[Kellam] Welcome to the combined AAST/Orthopedic Trauma Association symposium on the exsanguinating pelvis. Certainly, we in the OTA look forward to this and it's been a very stimulating time to put this together. I'm Jim Kellam, I'm an orthopedic surgeon who specializes in doing broken bones in orthopedic trauma from Charlotte, North Carolina, and I guess I've been chosen as moderator because for some reason I'm the chairman of the education thing for the OTA and have been elected to stand up here and try to put some control on these people at the head table and perhaps the audience as well.

As we start I would like to introduce who our panelists are going to be, and as I guess we run down here the first person would be Chip Routt. As we go ahead and do this you'll note that there are some algorithms up there that I'll get to in a moment; this is where these people are coming from and Chip is from Harborview in Seattle. He is the pelvic traumatologist there and has had a great experience involved in particularly in internal fixation.

Beside him is Mike Bosse, Mike is an orthopedic traumatologist from our institution, the Carolinas Medical Center in Charlotte, he has spent time both in the Navy as well as at Shock Trauma, and has had a tremendous interest in looking at evidence-based medicine, and is my conscience at our institution.

Next to him is Tim Pohlemann, Tim is from Hanover, he is the guy who does all the work there, everyone tells everyone, but Tim has had a tremendous experience in pelvic fractures. He both is the typical European general surgeon and orthopedic trauma surgeon, and will give us a little bit of an idea there, he also has been instrumental in establishing the German multicenter pelvic study group, which has brought a lot of epidemiology and some science to this.

Next to him (look at all the orthopedic people at this) Andy Burgess, Andy is professor and chairman of orthopedics at the University of Maryland and formerly and still does do some orthopedic trauma at Shock Trauma, I think, and Andy's had a tremendous interest in the pelvis for years.

Sal Sclafani who is the Director of Radiology from SUNY downstate in Brooklyn, New York, and he's here to keep us all in line about what we think we can do surgically. He's had a tremendous interest in the interventional aspects of radiology in trauma and we welcome him.

And at the end but not last, Tom Scalea, who is the guy who runs Shock Trauma and who has kept Andy in the straight and narrow for the last several years and we welcome him.

There are a couple of other people, Karim Brohi who is my compatriot on the far side, Karim is a general surgeon from the Royal London Hospital, and he does trauma and critical care. He's probably instigator of all this because he developed the thing called trauma.org, which a lot of you probably have seen as a website and he may regret it because he's getting busier and busier doing it, but he's been very helpful in establishing the web-based program of this and if you haven't seen it, the web address is in the programs and it's also at the AAST and OTA site.

The other person who's hiding behind the panel from Karim is Bill Burman, who has done a lot if not all the legwork in putting together all this, a lot of the links and everything else and I thank him for doing it.

This whole panel, and I'll get to them in a moment, is to deal with the exsanguinating pelvic fracture.

[LOST 30 SECONDS OF AUDIO]

[Kellam continues] McLaughlin, of Columbia P&S in Accident Surgery, Moseley, V2 said:

"In general fractures of the pelvis should not be considered as specialized orthopedic problems or even as fracture problems. They are problems for a physician who will not permit himself to be diverted from considering the possibilities of lethal visceral damage by the presence of broken bones, no matter how spectacular these may appear; one who will discipline himself to maintain a broad surgical horizon and who will not hesitate to call for help when it is required."

And hopefully those words will be what we're trying to do in the next hour and fifteen minutes. Sit here, talk amongst ourselves, and come up with maybe a consensus that may be the appropriate way of handling these aspects. That said, we've gone through the people who've done it, the case studies were submitted by numerous people, and I thank all of you for doing that, and you can see there …

[LOST NEXT FIVE MINUTES OF AUDIO INCLUDING ALL QUESTIONS AND ANSWERS RELATING TO HEMODYNAMIC INSTABILITY AS WELL AS THE RECOMMENDATIONS FOR PREHOSPITAL FLUID RESUSCITATION. A DEFINITION OF HEMODYNAMIC INSTABILITY AND A RECOMMENDATION FOR PREHOSPITAL FLUIDS IS REQUESTED.]

[Frykberg] Eric Frykberg, Jacksonville, Fla. (10/27/2000). Hemodynamic instability is the presence of any indication of active bleeding that could endanger life--any episode of hypotension (BP < 100) or substantial base deficit.

[Kellam] As far as a definition of what we're going to be dealing with, we're sort of gut visceral response, bad looking injury, bad things and we'll sit tight and watch where he's going from there.

[Brohi] So you can tell that this guy's a no-brainer, in many sorts of ways. What about actually deciding whether he's got a pelvic fracture or not--how does your paramedic do that? Is his clinical examination good or is it positively harmful?

[Scalea] We don't encourage the prehospital people to spend a lot of time doing diagnostics particularly in a patient like this and Andy has certainly been very vigilant in helping to train our prehospital people in Maryland to not do a lot of manipulation at the scene. What you want to do is get a global assessment, you want to make as rapid a triage decision as you can and then you want to get them out of the accident scene and get them someplace that's not on the street.

[Kellam] Andy, any comments as to the diagnosis of a pelvic fracture in the field because it's going to lead to the next question--is there anything that one should do noninvasively with these with all the new belts and stuff that are coming along? How does the poor paramedic decide, or does he?

[Burgess] I don't know. I just discourage a lot of the manipulation, I'm obviously worried about displacing their first clot which has--the same thing occurs as you arrive at the hospital--as your first load of platelets, your first thermal load, a bunch of things sitting around wherever it is, the more you manipulate it the more risky for the patient. It will change rural versus urban, and in a guy like this I agree with Tom, basically you can also read the scene--if you look down at his bike and you're picking him up, what we've excluded here is looking at the side impact of that car. That and his blood pressure gets him a ride to the trauma center. So, that might suffice. If you're in a rural area, and you have a little more time involved, maybe you need to get some information from his pelvis too. The next few years will show us a field application of what stabilization devices will be. But always time has to be running through there, time and transport.

[Kellam] OK, so time and transport is easy enough. Mike, you've developed a belt that--one of these things that--you've made the comment that these will be applied to everybody in the field. Have you got any comments on what you think we will be doing?

[Bosse] I'm not sure I want to be quoted quite the way you've quoted me. I think that there's some very good evidence that in the emergency room situation and we know what the fracture is, that be it the belt that they're using in Parkland or the simple sheet is an effective mechanism for stabilizing or splinting the fracture. I think if your EMTs can recognize that they have a fracture pattern that's amenable to some kind of stabilization--beanbag, sheet, belt or whatever--and it's a long transport time then maybe evaluate. I'm not sure that it's the appropriate thing to put a compression device for every patient. Certainly a lot of compression you do may do you more harm than good.

[Kellam] OK, Tim any comments because I know you people have done some …

[Pohlemann] Well, basically the examination on the scene. We always encourage a complete physical examination, so it's not repetitive wobbling around the pelvis but the first clip will show you that you have a massive instability or you have only some movement around the pelvis which gives you movement like a hinge. Because if you go a little bit away from this case and if the patient would be conscious and talking you run into difficulties with opposition there. And so this is a more brainer, so you need some more information. They are all put on the bean bags in our system.

[Kellam] OK. So it appears that right now we're not sure but it doesn't make much difference to anyone if everybody got one of these things if it was a severe injury and so we don't have to concern ourselves so therefore we've now got a rapid assessment, quickly moving the patient, plus or minus something to where? Karim?

[Brohi] OK, so this patient didn't actually get wrapped up in anything on the scene, and those have said that this guy also needs to go to a Level 1 trauma center. Does the rest of the team agree with that?

[Scalea] The patient clearly needs to go to a trauma center, the only question is in this rural environment are you going to do it directly or are you doing to do it in some manner of steps?

[Brohi] What if he turns up at a community hospital? What should they do there, if anything?

[Scalea] I think with this patient, to control his airway, they make a very rapid assessment of--there are only five body compartments into which he can be bleeding, and you look into those five very quickly, if you believe that you can do something to stabilize him, like take out a ruptured spleen and then send him, you do that. If not, you get him to the trauma center in the quickest manner available.

[Kellam] OK. Any comments from the audience with regards to this? Paul and Ken, anybody want to make any comment, experience?

[Adam Starr] Question about shock.

[Kellam] OK, Adam, question about shock.

[Starr] The question about shock is not a--you didn't give us an answer though. We asked you to define shock and you didn't define it. You said that 'sick patient' and because of that type of definition we have a slew of articles that claim that ex-fixes save lives, clamps save lives, sheets save lives, but none of those articles really define shock and compare the use versus no use of those devices in a subset of patients who are clearly ill. So unless you all are able to define shock, we're never going to answer this question. Somebody has to take a stand and say, "shock equals x."

[Kellam] OK.

[Scalea] You've got a very primitive ability to measure things in the field, and we learned many years ago that things that you have in the field, like blood pressure and pulse rate are very inexact and don’t correlate with the degree of blood loss.

[Starr] What about in the ER?

[Scalea] Well, we haven't gotten to the ER yet.

[Kellam] We haven't gotten to the ER yet. We'll get to the ER and then we'll ask them to define it again. So the patient ends up moving to your ER and I would guess perhaps--Tom's mentioned a bit about what you assess, but let's say they make the assessment in your community hospital, and there is a pelvic fracture that's unstable, the patient's hemodynamically not doing well, and everything else. Do they keep them, or do they not? And there's no general surgeon around, it's the--you know, it's the usual thing--what do I have to do? What do you do? What do you tell them? What should they do?

[Scalea] They should control the airway and send the patient.

[Kellam] OK. Any disagreements with that? OK. Let's go to the ER.

[Brohi] No, let's not go to the ER. OK, you send the patient another hour down to the Level 1 trauma center, and do you resuscitate this patient on the way? If so, how vigorously? We have a Mattox comment on this. Anybody?

[Kellam] Comments? We'll give Tom the comment, because he's the critical care general surgeon.

[Kellam] Blood and speed. Tim?

[Pohlemann] Yes, we do the same. Most of these patients are put into the trauma centers primarily due to the prehospital rescue system, and the others who are transferred we try to give transfusions as early as possible.

[Brohi] Fine.

[Kellam] Good.

[Brohi] OK, so he arrives in your Level 1 facility, he's not looking good. Pulse rate is 160 and his blood pressure's 70, he's been intubated and ventilated by the paramedic crew, his sats are 99%, he has two large bore IV's in and he's been diluted and he's immobilized to a long backboard. He's had a chest x-ray done which shows he's got a left hemothorax and he's had a left chest tube placed, and later a pelvic x-ray. Is it a priority to do the pelvic x-ray? Are you selective when you order one?

[Kellam] Let's start there. Basically, yes or no--OK, the patient's arrived, everything's under way, we're sitting there, we've got the ABC's done. Chip, yes or no--it is mandatory to get a pelvic x-ray at this stage?

[Pause]

Any idea? Or in this case, because we will agree that in most trauma centers this will go on as a simultaneous or near-simultaneous event. Do you need it?

[Routt] I think physical examination and x-ray are very helpful and I think this is a quickly available imaging modality that can be done very simplistically without hurting the patient, so yes, I'd like to have at least an AP view.

[Kellam] Mike, I'll change the question a bit. How good do you think the physical examination is to determine an unstable pelvic injury?

[Bosse] I think it has a number of variables--the size of the patient and the skill of the examiner. A skinny patient and an average examiner can pick up a pelvic instability. A large patient and a good examiner and you're going to miss a pelvic instability.

[Kellam] OK. Tim, do you always get one in Germany?

[Pohlemann] We do a physical examination, you know, from head to foot and in addition we get the AP pelvic x-ray. But if the doctor in the ER or the doctor on the outside says that he has gross pelvic instability already diagnosed on the scene, we won't repeat the exam.

[Kellam] Andy?

[Burgess] With the history given that would come in from the field this guy with this blood pressure would get an x-ray. And the minute this piece of data came back, I would suggest the trauma system needs to react every bit as much as you do with chest tubes and everything else. This is either what will kill him, or probably more appropriately, one of a series of multiple offenses occurring in his body that will kill him fairly soon. This guy's in the act of dying, based on this pelvic x-ray and his blood pressure.

[Kellam] Sal? From a radiology point of view?

[Sclafani] Well, the first thing is that I'm looking at this x-ray and I don't see him still on a board, so I'm not happy that …

[Kellam] It's a radiolucent board.

[Sclafani] Oh. I don't want to …

[Brohi] It is there.

[Sclafani] OK. Well, as long as he's got him on a board I think the x-ray is useful for this particular patient because of his blood pressure is probably hemodynamic instability, but in many of the other patients who have pelvic fractures as well who are not in shock, this also plays a big role in the algorithm of diagnosis not just for hemorrhage but for many of the other things that we need to diagnose. And where he goes from here and how he gets managed is often driven by the results of this x-ray--whether he has a urethral catheter in place or how it gets placed, what imaging studies he gets, whether there's a red light going off or not really is helped by this x-ray.

[Kellam] OK. Tom, what do you think, is it worth it, because there have been some comments, and some other protocols written that this isn't needed until you are in deep trouble trying to resuscitate a patient.

[Scalea] I think you're in pretty deep trouble here. Once again, this is a patient who's sick and you don't really have the luxury of being selective or cutesy. The best information you can get is needed as fast as you can get it, because I agree with Andy, this patient's dying.

[Kellam] OK. So in a sick patient in the emergency department and we'll just sit back right here to answer Adam's question, because now we're in the emergency department. Do you still abide by the fact that we're crudely determining what shock is or is there something that you can now hang your hat on at this stage that would give us something to compare results to, or do we care?

[Scalea] Yes, I think you do, because here's a patient who's clearly bleeding and is hypotensive, is almost certain to sustain significant blood loss. I think that the single best determination to get an idea of the depth of shock, is arterial blood gas and a base deficit. Because if this person--you give them a unit of blood and their blood pressure's up to 100, and they've got a base deficit of -15 or -18, this is a patient that's, you know, you've bought yourself a few minutes, but you obviously ought to be moving very quickly down the blood-stopping algorithm in your hospital. If they've got a base deficit of -4, the depth of shock is not as bad.

[Kellam] OK, so basically base deficit is the key.

[Scalea] I think it's the single most useful test in the resuscitation area.

[Kellam] OK, so from now on we need to get base deficit on all our things. You're agitated, Tim. Are you? Are you agitated or not?

[Pohlemann] You know, in this case it's very clear because he's hypotensive and we heard the unstable pelvis. We see a lot of patients coming in earlier, so they have an unstable pelvis, they are normotensive due to resuscitation. We rely more on the primary hemoglobin, which is not that hard as a parameter but we can get it through photometric measurements within one or two minutes after arrival. So we found that hemoglobin below 8, unstable pelvis--this is a combination where the resuscitation process should start. All the other measurements we have--base excess or lactate--they reinforce our findings of shock, but these two parameters are very easy to get and we can get them within two minutes.

[Scalea] How about the patient who has a bad x-ray and a hemoglobin of 10 though? If you haven't diluted them out in the field, their hemoglobin coming in the front door might be OK--they're still bleeding.

[Pohlemann] This is why we--if we have the mechanical instability, and a hemoglobin of 10, and if you have a blood pressure which is high, we have more time so we get all the other diagnostic tests. But if we have a combination of a low hemoglobin plus this x-ray, this is something we found indicative for higher mortality and so we start the resuscitation process earlier. The problem is, we want to prevent hemorrhage, so the problem if we measure the rate of hemorrhage through shock, we are a little bit behind. So we have a direct measurement, in the optimum case, before the hemorrhage occurs, or just when the hemorrhage starts.

[Kellam] So to answer Adam's question, we're probably not there yet. We have a couple of different things we can hang our hat on, one looking at some of the effects of shock, one maybe trying to get to there, but as yet we're probably just scratching the surface as to where we go.

[Scalea] Correct.

[Brohi] So Scalea has said that this x-ray looks bad. Does anyone else want to comment on that x-ray, and is there any point in giving a more detailed classification of it at this stage?

[Kellam] Or, what do you see there that makes the pit of your stomach turn, where you get that horrible feeling, and I don't want an APC-II or that sort of thing, we'll put those up. But Tom, what's bad about that--you're the trauma team leader and you get that x-ray.

[Scalea] The bones are broken and they're not anywhere near where they're supposed to be.

Andy's taught me well.

[Kellam] Sal, what about yourself? As an erudite radiologist--do you write that as a report?

[Sclafani] I'm not writing a report, I'm too busy right now. What I really want to know is if this patient does not have a pelvic fracture, then my directions are elsewhere. If there's a pelvic fracture, I really don't care what it looks like in the moment, somebody may have pushed it back together, I don't know. It doesn't matter to me, if I see any fractures in the pelvis, my algorithm is a bit different than if there's no pelvic fracture. So I think that the trauma series, all three of those images that we do in a critical situation, are exclusionary images. The purpose of those films is to identify, but more importantly, to exclude life-threatening injuries. So we don't get a cervical spine film to identify all of the possible injuries on the cervical spine film. We want to say, does the patient have something that could kill him or not, because we change how we manage the patient. So I'm just using it as a screen--if I see a bad pelvic fracture, which is most pelvic fractures, my algorithm's different, that's all. I'll look in the books later and give you a classification.

[Kellam] Andy, you've done a lot on this and have some ...

[Burgess] I'm an orthopedist so I need to stay monosyllabic.

[Kellam] You're allowed in this group to get a little more, we know you can.

[Burgess] You get two syllables and then you feel bad.

Basically if you do cadaveric studies or whatever, it's been mentioned a bunch of times this is a moment in time. If he's this wide now after his body has recoiled back to this position at the moment of impact there's a good chance he was twice this distance. That manifests itself in the viscera that occupy the posterior pelvic ring and that includes the posterior division of the internal iliac. So I look at this and think of what it represents in terms of risk to this guy and it represents a grievous injury to the vascular tree in the back of the pelvis until I can either disprove it or whatever, and I think I can do something to mitigate that effect every bit as useful as putting a chest tube in for hemopneumothorax and I think he needs it now. It could be as simple as tying his legs together, it could be a binder, like the one from Dallas--there's a number of ways. The hardware doesn't matter. Our intervention at this time needs to be done. And even if it's getting them ready as Sal's getting his shop ready, but we can mechanically add quite a bit.

[Kellam] Mike?

[Bosse] I just would like to raise the issue that a free piece of information that's available just by observation is the status of the scrotum and the perineum when the patient comes in. Often these patients have a tremendous amount of edema, hemorrhage and a large scrotal hematoma and it's often a harbinger of what's deep. I think Andy is an expert on perineal injuries and observation.

[Kellam] Any comments Andy about association of external hematomas and perineal injuries with the severity of the pelvic fracture?

[Burgess] Yes. I agree, especially if it's there real early. But as many things as we're looking at here, that is one of the more time-dependent things that I've seen. If you catch them real early, they may not have been there yet--if you're getting them fifteen minutes off the highway although if you do and they're already there that is an ominous sign but a lot of these don't show and they show more in your transfer patients.

[Kellam] But again it's back to the old physical examination and looking and seeing the evolution of the patient and what goes on and I agree with you that that's a very major thing. Tim, any comments that you'd have to make?

[Pohlemann] Well, the AP x-ray, you know, it's basically the same, it's an awful looking x-ray. What we see is the wide-open pelvis. So this is something which is very unstable, the moment you try to manipulate the patient around, this is going to be more. So the course will be to stabilize it somehow, just with a binder or something.

[Kellam] You guys have all said it's a wide-open pelvis. What happens if it's a closed pelvis?

[Pohlemann] It's a little bit more stable, though it's no so bad actually.

[Kellam] It's not so bad?

[Pohlemann] We have very bad, little bit bad, and this is very bad.

[Kellam] That's three syllables, right?

[Pohlemann] It looks really bad, you know, because we don't have very significant posterior displacement, but it's still quite bad.

[Sclafani] I don’t think it matters. If you look at this film and you see no fracture, it matters. If you see a fracture and the patient's in shock, it matters. But I don't think it makes a difference--I mean, I don't say it doesn't make a difference in the sense that you're more likely to see massive hemorrhage when the pelvis is really displaced and opened up. On the other hand, just from fractured pubic rami, the patient could be in shock too. So I mean, I think that shock is what the issue is--or blood loss. If you think somebody is bleeding, it's bleeding. It doesn't matter where it comes from.

[Kellam] OK. Andy, then Tim, then we're going to move on.

[Burgess] OK. That I do disagree with. If this guy got T-boned and it was a closed, in other words let's say a lateral compression variant, his pelvis--there's a very good chance it wouldn't be involved in what's killing him. It's a sign to me--in spite of some of the other work, to me in my mind that's a sign to look again at solid viscous, perhaps a pulmonary contusion, that type of thing up and down--the factor that's really contributing to his downward spiral.

[Pohlemann] I think it's very important because we can judge the probability of the bleeding arising from the pelvis or in another body region. If you only see a fracture but basically the pelvic ring is in order, the probability that the shock arises from the chest or the abdomen is higher than with having an x-ray like this along with everything else.

[Sclafani] I agree with you, but I'm saying that it doesn't matter. You're still going to do the same thing. You're not going to stabilize the pelvis that doesn't look unstable, but your algorithm doesn't change. You have to--either way, you still have to evaluate hemoperitoneum first, and then move on.

[Kellam] If you have a pelvic fracture, and a patient's hypotensive, he's bleeding. Question. Next question is, where? And we'll get to that in one moment, but just so we get along with this, some questions have been asked, is there any way or any predictive value--we'll start off maybe with Chip--when you see these patients with a history mechanism, the fact is that maybe you put a binder on and they suddenly get better. Does that make you happy or is there any predictive value in anything you're doing with these noninvasive techniques in the history that guarantees you or can lead you into a different way of thinking or not? Or is it you're still moving with the same speed?

[Routt] Well, I think anytime someone gets better that's good. So I like it when someone gets better, and I think several of the points that have been made we need to amplify. The physical exam doesn't have to include destabilization of the clot--simply compressing or palpating the patient's pubic area, you'd feel a large defect unless it was just he was just a massive human, for whatever reason. So we don't have to disturb the clot to identify a defect in this zone. And I think if a patient responds to volume resuscitation or thermal regulation or a circumferential wrap, I don't think you have to buy devices. Everyone has a sheet in their hospital they can function quite well on, go back to beanbags, they're very readily available. I think if the patient responds to some form of circumferential sheet, I think it gives everyone a sense of relief but I think we're all aware of the--I think if you work long enough, hard enough, good enough --if you work enough, you know these patients can turn left quickly, or turn the way you don't want them to turn, depending on which country you're in. Maybe that was impolite--go the wrong way clinically. So I think everyone uses a little bit but, I think, not so much.

[Kellam] OK, Mike, is there any proof that any of these work yet? These noninvasive things?

[Routt] Is there clinical proof?

[Kellam] Well you don't have to answer that, clinical proof, I was going to ask Mike.

[Routt] I'm sorry.

[Kellam] You can add it though.

[Routt] There's certainly anecdotal proof.

[Bosse] Proof in the way that you want it, Jim, there's no proof that this works, that's all.

[Kellam] OK.

[Brohi] So this patient does get a sheet wrapped around him, and a towel clip you can see there and maybe supports Sal's claims--his pelvic fracture disappears to a certain extent, but Sal would still be worried.

[Routt] Can I make the point? A normal-looking pelvic x-ray does not mean a stable pelvis. And I think if all of you remember one thing today, from here, just because you have a fairly normal-looking pelvis and assembly of bones, that does not mean a stable pelvic ring.

[Kellam] OK. Before we move to the next stage there are a couple of questions that we'll take a couple of minutes and see if we can address.

[Mark Vrahas] Mark Vrahas, Boston. I wanted to rephrase Adam Starr's questions and get very specific answers from the panel because I think it's critical as Adam said, moving on to what we do in the next stages. I don't think there's any question the definition of shock--the patient's in shock if they have hypoperfusion and he certainly has indicators of hypoperfusion--even if he had just an elevated pulse he would have an indication of that. The question is, what category this pelvis falls in. When patients come in with pelvic fractures, I think, they come in three categories--there are the patients that have had the pelvic fracture and they've already stopped bleeding in the field. They may need further resuscitation to get them out of shock, but you can put a band-aid on their head, and they'll still stop bleeding.

[Kellam] Hurry up, Mark.

[Ferris] There's a second group of patients that come in and they're bleeding still but are going to stop no matter what you do, and there's a third group of patients that aren't going to stop. Is there anything you can do, base excess, pelvic x-ray, initial blood pressure, that tells you if that patient's going to go on to 30 units of blood loss or not?

[Kellam] Tom, yes or no?

[Scalea] No.

[Kellam] Sal, yes or no?

[Sclafani] I think most patients with pelvic fractures will not come, present like this. And those patients are unlikely to develop, in four hours, shock. The people with shock come in with shock and either stay in shock or come out of shock, but I don't think that most patients will do that. They may require transfusion--maybe they don't go into shock because we do angiography so quickly, I don't know.

[Kellam] OK. Mike--ah, sorry Mike--Andy--yes or no? Sal's taken half your time.

[Burgess] We don't know, to be honest.

[Kellam] No. Tim?

[Pohlemann] There's no way to know this. Especially in this case, he is late.

[Kellam] Mike?

[Bosse] No.

[Kellam] Chip?

[Routt] It's a good question, Mark. I'm going to pretend that they're all in your Vrahas Group 3, and I'm going to try to take a few to Group 1. And so I would like to attempt that everyone who we treat or we see, potentially can be your Group 3, and then we're going to try to get them to Group 1 as fast as we can, and then we can really sort of deal with it. So, predictive--perhaps not, but pretend we're going to treat them as Vrahas 3.

[Kellam] Thanks Chip, I tend to agree. Any other questions? OK, let's move on.

[Brohi]. OK, this guy's bleeding. Lots of studies to show where the pelvic injuries bleed from. What's the panel think about where the source of his bleeding is coming from, in the pelvic region in particular? And does it matter?

[Kellam] Tom, where is he bleeding from?

[Scalea] I guess I think it's got to be--I mean, he's bleeding from his hypogastrics. With that fracture pattern I'm not sure that you can predict very well which individual vessel, and I don't really care, because we're going the same direction, and it doesn't make any difference what's the name of the blood vessel.

[Kellam] I think most of us would say where is he bleeding--well, he's either bleeding from four or five different places, but the next real question is, wouldn't you say, once he's bleeding, what's next? OK, so here we are, what's next? Where do we go? Andy?

[Burgess] Just a comment on what everybody's saying. I would guess loudly and make it known to at least one person that can embarrass you--take a guess on this plain film where he's bleeding from and state it in front of a partner or a colleague. The more you do that, when you're right you will gain some experience--it's hard to describe when you're wrong. You're so embarrassed how you're reasoning you'll follow this case down until you find out. That's how you really learn this anatomy back there. Actually commit to where you think it's bleeding, right now at this place in time, and then if--it's an incredibly educational experience.

[Kellam] OK, what next?

[Brohi] Where are you going to take this patient?

[Kellam] Here you are--emergency department. We've got these vital signs, we've got this x-ray.

[Pohleman] That's all the x-rays?

[Kellam] That's the only one you've got. You want more?

[Routt] Can you tell me where the patient is?

[Kellam] He's in your hospital. He's in Harborview. He's in Harborview, Carolina's Medical Center, Hanover, Shock Trauma.

[Brohi] Do you want to do anything else in the ER? Or do you want to take him somewhere else?

[Scalea] We need an ultrasound.

[Kellam] Ultrasound. Tim?

[Pohlemann] Yes. The pelvic x-ray is the same x-ray we get. The patient gets a chest x-ray and then …

[Kellam] We had that. He had a hemothorax, he's got a chest tube.

[Pohlemann] The pelvic x-ray is simultaneous with his ultrasound. That would be the next step.

[Kellam] Your algorithm that we had at one point with a mobile pelvis said he should go to the operating room, but you would do an ultrasound first?

[Pohlemann] This is not for the mobile pelvis but this is for the exsanguinating pelvic injury with external mass bleeding.

[Kellam] External mass bleeding, OK.

[Pohlemann] But not with this case.

[Kellam] That one, OK. So two ultrasounds. Sal, would you as a radiologist run in there and tell them they're crazy and that you should go directly to angio, or would you let them at least get the ultrasound done?

[Sclafani] Well, I still think we haven't excluded hemoperitoneum, and until we exclude hemoperitoneum, I don't really want him to leave the resuscitation area. And that's the next driving force for the algorithm. At our institution, where we're not really very in depth in ultrasound, or FAST, pretty good ultrasound but we don't do the FAST, and it's really not something that's done very often. We mainly do an old-fashioned open supraumbilical peritoneal lavage.

[Kellam] The old way?

[Sclafani] But the same principle is to just find out if there's hemoperitoneum that's causing part of this blood loss.

[Brohi] OK, so he's has an abdominal ultrasound done, and he has fluid in his hepatorenal space, in the right upper quadrant. Is this a positive examination? If so, what is that fluid, and do you trust FAST in this case?

[Scalea] He's positive. And frankly not very impressive for a patient with a blood pressure of 70 or 80. But it's clearly positive and we would take that patient to the operating room, but on my way out of the resuscitation area, I'd call the angiography people and tell them that they should come here now, and that I would probably be coming from the operating room to the angiography suite.

[Kellam] Tim?

[Pohlemann] I think this is a typical ultrasound examination. It's about two hours after the accident …

[Brohi] No, less.

[Pohlemann] Less?

[Brohi] Hour and a half.

[Pohlemann] We started with ultrasound over ten years ago now and what we found if you make repetitive ultrasounds in the unstable pelvic fractures you start with no free fluid in the abdomen; if you repeat this after ten to fifteen minutes you see some retroperitoneal hematoma, and if you repeat it another fifteen or twenty minutes later you find a little free fluid in the abdomen and if you repeat it another fifteen minutes later you have massive free fluid, and several of these patients underwent laparotomy, and there was no organ injury. So this was a retroperitoneal hematoma penetrating the abdomen. So in this situation, this is the normal way the bleeding from the pelvis occurs.

[Kellam] Mike--what's your comment on ultrasound versus the old-fashioned way that they do it in New York City?

[Bosse] I think that various centers are skilled in the process of evolving their techniques. I think in a patient like this the tried and true method is probably to somehow get in the abdomen rapidly, and aspirate to see if there's free blood. In my mind if you do the peritoneal lavage you'll have a catheter there and you aspirate and you don't get gross free blood, then the reason for the patient's exsanguinating hemorrhage is probably not inside the peritoneal cavity, and I would push on to the angio suite. If it's gross free blood then I agree that the OR's probably the perfect place for the person, because that's where the money is.

[Kellam] Tom, is there a role for a diagnostic peritoneal lavage tap?

[Scalea] Oh, I absolutely think there is, I think one of the most dangerous things about the ultrasound probe is if you pick it up and you don't know what you're doing.

[Kellam] What happens if you do know what you're doing?

[Scalea] Well, I think if you're good at it and you get a technically good exam, and the patient's bleeding to death, you're going to have a positive ultrasound exam almost always. Now there are some times, I'll be honest, you've got to be able and willing to say 'I don't know--I can't see very well'. But, if you've got a good crisp exam and you're looking to explain hemoperitoneum as the reason that the patient has just soaked up four units of blood and is still in shock, you'll have a positive ultrasound.

[Brohi] Are you worried about doing a laparotomy for no reason?

[Scalea] I'm worried about it; I think the most important thing when you make the decision to explore these people is to remember what the indication for operation was. The indication for operation here is hemorrhage control. And if you get there and you find an insignificant liver injury or a significant problem you take care of it and you keep moving. That is not the time to do a long exploration to look for non-life-threatening issues like pancreatic injury or a fully kocherized duodenum or to do any of those other things--I think you stop the bleeding, you pack the patient, you get them some place to stop the pelvic bleeding if they have evidence of significant pelvic bleeding, and you come back a few hours later and you clean up or you come back several days …

[Audience Member] Can you make the pelvic bleeding worse?

[Kellam] Can you make the pelvic bleeding worse?

[Scalea] Yes.

[Kellam] Tim?

[Pohlemann] The question is, what do we want to get out of the diagnostics? What we want to differentiate now is whether the bleeding is only focused on the pelvic region, or whether we have an additional problem within the peritoneal cavity. So we use this just as an additional method to determine whether we have primarily massive free fluid in the abdomen. This tells us we may have additional problems to face.

The decision-making of this case would be to start with mechanical stabilization of the pelvis, however you can manage this (c-clamp, external fixator, towels, etc.). If we don't have a positive ultrasound, which can be repeated several times, we would focus on the pelvis. But if we have both problems (intraperitoneal and retroperitoneal bleeding) we would have to attend to both problems at the same time.

[Brohi] OK, so what if--just for the sake of argument, this FAST is negative, and the supraumbilical DPL and your tricorder reading also show there is no blood in the abdomen, what would you do?

[Scalea] Then you address the pelvic fracture bleeding and in a patient with this degree of hemodynamic instability, we would do that with an angiogram and probably an external fixator as well.

[Kellam] In what order?

[Scalea] We would put the external fixator on in the resuscitation area--I think that this is the time when you need to be portable. Andy has really spearheaded that long before I got there and we've got this on wheels. It comes out to the resuscitation area with the operating room nurses. The two of us actually just did a case not that long ago where it was documented that in less than 20 minutes we made a decision, the fixator was on, and we were in the angio suite.

[Kellam] Andy?

[Burgess] Just a couple points with what's happening with everybody's experience with sheets and stuff--it's pelvic stabilization. We happen to prefer the fixator although Alan Jones and Charlie [Reinert] are having a go at me and changing my mind slowly because I got involved with hardware, but it's pelvic stabilization that's the key here. The way we do it is almost incidental--and we did it with hardware because we're orthopods. I mean, to be brutally frank that's the reality and you need to be employed.

The second thing that I think is going unsaid here is that not everybody has a Sal (Sclafani) nearby, or a Yoram Ben-Menachem. When I went back and looked at the deaths we had the first couple of years I was at Shock Trauma, there were blocks of 15, 20, 45 minutes of unused time as these patients passed through the system. And it started, to be brutally frank, not as science, but as a chance to occupy that time while we got the angio suite ready to do something that would help the patient. In our case it was mechanical stabilization. If you formalize this too much, and you expect because you read an article by Sal that his colleague in your hospital would be there in ten minutes, you may not be correct. You may occupy that half hour with another life-saving event.

[Kellam] OK. Tim? Negative FAST?

[Pohlemann] Yes. Same. It's mechanical stabilization or a c-clamp, that's the first choice, because it's readily available, takes only a few minutes to put it on, if you don't have it it's an external fixator, if you don't have this for some reason it's some other external mechanical fixation.

[Kellam] Mike?

[Bosse] Early traction has a role with these patients in the resuscitation process. Early femoral traction on the same leg.

[Kellam] Traction?

[Pohlemann] It's one of the methods.

[Kellam] So traction, plus something around the pelvis, be it a fancy external fixator or pins in the back. Chip, you have had some experience with the c-clamp, haven't you?

[Routt] Yes.

[Kellam] What do you think about this? Is it valuable or should we be using sheets?

[Routt] Yes, but the sheeted x-ray that we have was, for this example, sufficient. I don't see a reason to convert at this point unless people are sitting here with nothing to do but I can't imagine that situation.

[Scalea] Do you think that the stability that's afforded by the sheet is sufficient when you bounce them over to the angio table?

[Routt] We don't bounce. We slide.

[Scalea] Or is it important to provide more definitive fixation? Do you get better fixation with a clamp or an external fixator to protect the patient during transfers?

[Pohlemann] We found the c-clamp is superior with mechanical tests. The c-clamp gives you better posterior stabilization.

What we find very helpful is that the accessibility with the c-clamp is perfect. So you can perform the diagnostics, you can either do a fixation of the femur or you can go to the CT suite--everything can be done with the c-clamp. And the accessibility, especially for laparotomies, is perfect.

[Kellam] And we'll get to that in a moment. But let's go to Sal for a moment, because if you've wrapped this sheet around someone's pelvis, or you've wrapped these fancy belts around them, I think you have to get access to the femoral artery to do your arteriogram, and it's not there anymore. So then you've got to take this all apart, so there the pelvis now falls apart.

[Bosse] I don't think we should get wrapped up with the device that we are using.

[Burgess] I think that Chip uses the beanbag, and a lot of us do too and that gives you perfect access to the groin, to the abdomen and for future examinations.

[Routt] I would also like to also say though that Tim is skilled in the application of the c-clamp which he helped devise (I think), and is a part of the technical committee for this; not everyone here is. They're sometimes hard to find. They're sometimes hard to apply. And I think if you're going to, once every four years, apply this c-clamp as you see on your left, and your patient is sick enough to need a c-clamp, I would put it on under fluoroscopy, because that patient is sick enough for an angiography. So zip them on in, slide them, onto the angio table, and then using imaging apply this unless you have great experience like Tim may. We've found these in the rectum, we've found these in the spine, we've found these through the greater sciatic notches not quite to the rectum so we've found these applied in a lot of different places when they first came through with their first wave of popularity. So--that stunned us a little bit.

[Kellam] Sal, any comment about angio that we should be aware of at this situation? A negative FAST in a hemodynamically unstable patient?

[Sclafani] So in this patient, I would presume that he has an arterial disruption, so I'm unclear about the value of any of these immobilization devices for the treatment of arterial hemorrhage. And here, my angiography shows lots of frames and lots of arterial hemorrhage. So it's unclear to me why we should take 20 minutes to do this. Of course, if the angiographer is home having dinner, then that's a good reason to do it, I think. We can finish dinner and then come in and do our work.

Andy, what if the angio suite is open right now, the patient just came in. You just said to me that you need that extra 20 minutes. Why waste it? I'm telling you that they're ready to do the case immediately in this particular patient, and you're pretty sure this patient has arterial hemorrhage.

[Burgess] To think that it's only the artery that's bleeding here, I think is incorrect. What you don't see are the tensile and shear forces which went through a lot of venous plexuses before producing the arterial injury. What you see by the obvious rise in the systolic pressure when you apply these things is you've helped control the venous bleeding.

What happens in the ones that have the big arterial bleed is then they continue to drop their pressure, but you get this instant of returned systolic pressure. I think what you're doing here is controlling the venous bleed. I think you're assisting whatever clotting is done and the clot that you're going to add. You're actually adding mechanical stability to the clot.

So during transport what you don't want to do is once he's got his first clot there that's got him a little pressure--this is his first load of platelets, his first thermal load, and now you've filled him full of fluid, (a lot of it is cold)--is to shake that clot loose because you've added no mechanical stability to protect the clot that either he has or you're about to give him.

[Sclafani] Don't get me wrong. I don't want to be misquoted as saying this patient only has arterial hemorrhage, I'm saying that this patient has arterial hemorrhage because of the nature of his presentation. It doesn't mean that he doesn't have bone bleeding or venous bleeding in addition. If you had a choice between controlling arterial hemorrhage first or venous hemorrhage first, which would you pick?

[Burgess] I'd pick both.

[Sclafani] Both? Well, you can't do both simultaneously.

[Routt] I think this is communication time when everyone that's playing has to talk and make decisions, because you can work together and they do take some time to set up and you do take some time to set up and whoever's ready to jump jumps first, and then use the image to put it on if you like this clamp.

[Pohlemann] You might determine from the x-ray (which you've just said is not so important) that arterial bleeding is the problem. I think every pelvic fracture causes some sort of arterial bleeding. The question is whether the arterial bleeding we find is really the problem. As we explore this situation, we found that venous bleeding is the major problem, even if we have some arterial disruption of smaller branches.

[Kellam] We've let half an hour go by here and the guy's been wrapped up in a sheet, and he's still hypotensive. I say you've had your half hour to control venous bleeding, and you're pouring fluids in until maybe it's time to get out and do something else. But we can leave that and move on to the next scenario.

[Routt] Is he hemodynamically unstable yet?

[Kellam] He remains.

[Brohi] While you may want to change the stabilization from a nice wrap to some bit of metalwork, there really is no evidence for this in terms of adding anything like tamponade or control of retroperitoneal hematoma. Is there any evidence to show that metalwork does more than basic stabilization methods?

[Kellam] I think to date the answer to this is probably no, but there's really no evidence that any of us are right. Whether you put metalwork on as Andy wants or whether you wrap it up with a beanbag or sheet or the Dallas binder or anyone else's device, there's no real proof that any of this is working.

[Burgess] I was trying to stay out of the femoral triangle to permit angiography and not block access to the abdomen in case the patient had blood in his belly. That was my advantage, but I don't think it's ever been proven. Just slide the binder down to the thighs if you have to.

[Brohi] OK, so he does have blood in the belly, he goes up to the operating room, and at laparotomy he's found to have quite an extensive liver laceration, which is controlled. This is actually a picture later, a few days later after reoperation which is why it looks so neat. So, at laparotomy, does anyone here open retroperitoneal hematomas? And if they do, would they tie off those internal iliacs?

[Kellam] The scenario is we've gone in, you've got a ruptured liver which is packed off. Let's say there's a retroperitoneal hematoma developing. What do you do next?

[Pohlemann] We have to decide where the bleeding comes from. What we basically see at laparotomy is the region where the bleeding goes to. It's coming down from the small pelvis, flowing up and out behind the abdominal cavity. So one of the first things to do would be to tamponade the liver. Then we try to pack the retroperitoneum starting in the small pelvis.

So this is basically accomplished through an extension of the midline incision down through the pubic symphysis. It's very similar to the Pfannenstiel incision. The moment you open up the fascia, you will encounter a major hematoma--a cavity filled with hematoma--no further dissection has to be done. So just slide your hand in and you can pack the small pelvis. This is the region we find the bleeding comes from.

We have experience with opening the retroperitoneum behind the abdomen and have tried to pack this region. But what we experienced fifteen years ago, when I stood for hours changing the packs, was that they swim in a rising pool of blood. But the moment you pack the small pelvis, and have some mechanical stability provided by a c-clamp or some other mechanical stabilization device, then all the venous plexuses can be compressed and even arterial bleeding, as we showed in some cases, can be tamponaded.

[Kellam] You just added a little caveat there. It was called mechanical stability of the pelvis, which we haven't really discussed thus far. Mike, what do you think the role is here for the orthopedic surgeon, if the patient ends up with a belly full of blood at laperotomy, and has a pelvic fracture which is wrapped up in a sheet or something else which may have to come off?

[Bosse] I think this is a time when the orthopedic surgeon and the trauma surgeon need to communicate and cooperate. Certainly the trauma surgeon wants to address the intra-abdominal hemorrhages as expeditiously as possible, and when he finishes, he'd like to have a stable platform for the pelvis. The incisions should be planned and made so they both could work through the same incision, or if they're going to apply just an external fixator to the pelvis, there has to be agreement in such a way that the orthopedic team can work at the same time or quickly after the completion of the abdominal surgery.

[Kellam] Tom, when are you going to let us put the external fixator on?

[Scalea] Not yet. I think you put the fixator on quickly as you're prepping. I want to get in and do damage control for the bleeding and I want to get the patient to the angiography suite. If we can provide something more stable, in terms of an external fixator or a pelvic clamp that doesn't delay, then I think that's OK. Particularly in this scenario, I would be very much loath to open up the retroperitoneal hematoma, and I would certainly not want to dissect the internal iliac artery. I think they're just going to bleed to death.

[Kellam] Chip?

[Routt] Will you let me go ahead and just put in screws if they need in the back instead of the clamp that's going to stick to the skin? Can I just have a few minutes to put in screws?

[Scalea] Orthopedic "few minutes" is kind of like general surgery "few minutes," it's almost always more than a few.

[Routt] You haven't quantified them.

[Kellam] Well, I think the answer is that we all come from different environments. Chip can probably put screws in faster than I can put an ex-fix on, but in our environment if you have a patient that you're going to pack, then you probably need an ex-fix. If you're not going to pack them, then you probably don't have to add an ex-fix and you could continue on with something wrapped around them. At Shock Trauma, you've probably got it on because in your environment it is readily available in your admitting area (emergency room), but we don't have that anywhere else. The question still arises, when is it appropriate? In other words, if you're out prepping the patient--out getting washed, can I stick two pins in the iliac crest and get out of there in time? Is that reasonable?

[Scalea] I think that's reasonable.

[Brohi] So Tom, if you've got a stabilizer on--some form of stabilization on, how would you treat the pelvic retroperitoneal hematoma?

[Scalea] Take him off the table as fast as I could, and get him over to the angiogram suite as fast as I could.

[Brohi] Do you pack them?

[Scalea] No. We've just recently had two patients where we had to open a big pelvic retroperitoneal hematoma to fix a bladder bleeding that ended up with a very distended bladder and intra-abdominal hypotension. In each of those cases we opened it up to go fish the bladder out and they decompressed. We ended up packing them. It was not very satisfactory--we got them over to the angio suite, and re-embolized them. If you have to, you have to, but if you don’t have to, I just can't see why you'd want to do that.

[Pohlemann] In this case you had a mechanical stabilization of the pelvis?

[Scalea] Actually yes, we did have an external fixator on.

[Pohlemann] Shall I comment, because I am standing on both sides of the issue? We started by putting the external fixator on followed by lapartomy, but this is painful. We tried to change to some stabilization device, which is more appropriate.

We found the c-clamp very helpful because it can be rapidly included in the resuscitation process. The moment the lines are put in and everything is done, we have a time window where the c-clamp can be applied. By doing this we found that even opening the retroperitoneum, way down in the pelvis, is not really a problem, because the bleeding can be tamponaded. It's not very much that you need--three towels on both sides of the pelvic cavity. A small pelvis is only a cube like this size [gestures] that we can compress very effectively.

[Kellam] What about angio in the OR? Karim, you've got that set up now.

[Brohi] Yes, we have angio in the OR, but we would pack them intraperitoneally first and then we'd let our angio people take control.

[Bosse] Can I ask Tom a question?

[Kellam] Oh, you can.

[Bosse] You've finished controlling the abdominal bleed and the retroperitoneal hematoma is rapidly expanding. You can't close the abdomen. This guy's very unstable; he needs to go to the angio suite. If you're not going to open up the retroperitoneal hematoma and explore it, is it ever worthwhile to at least find the aorta and gain possible control until you get to the angio suite?

[Scalea] I think it could be, if they're so unstable that the hematoma is all the way up to their diaphragm and still going. In order to really get aortic control you're going to have to fairly widely open the hematoma. If the patient is dying, then you take your best crack at it, and sometimes that may be appropriate. I know Sal had a case where they did exactly that--i.e. put a clamp on the internal iliac and then took the patient to the angio suite with the clamp on.

So I think it can be worthwhile. The chances that you're going to be able to clamp the aorta, and keep that patient alive through a transfer to the angio suite, an angiogram, and clamp removal, are practically nil. I'm thinking that this patient, if you have to do that, has close to 100% mortality if not 100%.

[Kellam] OK. Are there any questions the audience wants to bring up at this stage with anything that we've discussed?

[Audience Member] We'd like to have some decision, maybe not perhaps in this particular patient, but what is your algorithm, as far as going to the angio suite? You stabilize his intra-abdominal bleeding, you mechanically stabilize his pelvis. When do you decide to go to the angio suite? What sort of numbers? How much blood? How much fluids? What can we go home and use to make that decision? I don't think you've made it clear yet.

[Kellam] I don't know if we can make it clear. Tom, do you have anything to make it clearer?

[Scalea] No.

[Sclafani] In 1976, we arbitrarily defined some numbers, and came up with four indications for which we've just added one more for angiography.

The first was persistent shock and blood loss in the absence of hemoperitoneum. That one is pretty straightforward, and doesn't have a transfusion requirement, although they usually will get quite a few transfusions.

The second one is to estimate their blood loss from all of their fractures and other body cavity hemorrhage, and then add four units (for a pelvic fracture). For anybody who bled more than four units for a pelvic fracture, we would do arteriography. If you account for other bleeding sources, probably about 85% of the time you'll see some arterial hemorrhage on those patients. Usually those patients require that four units of transfusion in the first four hours, not 24 hours.

Then there are some other patients who will have slow persistent bleeding, and we arbitrarily came up with the number of six units for the pelvic fracture in 48 hours, and that one is a very uncommon indication. Of course, another is the one that we've had in this scenario, which is the patient with a visible retroperitoneal hematoma at laparotomy.

And the last indication that we've used which is not as accurate or as helpful as the others has been a large hematoma seen on CT. And what we've added to that one is if you see an arterial blush on a CT scan we would do arteriography on that patient and not wait for spontaneous hemostasis.

These indications which we've used for the past 24 years are very arbitrary, but we don't have a high incidence of negative arteriograms, and we're quite comfortable embolizing an arterial bleeder even if it may not cause shock.

[John] Back to the emergency department. Tom, if the patient's hemodynamically unstable, you did your FAST, it shows some blood only in the pelvis but no place else, your resident decides to stick a lavage needle in, gets no gross blood back on the lavage but gets a reddish fluid. Will that change your algorithm? And then Andy, do you think there's an advantage in using the MAST trousers with low pressure to enable you to go to the OR or angio rapidly? Thanks.

[Scalea] If we went the route of diagnostic peritoneal lavage and we didn't get gross blood back, I would not operate on that patient.

[Burgess] John, if your question is MAST trousers, I consider those another pelvic stabilizer. I don't buy into them, but I agree with some of the work out there pertaining to their use by other surgeons. That would give me stability. Actually, it's coming down to an interesting difference between Sal and myself--I think to get good clotting, be it by angio or by the patient's own mechanisms, it has to occur in a stabilized physical environment. And if MAST trousers help me to do that, then fine.

[Kellam] If we just go back momentarily to Chip, because he brought up internal stabilization, and has popularized it a bit. How do you get around doing it, because I'm not so sure all of us are that skilled? What are your indications, when do you do it, how have you managed to convince your general surgeons to be different than everybody else?

[Routt] I don't think we're any different. I think you need to hang around for a long time. They are watching what we do, and sometimes they're willing to let me work and sometimes they're not. I think it's important for them to have an awareness of what you do. If you say you're going to be fast, or real quick--the faster the better. Dr. Hansen taught us all that a long time ago--you need to do what you say you're going to do, and if it's going to take longer, you don't try. We submitted for this session some cases of the application of percutaneous iliosacral screws. They show the time it takes and some of the indications, but in general we use them whenever they'll let us and whenever the pelvis is unstable posteriorly.

[Kellam] Is there any point in fixing the front?

[Routt] Yes, you'd like to fix the front too, that's a good thing to do too.

[Kellam] Mike, any comments about internal fixation in the acute phase?

[Bosse] I think if the patient is not dying in front of you and the trauma team feels comfortable with it, you could take the additional time that's required to do what is feasible and necessary. The incision should be planned with the trauma team in advance so you'll have access to the symphysis pubis if that's what you plan to do.

[Routt] If there's going to be an opportunity for me to work, I'd like to prep and drape myself so I can do these screws without interfering with anyone.

[Kellam] For the orthopedic surgeons you'll notice that the orthopedic surgeon has made major presence in the operating room …

[Scalea] That's a good place to be.

[Kellam] … which is a good place to be. Even if you have a resident it's probably a good place to be.

We are nearing the end of this session and I'm going to try to come up with a summary and see if we can pull it together. First and foremost we started off with the trauma patient lying on the road after a severe injury. Basically we have failed to arrive at a definition of hemodynamic instability. At that stage, the paramedics decide he is a patient who looks sick and has a bad injury. The whole point is rapid transit, probably with some kind of noninvasive support wrapped around him. I think that probably is where we stand at the present time as far as prehospital care.

Hopefully this massively injured patient would be taken directly to a Level 1 trauma center that could look after him, but if not then to a hospital that would rapidly arrange his transfer to a Level 1 trauma center.

When the patient arrives at your institution, it's the usual expeditious ABC's, and there are still three x-rays (the pelvic x-ray is one of them) which must be taken of patients who are ill, sick, hypotensive or whatever--who are not responding to what you want to do and not living up to making your life easy. So we still get a pelvic x-ray--that's still there. The reason for the x-ray, I think as Sal has well said, is to …

[Sclafani] rule out

[Kellam] … certain things and guide us in a different way and that's where we're going to head.

So the next question is, having dealt with the A and B, we're into the C's--FAST versus DPL. If you're good at FAST, it's worthwhile using. If you aren't, or you don't know what it means, you should go to a diagnostic peritoneal lavage which is gross blood only. Right?

I think we've come to a conclusion. Having gotten a negative laparotomy, or negative intra-abdominal blood, we've all agreed that at this stage some form of pelvic stabilization needs to be done. And that can be anything that you do well.

[Burgess] I don't think we all agree. I think Sal disagrees.

[Kellam] OK. Sal, disagrees.

[Sclafani] If you look, you'll see about eight different algorithms. There are so many different algorithms because each environment is different. In my environment, I'm there all the time. The same technologist that does the CT, who has to be in the trauma center 24 hours a day, sets up the angiogram. There are residents in the house who have the privileges to start the angiogram--we can do this very quickly. I have no objections to stabilization, I don't think there's anything bad about it.

[Kellam] OK, so given the situation where the angiographers are there acutely, go to angio and work with them. If not, noninvasive stabilization, angio and then deal with the problems later on. If he's got a belly full of blood, to the OR, with your orthopedic surgeon.

As Chip pointed out, you talk to each other, you decide what you're going to do, you probably take your noninvasive stabilization if you can to something a little more stable. Open the belly, deal with what's inside there, and the big debate has to do with the great Atlantic ocean, and one side will pack and on this side probably we'll go to angio and I think that's probably again related to the fact that it depends on what you do best in your institution.

Comments? Have I misinterpreted anybody? And any other questions from the audience? Tim?

[Pohlemann] One comment. The crucial word is speed. I think we have to keep in mind that it's crucial for the patient that we get a very rapid resuscitation, and rapid control of the hemorrhage because this is what the patient is dying from. What method we are using depends on the system, but it has to be effective and it has to be rapid. The patient has to be in the ICU as soon as possible for further stabilization.

[Bob Meek] Question. Bob Meek from Vancouver. Something I don't understand about this fractured pelvis is this: if we had this exact patient with a ruptured bladder, everybody would open what Tim calls the small pelvis, the true pelvis, and fix the bladder and if he was bleeding we'd pack it. I gather if there is no punctured bladder everybody's afraid to open that space except Tim. That doesn't make any sense to me.

I've been involved in lots of these cases where it's been opened to fix the bladder and we just go ahead and fix it and then we fix the pelvis at the same time. So could the people who don't want to open that space tell me why they want to open it when there's a bladder rupture, why their patient is not going to die, and why they don't want to open it when there's no bladder rupture?

[Kellam] Tom?

[Scalea] If there's an opportunity, we'll embolize that patient before we fix their bladder. We've done that a number of times. They have a negative FAST, we embolize and we do a cystogram if they have an intraperitoneal bladder rupture. Nothing kills them faster than blood loss. The ruptured bladder doesn't kill them. If I'm in the operating room, and they are bleeding significantly, I don't bother fixing the bladder. I stick a lap pack down there, I embolize them, I bring them back and fix their bladder later.

I think the patients get selected out, in that if you're in the operating room and the patient is relatively stable, that probably means they don't have significant ongoing bleeding. Whether or not you open up the hematoma, it probably doesn't make a lot of difference, so if they have an intraperitoneal bladder rupture, you open the hematoma, you fix the bladder, it's OK. This is a different situation. This is a patient who's bleeding to death, and I think you stop the bleeding the best way you can. In my hands, that's in the angiogram suite. I'll control the hemoperitoneum, but we've got very good angiography people and I think they're better than I am at taking care of hypogastric arterial bleeding.

[Kellam] One last question.

[J. Spence Reid] J. Spence Reid from Hershey. I'm wondering if as a group we should not be moving towards one stop shopping, and with the advent of digital subtraction capabilities on intraoperative fluoroscopy, do it all in one location instead of having to continually make the decision of where we should be in the hospital. We should be in the operating room, and I'm wondering if we shouldn't be moving towards that as a group because I know in our hospital we've done that on several occasions. Instead of going down to angiography, the angiographer comes up to the OR and brings his cart full of coils and gel foam, and it's a wonderful thing to watch happening.

[Sclafani] Yes, I think that it's just another form of surgery, so why can't it be in the OR? There are a couple problems. One is that you're probably using portable x-ray equipment, and the portable x-ray equipment is quite good for the focused area of the pelvis. I have to look for associated lumbar bleeding; I've got to do some manipulations of the catheter that require a larger field of view than I could get in the OR. If you give me an angio suite in the OR I won't leave the OR ever, I'll just stay there with the rest of you guys. I have no problem with that.

[Kellam] OK. Thank you all very much, I've enjoyed it, greatly enjoyed it.

[Applause]

[Kellam] As you're leaving I'll make one last plea. All this will go back up onto this website once again. We welcome your comments. This has been sort of an educational first for the Orthopedic Trauma Association, and I would ask you to look at this because I think you might find there's an awful lot of information and a new way in educating yourselves by this process. Thank you.