fixation nor packing of the true pelvis addresses such bleeding reliably. Only angiography does.
Having been there and then having reread the 2000 OTA-AAST Pelvic Injury Symposium cited below, I think the general approaches to the issue of control of pelvic fracture-associated hemorrhage discussed there were essentially and fatally flawed. The participants focused on specifying which mechanical patterns of pelvic injury required an ExFix to stabilize them and then went on to discuss the utility of angiography in those that continued to bleed. To me this demonstrates an underlying bias that ExFix is in some way hemostatic. But nothing that I saw or heard there, and nothing in the literature convinces me that pelvic fracture associated bleeding treated with an external fixator per se has any greater tendency to achieve hemostasis than does pelvic fracture associated bleeding treated 'expectantly'.
I therefore have zero concern for the AO, Tile, or any other classification of the pelvic injuries of my patients in the acute phase of their care. These classifications are crucial determinants of the need for and methods of achieving mechanical stability. They may suggest a risk of hemorrhage, but "high-risk" type fractures may not bleed and fracture patterns that are supposed to be "low risk" may still bleed like stink. So my only concern is for the physiologic classification of the hemorrhage. In my practice, all patients with a pelvic fracture that is the presumed source of any sustained hemodynamic instability (including acidosis alone) or patients who have a contrast blush in any truncal parietal tissues on CT are treated by immediate interventional arteriography. The pickup rate for arterial injury is >90% (using Ben-Menachem's approach, which includes embolization of all 'cut-offs' and 'beaded' vessels), and achievement of hemodynamic stability is essentially universal. I have not requested that an ExFix or C-clamp be placed on one of my patients in the last 4 years, and I've never been sorry. I have not lost a patient to pelvic hemorrhage (that made it to the table) during this time. The orthopods seem happy too, since ExFix's are terrible mechanical fixation, and they're much happier fixing a stable patient who's not in MOF electively a week later.
CJH
Date: Fri, 09 Nov 2001 17:54:15 +0100
From: Hans-Christoph Pape
So where exactly is the problem in pelvic fractures ?
Are we really discussing a controverisial issue or just different injuries ?
Does the bleeding come from
To my experience, injuries / ruptures of the the large iliac vessels are extremely rare, I feel that a surgical approach is required to "close the leak". The fracture site alone appears to be less of a problem than the venous injuries.
So when do we pack pelvic injuries ? I entirely agree that a purely anatomic approach is nonsense, because it does not reflect the dynamic nature and the extent of bleeding. I also entirely agree that the discussion during the 2000 meeting was misleading in regards to the importance of this issue...
However, I feel that a patient whith an unstable pelvis who comes in in extremis needs both, hemorrhage control and stability. Packing alone may provoke further dislocation of the fracture and may therefore become insufficient if the packings are not against the "wall" of the pelvic ring (please excuse the terminology).
The dynamic nature of the hemorrhage appears to be crucial to me, this is probably what you mean by "physiologic" classification, but it is hard to forward this information to someone who does not have to deal clinically with the problem of MOF later on...
Another issue that none of us has addressed so far is the importance of concomitant injuries, which may also affect the situation ! Does any of the studies address this problem sufficiently ? There appear to remain a lot of open questions...
HCP
Date: Fri, 09 Nov 2001 09:28:12 -0600
From: Adam Starr
I feel that some of CJH's statements should be challenged.
First, he says he uses "immediate" angiography. I don't think there's any such thing as "immediate" angiography. Radiologists are not trauma surgeons, they are slow to set up, slow to get going, and slow to find and embolize bleeding vessels. At the best angiography centers, in the middle of the night, mobilization of an a-gram suite takes an hour at minimum.
I agree with CJH that the thing that matters is the physiologic status of the patient - SBP, base deficit, RTS. I agree that those things are better predictors of mortality than pelvic fracture pattern.
The question of packing the true pelvis is a tough one. Ertel's recent paper in JOT is a nice, clean paper. Wolfgang presented a series of exactly the type of patient we're all worried about - patients in hemodynamic shock. It's nice that he restricted the series to ONLY those patients who were hemodynamically unstable.
Better yet, he even defined "shock", using SBP < 90mm Hg. In my book, Wolfgang gets a lot of points right there. The vast majority of papers dealing with pelvic fractures and hemorrhage never even bother to tell the reader how many of the patients were in shock, or even how the author defines shock. Nice work, Wolfgang.
Anyway, Ertel's mortality rate in this population of patients was 25%. That is very, very low.
Packing makes sense to me. CJH criticizes ex-fix, but he seems to understand packing, at least in some instances.
If the pelvic ring is floppy and loose, and you don't stabilize it somehow, won't you be packing into a hole that can expand and expand and expand? I see Ertel's c-clamp as a way to keep the ring from yawing open while the packing is going on. So, in that situation, I think a c-clamp may be of use.
CJH says that, using angiography, he can obtain hemodynamic stability in virtually every one of his patients bleeding from their pelvis.
He says, "...achievement of hemodynamic stability is essentially universal"
That's a pretty bold statement.
My response to this is, "publish your results, for God's sake!"
CJH needs to show us his data. If he can show that he can save ALL the pelvic fracture patients who present to his center in shock by using angiography, then he'll really have something worth reporting.
To meet the standard set by Ertel, CJH will need to report on all his pelvic fracture patients who present to the ER with SBP < 90 mm Hg. Tell us how many of those people kicked the bucket. Also, it would be nice to know how long it took to get each patient into the angio suite. How immediate is "immediate"?
However, until he can show some data, I'm afraid that I have a hard time believing the claims about "universal" restoration of stability, and "immediate" angiography.
Maybe I misunderstood what CJH means. Maybe he's using angio on a smaller subset of patients. If that's the case, how does he select out who goes to angio and who does not? Again, we need to see the data.
Date: Fri, 09 Nov 2001 17:29:25 -0500
From: carl hauser
Adam:
I'm happy to reply. I hope Sal Sclafani will chime in, too. Also, please feel free to post this dialogue to whatever orthopedic sites you choose. I hope it will "make a difference", though since the external fixator is thought of up there with Motherhood and Apple Pie in much of the orthopedic community, the more likely result is that someone will report me to the Office of Homeland Security as some sort of anti-orthopedic terrorist.... Maybe I'm "Osama Ben Data" - "The Antipod".
But I'm not too worried taking on the orthopedic community on this issue. After all, a Medlines search using the terms "external fixator" and "pelvis" produced 53 'hits'. But the addition of the terms "randomized" or "prospective randomized" to that search reduced the number of 'hits' to....
Adam Starr: I feel that some of CJH's statements should be challenged. First, he says he uses "immediate" angiography. I don't think there's any such thing as "immediate" angiography. Radiologists are not trauma surgeons, they are slow to set up, slow to get going, and slow to find and embolize bleeding vessels. At the best angiography centers, in the middle of the night, mobilization of an a-gram suite takes an hour at minimum.
Our time to angio in sick patients is in the 30 - 45 min range from the time we call, and I can usually tell we have a pelvic bleeder within about 15 minutes. So the patient can meet the angiographer within an hour. Control is usually another 30-60 minutes. That actually turns out to be plenty fast for pelvic bleeding since it's intra-parietal and tends to proceed at a slower pace than intracavitary hemorrhage. If I have intracavitary plus pelvic hemorrhage I'll tell angio to expect me out of the OR in an hour. What I'd really like is an OR equipped for IR. All of this is as fast or faster than putting on an ExFix, and much more effective. But I'd agree in a second that we have an exceptional angio group in Newark, and that places that can't get experienced IR's to come in that fast can't play at this table. Maybe they shouldn't be Level I's either.
Adam Starr: I agree with CJH that the thing that matters is the physiologic status of the patient - SBP, base deficit, RTS. I agree that those things are better predictors of mortality than pelvic fracture pattern.
Glad you agree. It seems pretty obvious to me that the patient's circulatory status is better correlated with arterial hemorrhage than is fracture classification, so it's a better guide as to who needs a procedure (of any kind) to control bleeding. I make no comment about who needs mechanical stabilization and what type. That's a purely orthopedic issue.
Adam Starr: The question of packing the true pelvis is a tough one. Ertel's recent paper in JOT is a nice, clean paper. Wolfgang presented a series of exactly the type of patient we're all worried about - patients in hemodynamic shock. It's nice that he restricted the series to ONLY those patients who were hemodynamically unstable. Better yet, he even defined "shock", using SBP < 90mm Hg. In my book, Wolfgang gets a lot of points right there. The vast majority of papers dealing with pelvic fractures and hemorrhage never even bother to tell the reader how many of the patients were in shock, or even how the author defines shock. Nice work, Wolfgang. Anyway, Ertel's mortality rate in this population of patients was 25%. That is very, very low.
Wolfgang is a good man, a good basic scientist, and he's my friend, but the appropriate endpoint for determining acute control of hemorrhage is death in shock. I suspect (but can't prove) that early ARDS and late MOF / sepsis will also prove to be reasonably good markers for prompt reversal of shock. Looking at gross mortality will be deceptive unless you stratify these patients, since the majority of deaths are from head injuries and sepsis.
Adam Starr: Packing makes sense to me. CJH criticizes ex-fix, but he seems to understand packing, at least in some instances.
My point was that if you're dealing with the (very rare) individual who has bleeding from pelvic veins that has broken through the pelvic peritoneum, only packing would seem to have any chance of achieving control. The vast majority however, of hemodynamically significant pelvic fracture-associated hemorrhage is arterial, and neither ex-fix nor packing will control pelvic arterial hemorrhage. I would therefore reserve consideration of these interventions for the odd patient who fails to stabilize with arterial embolization. But I would emphasize that with perhaps one exception over the last 5 years, all our early failures to achieve hemostasis initially with embo have occurred when our regular IR guys were being 'covered' by outsiders with less interest / experience in trauma. So I leave the arterial sheathes in in these patients for 24-48 hours, and if there's any residual bleeding the 'regular crew' can then 'mop up' the next morning. Only if that failed would I consider an ex-fix. As to packing the pelvis, well, maybe, but remember that if you do open up the pelvic peritoneum unnecessarily you may be kissing the patient's gluteus maximus goodbye.
Adam Starr: If the pelvic ring is floppy and loose, and you don't stabilize it somehow, won't you be packing into a hole that can expand and expand and expand? I see Ertel's c-clamp as a way to keep the ring from yawing open while the packing is going on. So, in that situation, I think a c-clamp may be of use.
Agreed, but a bed sheet works, too. Again though, if you ever have to open the abdomen on one of these (when I trained, we did that all the time and it was a disaster) you'll find out right away that arterial bleeding dissects hydraulically up and down the planes into the RP (as well as the flanks.) So it makes no difference whether the bony true pelvis can expand or not.
Adam Starr: CJH says that, using angiography, he can obtain hemodynamic stability in virtually every one of his patients bleeding from their pelvis. He says, "...achievement of hemodynamic stability is essentially universal" That's a pretty bold statement.
With the exceptions noted above, yes, control of arterial pelvic hemorrhage associated with closed pelvic fractures is essentially universal with angioembolization in our local experience.
Adam Starr: My response to this is, "publish your results, for God's sake!" CJH needs to show us his data. If he can show that he can save ALL the pelvic fracture patients who present to his center in shock by using angiography, then he'll really have something worth reporting. To meet the standard set by Ertel, CJH will need to report on all his pelvic fracture patients who present to the ER with SBP < 90 mm Hg. Tell us how many of those people kicked the bucket. Also, it would be nice to know how long it took to get each patient into the angio suite. How immediate is "immediate"? However, until he can show some data, I'm afraid that I have a hard time believing the claims about "universal" restoration of stability, and "immediate" angiography. Maybe I misunderstood what CJH means. Maybe he's using angio on a smaller subset of patients. If that's the case, how does he select out who goes to angio and who does not? Again, we need to see the data.
Adam - we've kicked around the idea of reviewing our pelvic embo experience here, and actually asked our IR people to dredge up the files, but I must say (I'll do a Frykberg here) that I don't see much value in comparing angiography to a totally unproven modality, namely the use of ex-fix. It's up to you to show that the ex-fix is effective if you want to put one on my patient. Ans as I said, I can find no data directly comparing ex-fix to the expectant management of pelvic fracture-associated hemorrhage. Similarly, any experience we published here with embolization would be retrospective and subject to the usual criticisms on that basis. So yeah, it'd be a nice resident presentation, but it wouldn't answer any important questions definitively.
So it seems to me that we're forced to take a 'common sense' approach here, though that's not so bad. That being the case, since my concern is the control of arterial bleeding, it makes more 'sense' to me to occlude the bleeding arteries directly, interventionally, than to "close the book" using an operation done under general anesthesia in the fond theoretic hope that diminishing the volume of the true pelvis will help the poor patient to stop bleeding.
As to proving that point with a PRCT, I think that'd be a great thing for some group to do that presently uses ex-fix as their primary management. Then they can happily publish how much better their results are and nail the coffin shut on the ex-fix. With our present experience, I would not be able to present a PRCT of embo vs ex-fix to our IRB in good concience. Frankly, if I did, I think I'd end up sharing a cell with Milosevich in the Hague.
You know, I am a surgeon and I do love to operate. But operation has little or no place any more in the hemodynamic management of pelvic fracture hemorrhage. The general trauma surgeons learned that 20 years ago. It's now the orthopedists' turn. This has become the proper province of the interventional angiographer.
CJH
From: Sal Sclafani
Date: Sat, 10 Nov 2001 03:03:18 EST
In places committed to using angiography immediately, they have developed schemes to expedite angiography: techs on site, angio suites capable of resuscitation, resident radiologists prepared to initiate the procedure, radiologists dedicated to caring for the injured to name a few
I usually have to wait patiently for the patient to get films and then the fixator to be applied so it can get in the way and slow down the angiography.
sal sclafani
Date: Fri, 09 Nov 2001 09:24:33 -0800
From: Chip Routt
Eight weeks ago, a male patient presented to our ER 20 minutes after a motorcycle accident with bilateral closed wrist fractures, a closed femoral shaft fracture, and an open pelvic ring injury. He had a 20 inches length traumatic perineal laceration with true torrential hemorrhage from it, which had not responded to aggressive packing. His symphysis was separated ~ 8cms with bilateral incomplete SI joint injuries. His systolic pressure was 6-70mmHg, tachycardia, Hct 18%.
His open perineal wound hemorrhage was so impressive that he was believed to have an iliac artery or vein injury.
A common large fragment pointed reduction (Weber) bone clamp was easily applied to the visible symphysis through the traumatic perineal open wound in the ER. His symphysis was held reduced, and his hemorrhage stopped in less than 30 seconds. No surprise that he stabilized hemodynamically.
Then with the symphyseal reduction clamp still in place, he underwent midline laparotomy. Next his open perineal wound was irrigated/debrided, and using a separate Pfannenstiel exposure his symphysis was plated. Then we nailed his femur and the wrists were later fixed at the time of perineal wound closure (5 days after injury).
He returned to part time desk work this week. His only current complaints are midline abdominal wound dehiscence, and that his knee was stiff due to abundant femoral shaft fracture healing (we manipulated the knee succesfully last week when his wrist pins were removed under anesthesia). His wrists are also still stiff.
He's one that would not have "made it to the table" in Dr. Hauser's hands...a forgotten number in the "series".
We ("Orthopods") are "happy" here too, but HAPPIEST when we can help our colleagues manage these complex patients, regardless of the pelvic injury classification or selected treatment technique.
Common bone clamps, external fixateurs, C-clamps, sheets, MAST, open packing, angiographic embolizations, plates and screws, among many other techniques can all be useful when caring for these difficult patients...let's not forget them based on "the last 4 years" of Dr. Hauser's "experience".
Show up, treat your patients as family, work together with your colleagues, be smart, and be quick-
Chip
Date: Fri, 09 Nov 2001 17:57:31 -0500
From: carl hauser
This is classic "orthopedic data" - a case report....
Read my other post, Chip, otherwise let me know and I'll send it to you tomorrow. You'll get no argument from me about the big open fractures. I pack them with towels, and wrap 'em with a bedsheet for starters just like I suppose you do. And I think that's a great indication for a c-clamp, which I would have had the orthopod place as soon as they got there - with the patient already on the angio table, where we would control the residual bleeding, which will be arterial, and immune to the C-clamp.
But open and closed fractures are horses of a different color, don't you think?? Venous bleeding into soft tissues is self limited. Veno-cavitary and veno-atmospheric bleeding isn't. Arterial bleeding into soft tissues persists in a significant number of cases, and that's what we're talking about 99+% of the time. Let's not confuse the issue. The exception doesn't prove the rule here.
CJH
Date: Fri, 9 Nov 2001 20:10:31 EST
I just came back from a meeting at Wayne State in which their trauma orthopod--Berton Moed--completely agrees --with cases and x-rays to support--that a simple bedsheet or girdle-type device--works BETTER than an ex-fix, and is ALWAYS quicker than any orthopod can place an ex-fix--and without the known complications of a formal ex-fix. Anyone who has used the good old bedsheet in the ER knows this to be true--it is very effective--remembering of course that only a minority of all pelvic fractures are amenable to being helped by fracture reduction--only those in whom a reduction in volume can be achieved (i.e. an open-book fracture)
ERF
Date: Fri, 09 Nov 2001 20:26:59 -0500
From: Jeffrey Salomone
> a simple bedsheet or girdle-type device--works BETTER than an ex-fix,
Girdle-type device. . . hmmmmmm. . . like the MAST (PASG)? Flint and others from Louisville wrote a paper indicating this may be one of the best (if only?) indications for the PASG. .
Jeff Salomone, MD
Date: Sat, 10 Nov 2001 13:03:20 -0500
From: carl hauser
Rick:
I have used the "girdle". It's a bit easier to place than the bedsheet and stays on a bit better, but I've also heard people say that it can lead to skin necrosis. It costs a lot more than a bedsheet, too. I know of no formal studies of its' use.
As I said in the prior post though, I think the entire practice of pelvic compression to "decrease the volume" of pelvic fractures is based on inductive reasoning rather than the scientific method. I trace the origin of this practice to cadaver studies that showed external fixation decreased the volume of the true pelvis. Unfortunately, the true pelvis is a) not a closed space, and b) the differences in pelvic volume found (Ghanayem / Motta, J Trauma,1995 estimated ~700 ml; Moss, Injury, 1996 found less) can't explain hemodynamically significant pelvic fracture bleeding anyway. Recognizing this, Grimm (J Trauma, 1998) found that you have to infuse 30 liters of fluid directly into the retroperitoneum in cadavers before ex-fix's generated enough retroperitoneal back-pressure to make a difference to venous bleeding. In that study ex-fix's could not create enough pressure to effect arterial bleeding.
Of course, apart from the fact that the concept of pelvic volume reduction controls pelvic bleeding is on shaky theoretic grounds, it is as clinically unproven as the Vineberg Procedure was for angina and carotid sinus nerve transection was for COPD. Nonetheless, challenging its' use seems to raise similar howls of protest.
I think that (as Chip Routt pointed out, and as we've all seen) isolated instances may exist where "closing the book" may convert an open fracture with torrential external venous hemorrhage to a functionally closed fracture situation, or at least make it possible to pack the external hemorrhage. But these cases are pretty rare. It may also be that stabilizing a grossly unstable pelvis may decrease pain or minimize the mobilization of inflammatory hematoma / wound fluids into the circulation. These secondary issues may may be of some minor importance, but such theoretical indications for external stabilization bear no relation to the issue of major arterial pelvic fracture associated bleeding, which is the real problem we face on a once-a-week basis. Moreover, they'd require entirely different strategies to prove efficacy.
As a final comment, we see lots of big pelvic fractures here and haven't placed more than maybe 1-2 ex-fix's in the last 4-5 years, and we've been very pleased with the results. So if you have angio readily available, my suggestion would be that if the patient's on your service, take 'em to angio and "just say no" to the C-clamp. You won't be sorry.
CJH
From: Eric Frykberg UF Jacksonville
Date: Sat, 10 Nov 2001 16:55:13 EST
>take 'em to angio and "just say no" to the C-clamp. You won't be sorry.
Carl--
There is no doubt in my mind that --in open book fractures with hypotension, immediate reduction by wrapping something and pulling to reduce volume does help--I have seen it happen. But I do agree this is in only a small percentage of all comers who are amenable to this--this is where I detect a flaw everytime we have this discussion, as I sense that many believe this should be a routine maneuver in all comers--these clearly are those who just do not see pelvic fractures and don;t know any better.
ERF
Date: Sat, 10 Nov 2001 11:34:14 -0600
From: McSwain, Norman
Just to be the 'devil's advocate' I did the same literature search as Carl describes below only I substituted damage control laparatomy for External fixator and pelvis. I found no prospective randomized studies for damage control lapratomy either. Should we abandon this procedure because no RP studies have been done and therefore no one knows for sure if it even works?
Date: Sat, 10 Nov 2001 13:09:26 -0500
From: carl hauser
Norm -
The same is true for angioembolization, appendectomy and a wide variety of other medical interventions. It's a problem, Norman, but it won't be solved by doing unproven operations. As I said, someone who uses it and really believes it does work should try to prove that it does to justify its' future use. I can't do that in good faith.
CJH
Date: Sat, 10 Nov 2001 12:16:45 -0600
From: McSwain, Norman
I agree with you about 'unproven operations' I just don't know how to prove any one of them. No one of us does enough and in the same way to justify (evidence based medicine) what we do.
From: Barry Armstrong
Date: Sat, 10 Nov 2001 23:00:09 -0600
Carl: There is at least one randomised controlled trial of appendectomy, abstracted below.
Br J Surg 1995 Feb;82(2):166-9
Randomized controlled trial of appendicectomy versus antibiotic therapy for acute appendicitis.
Eriksson S, Granstrom L., Department of Surgery, Karolinska Institute, Danderyd Hospital, Sweden.
In a prospective controlled study the effect of antibiotics as the only treatment in acute appendicitis was evaluated. Of 40 patients admitted with a duration of abdominal pain of less than 72 h, 20 received antibiotics intravenously for 2 days followed by oral treatment for 8 days and 20 considered as controls were randomized to surgery. All patients treated conservatively were discharged within 2 days, except one who required surgery after 12 h because of peritonitis secondary to perforated appendicitis. Seven patients were readmitted within 1 year as a result of recurrent appendicitis and underwent surgery, when appendicitis was confirmed. The diagnostic accuracy within the operated group was 85 per cent. One patient had perforated appendicitis at operation. Antibiotic treatment in patients with acute appendicitis was as effective as surgery. The patients had less pain and required less analgesia, but the recurrence rate was high.
(Comments in Br J Surg. 1995 Jul;82(7):1000 and Br J Surg. 1995 Sep;82(9):1284 )
Date: Fri, 9 Nov 2001 12:12:25 -0800 (PST)
From: Zsolt Balogh
May I give my opinion here as being a trauma surgeon who deals with both ortho and torso trauma and special interest in critical care.
All the people who discussed this important issue mentioned several good points.
Patients with these type of pelvic injury (life threatening hemorrhage) is not an unique group at all. Different fracture patterns, different sources of bleeding.
Couple of months ago I entered my points in a discussion here about the same topic. I was criticized, that I am not able to support my opinion by randomized study. But who can? Who performed a randomized study of these patients evaluating the outcomes after IR or packing or pelvic clamp etc.?
I still belive that the injury pattern is important, but of course it should not be overemphasized. For example: Dr. Routt patient seemed to me to have an (open) open book lesion, which in my view no reason to embolize until it is not closed an emergency fashion (like he closed). It worked well, no need to go to IR.
In vertical shear lesions (Tile C) I really feel no place for Ex Fix to stop bleeding. Pelvic clamp and emergency IS screw may help if the bleeding is only from the cancellous bone, their effect on the retroperitoneal self-tamponading effect is very-very questionable. There is a significant place for IR! But, who do IR and who go to OR at first it is highly depending on the institutional background, the approach of the orthopaedic trauma and general trauma specialist.
I tend to fix these patients early by a minimal invasive procedure if their physiology allows me to do.
As for "pelvic damage control" IR embolization covers better the term than pelvic packing. Less invasive, more effective, less complications.
Again how can one perform a randomized trial without seriously biassing one of the study arms.
Date: Mon, 12 Nov 2001 10:39:41 -0600
From: Adam Starr
Carl,
So even in your center, with noted expertise at angio, it takes an hour to get going.
I'll stick by my call for data to back up claims of a 100% success rate in embolization of arterial bleeders and the universal return of hemodynamic stability in pelvic fracture patients in shock.
Ertel's study is retrospective, but it's still valuable. He tests an idea. Since Ertel's results in the population at risk are better than our results in that same population, we may begin applying the method he describes.
We did a retrospective review here to find out how we're doing. Why does everyone think retrospective necessarily means "horrible"?
We don't use ex-fix at all. We use sheets or binders on the APC type fractures. So, if you want a study that gives results with NO use of ex-fix, I have it. JOT has accepted it. Maybe it'll be published one of these days...anyway, we found that the mortality rate for patients who presented in shock ("shock" being defined as 90mm Hg or less on the first measured SBP) was 50%. 57% to be exact.
See: http://www.hwbf.org/ota/am/ota00/otapa/OTA00102.htm
The vast majority of deaths occurred early (within 48 hours) and were from bleeding. Ertel's series also had the majority of deaths occur early.
ARDS and MOF aren't good markers for the effectiveness of our ability to save the pelvic fracture patient in shock, or at best they're secondary markers. Looking at gross mortality is NOT deceptive. Ertel found, as we did, that most of the patients had other injuries (head, chest, belly - no surprises there) and it's not hard to stratify them. I don't agree that most die of sepsis. Most die from hemorrhage.
CJH > "we've kicked around the idea of reviewing our pelvic embo experience here, and actually asked our IR people to dredge up the files, but I must say (I'll do a Frykberg here) that I don't see much value in comparing angiography to a totally unproven modality, namely the use of ex-fix."
The value would be that you would learn what your actual results are, and you could tell the rest of us those results.
Angio is also totally unproven, if the current lit is any guide. The angio studies all suffer from the same flaws the ex-fix studies suffer from. And, it doesn't appear that angio alters results as far as mortality goes. Agolini reported data on 15 patients who were embolized in his series in JTrauma. 9 of them were in shock on arrival. 6 of the ones in shock died.
CJH > "It's up to you to show that the ex-fix is effective if you want to put one on my patient. And as I said, I can find no data directly comparing ex-fix to the expectant management of pelvic fracture-associated hemorrhage".
If we had honest, reliable data from a center that used angio as a first line treatment, it would help us discover if angio works or not, or might help us decide WHEN it's best to use angio. To really be of any use, such a study needs to focus on the population at risk - namely, the pelvic fracture patients in shock. Shock should be defined in such a way that we'll all know what you mean.
You could tell us how many such patients in shock you treated. It would be nice to know how many pelvic fracture patients rolled into your ER, and how many of those were in shock.
In a 2 year period, we treated 325 closed pelvic ring disruptions. 28 of them presented in shock. More than half of those patients died.
Out of your review of the pelvic fracture patients who arrived at the ER, you could learn a whole LOT of stuff. How many went to angio? How did you decide who to take to angio? How quickly you were able to get them to angio, what did you find at angio? Were there any who SHOULD have gone to angio but did not? How many lived and died?
Our study taught us a lot. The data's not pretty, but we learned how we're really doing. If you're not willing or able to conduct such a review, how can you be sure that what you THINK is right is really right?
CJH> "Similarly, any experience we published here with embolization would be retrospective and subject to the usual criticisms on that basis. So yeah, it'd be a nice resident presentation, but it wouldn't answer any important questions definitively".
I think that's too bad.
Date: Tue, 13 Nov 2001 17:00:50 -0500
From: carl hauser
What's wrong with retrospective data? Well, let's look at the case in point. The spin on Adam's data seems to vary depending on where and when it's getting published. The analysis of the UTSW 97-99 pelvic fracture data presented at the OTA
http://www.hwbf.org/ota/am/ota00/otapa/OTA00102.htm
is somewhat at variance with the presentation of the UTSW 1995-99 hypotensive pelvic fracture data that was supposed to have presented at the 2001 AAST meeting in Seattle (that got cancelled.)
http://www.aast.org/01abstracts/01absOral_007.html
It's strange also that in these two studies of a single-institution population there appears to be no overlap of authorship (was there no communication between the two sets of authors?) unless Adam J. Starr and Adam F. Starr actually are the same person...
It's always nice when the same data is reported by two different groups. Usually, the "salami slicing" of study data is done by the same group.
But in any case, as so often happens with retrospective studies, how you slice the data determines the answers you get. Looking at the AAST abstract, they found (as is our experience) that early frank hypotension from isolated closed pelvic fractures was uncommon. In that incarnation of the data, the authors appear to have looked at the whole patient instead of just the AP pelvis films. They found that the vast majority of hypotensive pelvic fracture patients had concommitant sources of blood loss. That's because (as I said in a prior post) intraparietal pelvic bleeding tends to be progressive rather than catastrophic. It does persist though. Eventually it kills some proportion of the patients in shock if left untreated, and I believe that where it doesn't, the prolongation of tissue hypoperfusion and I/R injury may contribute substantially to ARDS/MOF morbidity.
Hypotension on admission from the combination of pelvic plus abdominal hemorrhage has a very substantial mortalilty in our hands. It's a bad disease. You've assumed that I claim 100% survivorship in these patients, and that's not so. I expect this assumption is was based on your subspecialty focus: when you say "pelvic hemorrhage" you mean bleeding in patients you see with a pelvic fracture. When I said "pelvic hemorrhage" I meant that portion of a patient's total oxygen transport deficit burden specifically attributable to pelvic intraparietal bleeding. No wonder we disagree!
Let me be clear. Our results with embo of hemodynamically significant (NB - not "hypotensive") isolated pelvic fracture bleeding are superb, but this is a very specific population. We are in an urban center and our transport times are very short. That may make our patients very different from farm accidents flying in to Houston, or rural transfers to Seattle. So what do I mean by "hemodynamically significant"? Our patients may not (yet) be hypotensive on admission. SBP<90 on admission is a grossly inadequate cut-point, but our patients will often drop their pressure early in their ED course, or have a progressive base deficit. Using early embo in these patients, death in shock does not occur and ARDS/MOF is rare. Any mortality is from associated injuries. Predicting deterioration on the basis of an AP pelvis and a base deficit (yes, I even look at fracture patterns) or a CT contrast blush, we often get these patients to embo before frank hypotension occurs even with the 30-60 minutes it takes to fire up the angio suite. So perhaps we try to prevent 'our' patients from becoming 'your' patients.
Where there is frank hypotension on admission, resistant to small volume resuscitation, closed pelvic fracture patients typically have one or more other sources of bleeding. These are controlled (if possible) in the interim prior to embo, often in the OR. But patients with two rapidly lethal injuries that can't be treated in the same setting don't do well - duh! As in the AAST abstract though, if they do manage to make it to both the OR and angio they have a good shot. But again, this is a self-selected group, and those that die will die from the intra-abdominal injury or the combined abdomino-pelvic injury, and not from "pelvic hemorrhage". Where our approach would seem to differ from the UTSW group (the AAST version, anyway) is that in their patients with pelvic hemorrhage but without hemoperitoneum they only angioembolized a subgroup (about half) and their mortality was very high (about a half). Unless the study retrospectoscope didn't pick up thoracic hemorrhage, you'd have to ask "Why the hell not?"
Now - do you still want to do that retrospective analysis ?? Go ahead.
CJH
Date: Wed, 14 Nov 2001 07:32:07 -0600
From: Adam Starr
Carl,
The data Brian Eastridge would've presented at the meeting in Seattle covered more years - Jan 1995 through December 1999 - and looked at a broader range of hypotensive patients than the smaller review I carried out. My data was from Nov 97 thru Nov 99.
Brian looked at patients who had hypotension during their ER stay. I focused on those who were hypotensive on arrival in the ER. So, in my series, you got lumped into the "in shock" category if you had an initial SBP reading of 90mm Hg or less. In Brian's larger series, if you came into the ER in shock, or developed shock during your ER stay, you got added to the hypotensive group.
So, instead of accusing both Brian and me of BS data, you might do better simply to check the dates of inclusion. The data we're "salami slicing" is not the same data. There is overlap of data from Nov 97 to Nov 99, but Brian looked at a larger number of patients in shock.
In addition, the goals of the two papers were different. Brian was trying to learn if there were any clues that would help us decide whether angio or exploratory lap were the best first steps in management of these patients. My paper's goal was to search for early pieces of data that would help us predict later mortality, transfusion requirement, AIS/ISS, use of angio., etc.
The idea that most pelvic fracture patients in shock will have other sources of bleeding is nothing new. Nobody is arguing that point. Differentiation of bleeding sources is the problem. Brian's article's title reflects this dilemma - "to angio or operate?"
If it was easy to tell WHERE the bleeing was coming from, we'd have no trouble. Fact is, it's NOT easy to tell. At least, not for most of us. It seems easy for you, for some reason.
>CJH "In [Brian's] incarnation of the data, the authors appear to have looked at the whole patient instead of just the AP pelvis films".
I guess this is meant to be insulting. The stereotypical general surgeon's rant against the dumb orthopod who looks only at Xrays?
Kind of lame - can't you do better than that? I thought the AAST list was supposed to be so genteel and based on data - I was hoping for more entertaining, sophisticated zingers...
> CJH "When I said 'pelvic hemorrhage' I meant that portion of a patient's total oxygen transport deficit burden specifically attributable to pelvic intraparietal bleeding. No wonder we disagree!"
In an earlier post, you said you could tell if you'd need to call the angiographers within about 15 minutes of patient arrival. I assume you'd use angiography for patients in whom you felt the bleeding was due to a pelvic source. Correct me if I'm wrong. But it sounds like you're saying you can tell which patients are bleeding only from their pelvis.
This claim seems at least as incredible as your earlier claim about "universal restoration of hemodynamic stability". You're claiming you can look at a patient in the ER and know within 15 minutes if that patient's bleeding is arising from a pelvic source, or not.
God dawg! We got some of those ultrasound dealies down here, but we don't got no crystal ball. Where'd you get yours? What will you take for it? I'll trade you my truck...
If you feel that you have a way to look at a patient in the ER - a patient who has a pelvic fracture and is in shock - and tell if that patient's bleeding arises from the pelvis OR from, say, the spleen or the liver, then I would like you to tell me HOW you tell.
I would like to know how, in the first 15 minutes of hospital time, you can know what "portion of a patient's total oxygen transport deficit burden [is] specifically attributable to pelvic intraparietal bleeding".
Do you look at fracture pattern? Belly pain? Sono? Base deficit? Lactate? Heart rate tracing? Tea leaves? The phase of the moon?
It sounds like you're trying to select out the ones bleeding only (or mostly?) from their pelvis from the ones who are bleeding from pelvis AND belly.
Once that selection is done, you do an arteriogram, which has a high yield, and high success rate, because you're embolizing the pelvic bleeders only? Is that right?
Because us simpletons down here in Texas can't tell. We get these guys in the ER, and they've got a busted pelvis and a tender belly and they're in shock and we just don't know what to do first. We don't know if we should go to angio first, or to the OR for a laparotomy. Maybe you perfessors up in Jersey are smarter.
So, now we've whittled down the claim of "universal" restoration of hemodynamic stability to mean ONLY in those patients who are bleeding from a pelvic source. Is that right?
It would be great if you could review your data and tell us how often you were right in your prediction of which patients were bleeding only from a pelvic source. Test your own ability to predict the source of bleeding. Were there any in your series who SHOULD have gone to angio but did not?
Conversely, were there any who went to angio who failed, and had to have their belly explored for bleeding from guts or solid organs? Or, are you going to stand by your claim of 100% success rate with angio in that group of patients you selected out?
You seem to be waffling a bit on the issue of hemodynamic stability, too.
90mm Hg is a "grossly inadequate cut-point"?
I guess you could choose a higher number. Or, you could choose some constellation of markers - base deficit and RTS and lactate...maybe even publish a tracing of SBP readings for each patient? I chose 90 mm Hg because it was easy to understand and easy to track. Would you not agree that those patients are sick? That they're the ones at highest risk?
If you feel that I'm stacking the deck by selecting out the sickest patients, then that's okay. We can move the bar up higher. We could look at our track record in patients not quite so sick. A higher number will raise our apparent succes rate, too.
> CJH "Our patients may not (yet) be hypotensive on admission".
Ahhh. Now I understand. Your "universal" claim makes more sense to me now. It's much, much easier to "restore" hemodynamic stability when it was never lost in the first place. The trick to a 100% success rate with a procedure designed to "fix" shock is to do the procedure on patients who aren't actually in shock. Very clever.
> CJH "Where there is frank hypotension on admission, resistant to small volume resuscitation, closed pelvic fracture patients typically have one or more other sources of bleeding".
So, right away you exclude the patients in shock on arrival from your angio protocol? You assume the patient in "frank hypotension" on arrival is bleeding from at least 2 sources, so they won't be candidates for early angiography?
It's making more sense to me now why your success rate with angiography is 100%.
> CJH "These are controlled (if possible) in the interim prior to embo, often in the OR".
How often is it possible to control them? How often is "often"? How often do you take these patients to the OR?
Again, it would be great if you had a handle on your data.
And yes, I WOULD like you to conduct a retrospective review and tell the rest of us your results. It would be nice to know the mortality rate for those who get embolized early, and the rate for those patients who arrive in shock.
From this note, it seems clear that what you're doing is embolizing patients prior to the development of "frank" hypotension. Among those who arrive already in "frank" hypotension, you're taking some to the OR, some not - you're not sure how often.
So, for the patient population I'm worried about - the pelvic fracture patient in shock - you don't have any idea what your track record is.
It sounds like you're doing pretty much like what everyone else is doing. You use angio "early", on the ones who aren't that sick - not "yet" in shock - and you operate on the others. And if they ARE that sick - already in "frank hypotension" - you exclude them from your angio group. Which has the effect of raising the apparent success rate of angio.
It sounds like you don't feel angio has the ability to save the patient who is already circling the drain. If you DID feel it would work in such a patient, I assume you'd be doing early angio on them all.
These patients are very hard to deal with. If you have a better way to skin the cat, I'm all ears. But, I think we're better served if we stick to discussion of the patients who are most at risk - the ones who arrive in "frank" shock. That's why Ertel's paper was so useful. He looked only at the patients in shock. He saves more of those patients than we do. I know he does because I know our track record in that population of patients. I know what our track record is because I did one of those sorry retrospective reviews.
In my opinion, claiming a 100% success rate in restoration of hemodynamic stability in patients who weren't actually unstable isn't much help. Until you know what your success rate is in that severely injured group of patients, you can't really say that angiography is of any use.
From: Bill Burman
Date: Sat, 17 Nov 2001 08:30 AM
OTA & AAST colleagues
While waiting for sufficient cooling of a hot topic, I have taken the liberty of archiving e-mail representing the divergence of view re: "Evidence for Pelvic Fixation" since the 2000 OTA-AAST Pelvic FX Symposium and have posted it at:
http://www.hwbf.org/ota/s2k/mail/pdmail.htm
I have done what I can to tone down the rhetoric without completely devitalizing the discussion arising from mostly heartfelt conviction and a dash of mischief.
If you have contributed to this thread and wish to have your remarks revised or deleted, let me know before a hyperlink to the OTA-AAST Pelvic Fracture Symposium -
entitled "Aftermath" is established.
Perhaps nothing has been solved. But at least the positions are staked out, the stakeholders are identified and hopefully, repetition of argument devoid of better evidence is avoided.
Following the example of the Johns Hopkins Internet Autopsy Database
http://www.med.jhu.edu/pathology/iad.html
I would like to offer the HWB website as a repository for treatment failures - the exsanguinations. A combined multicenter collection of case presentations with autopsy findings such as the one provided by Wolfgang Ertl
http://www.hwbf.org/ota/s2k/cases/ertl1.htm
might help better define the pathoanatomy and answer the key question of Hans-Christoph Pape
"Does the bleeding come from
With some collaboration in the contribution of medical examiner's cases or trauma CPC/audits, such a collection might become a useful amplification of the work of Huittinen and Slatis http://www.hwbf.org/ota/s2k/abstracts/huit.htm.
It is not going to provide the definitive answer but it could be a starting point for better multidisciplinary dialog, cooperation and care.