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Bleeding from Pelvic Fractures
Three bleeding sources:
1. Arteries (10-15%)
2. Low-pressure venous plexus (80-90%)
3. Fractured cancellous bone surfaces
Giannoudis PV, Pape HC. Damage control orthopaedics in unstable pelvic ring injuries. Injury, Int. J.Care Injured 2004;35:671-677.Geeraerts T, Chhor V, Cheisson G, Martin L, Bessoud B, Ozanne A, Duranteau J. Clinical review : Initial management of blunt pelvic trauma patients with haemodynamic instability. Critical Care 2007; 11:204-212.White CE, Hsu JR, Holcomb JB. Haemodynamically unstable pelvic fractures. Injury, Int. J.Care Injured 2009; 40: 1023-1030.
External Pelvic Stabilization
1
Reduce pelvic volume
↓↓ blood loss
promotes tamponade effect
2
Return bony pelvic components back into
apposition ↓
Haemostatic pathways to control venous
bleeding
3
↓ clot dislodgement
↓ elimination of thrombotic process
↓ consumption of clotting factors
Miller PR, Moore PS, Mansell E, Meredith W, Chang MC. External fixation or arteriogram in bleeding pelvic fracture : Initial therapy guided by markers of haemorrhage. J Trauma 2003; 54(3):437-443.DiGiacomo JC, Bonadies JA, Cole FJ, Diebel L, Hoff WS, Holevar M, Malcynski J, Scalea T. Practice management guidelines for haemorrhage in pelvic fracture. Eastern Association for the Surgery of Trauma 2001; 1-15.
Pelvic Binder
Non-invasive, inexpensive
Easy to apply
Access to abdomen
White CE, Hsu JR, Holcomb JB. Haemodynamically unstable pelvic fractures. Injury, Int. J.Care Injured 2009; 40: 1023-1030 .
External Fixator
Mohanty K, Musso D, Powell JM, Kortbeek JB, Kirpatrick AW. Emergent management of pelvic ring injuries: An update. Can J Surg 2005; 48(1):49-55.
DiGiacomo JC, Bonadies JA, Cole FJ, Diebel L, Hoff WS, Holevar M, Malcynski J, Scalea T. Practice management guidelines for haemorrhage in pelvic fracture. Eastern Association for the Surgery of Trauma 2001; 1-15.
Posterior C clamp
Mohanty K, Musso D, Powell JM, Kortbeek JB, Kirpatrick AW. Emergent management of pelvic ring injuries: An update. Can J Surg 2005; 48(1):49-55.
DiGiacomo JC, Bonadies JA, Cole FJ, Diebel L, Hoff WS, Holevar M, Malcynski J, Scalea T. Practice management guidelines for haemorrhage in pelvic fracture. Eastern Association for the Surgery of Trauma 2001; 1-15.
External Fixator
Indications:
If laparotomy or packing is needed for unstable pelvic fracture
Heetveld MJ, Harris I, Schlaphoff G, Sugrue M. Guidelines for the management of haemodynamically unstable pelvic fracture patients. ANZ J.Surg 2004; 74: 520-529.
Suzuki T, Smith WR, Moore EE. Pelvic packing or angiography : Competitive or complementary? Injury, Int. J.Care Injured 2009; 40: 343-353.
Arterial Bleeding
White CE, Hsu JR, Holcomb JB. Haemodynamically unstable pelvic fractures. Injury, Int. J.Care Injured 2009; 40: 1023-1030.
Arterial Bleeding
Indicators of significant arterial bleeding:1. Lack of response to initial resuscitation
2. Contrast material extravasation (blush) on CT scan Sensitivity 80-84% Specificity 85-98%
Yoon W, Kim JK, Jeong YY, Seo JJ, Park JG, Keun HK. Pelvic arterial hemorrhage in patients with pelvic fractures : Detection with contrast-enhanced CT. RadioGraphics 2004;24:1591-1606.
Miller PR, Moore PS, Mansell E, Meredith W, Chang MC. External fixation or arteriogram in bleeding pelvic fracture : Initial therapy guided by markers of haemorrhage. J Trauma 2003; 54(3):437-443.
CT Scan
Axial CT scan shows pelvic haematoma (white arrows) with extravasation of contrast medium (arrowhead).
Angiography and Embolization
Digital angiography of the left internal iliac artery with extravasation of contrast
Geeraerts T, Chhor V, Cheisson G, Martin L, Bessoud B, Ozanne A, Duranteau J. Clinical review : Initial management of blunt pelvic trauma patients with haemodynamic instability. Critical Care 2007; 11:204-212.Heetveld MJ, Harris I, Schlaphoff G, Sugrue M. Guidelines for the management of haemodynamically unstable pelvic fracture patients. ANZ J.Surg 2004; 74: 520-529.
Angiography and Embolization
Indications:
1.Persistent haemodynamic instability
2.Ongoing bleed despite pelvic packing
3.Arterial extravasation of contrastHeetveld MJ, Harris I, Schlaphoff G, Sugrue M. Guidelines for the management of haemodynamically unstable pelvic fracture patients. ANZ J.Surg 2004; 74: 520-529.
Balogh Z, Caldwell E, Heetveld M, Amours SD, Schlaphoff G, Harris I, Sugrue M. Institutional practice guidelines on management of pelvic fracture-related haemodynamic instability : Do they make a difference ? J Trauma 2005; 58:778-782.
Suzuki T, Smith WR, Moore EE. Pelvic packing or angiography : Competitive or complementary? Injury, Int. J.Care Injured 2009; 40: 343-353.
Pelvic Packing
Preperitoneal space
White CE, Hsu JR, Holcomb JB. Haemodynamically unstable pelvic fractures. Injury, Int. J.Care Injured 2009; 40: 1023-1030.Giannoudis PV, Pape HC. Damage control orthopaedics in unstable pelvic ring injuries. Injury, Int. J.Care Injured 2004;35:671-677.Gansslen A, Giannoudis P, Pape HC. Haemorrhage in pelvic fracture: Who needs angiography ? Curr Opin Crit Care 2003; 9:515-523.
Pelvic Packing
White CE, Hsu JR, Holcomb JB. Haemodynamically unstable pelvic fractures. Injury, Int. J.Care Injured 2009; 40: 1023-1030.
Giannoudis PV, Pape HC. Damage control orthopaedics in unstable pelvic ring injuries. Injury, Int. J.Care Injured 2004;35:671-677.Gansslen A, Giannoudis P, Pape HC. Haemorrhage in pelvic fracture: Who needs angiography ? Curr Opin Crit Care 2003; 9:515-523.
Pelvic Packing
Indications: Ruptured pelvic haematoma at
laparotomy (transperitoneal)
Unresponsive to embolization/initial resuscitation
No angiography facilities available
Heetveld MJ, Harris I, Schlaphoff G, Sugrue M. Guidelines for the management of haemodynamically unstable pelvic fracture patients. ANZ J.Surg 2004; 74: 520-529.
White CE, Hsu JR, Holcomb JB. Haemodynamically unstable pelvic fractures. Injury, Int. J.Care Injured 2009; 40: 1023-1030.
Angiography +/- embolisation
External fixation Pelvic Packing
Advantages • Less invasive
• High success rate
• Can stop arterial bleeding
• Quick to perform
• Does not limit access to abdomen
• Can be placed in the AED
• Quick to perform
• Does not require special technology
• Stabilize patient for angiography
Disadvantages/Complications
• Time consuming
• Requires interventional radiologist
• Haematoma
• Pin site infection
• Nerve and vascular injuries (C-clamp)
• Invasive
• Intrapelvic infection
• May not be effective for treatment of arterial bleeding
• Removal requiredSuzuki T, Smith WR, Moore EE. Pelvic packing or angiography : Competitive or complementary? Injury, Int. J.Care Injured 2009; 40: 343-353.Papakostidis C, Giannoudis PV. Pelvic ring injuries with haemodynamic instability : Efficacy of pelvic packing, a systematic review. Injury, Int. J.Care Injured 2009; 40S4: S53-S61.
Comparison of Interventions
Time to interventionTime to intervention: PACKING group vs ANGIO group (45mins vs 130mins)(p=0.01)
Blood transfusionBlood transfusion in the first 24 hoursin the first 24 hours: ,less in the PACKING group (6.9 unit vs 10.1 units ; p=0.01)
MortalityMortality: PACKING group 4/20 vs ANGIO group 6/20 (p = 0.48)
Early mortality rate: 10% (95% CI: 3−18%)
Late mortality rate: 13% (95% CI: 5−22%)
Overall mortality: Overall mortality: 28% 28% (95% CI: 16.8−39.4%)(95% CI: 16.8−39.4%)
Increase in SBP after EPP (p=0.002)
Mortality : Mortality : 28% 28%
QEH Data
2005 2006 2007 20082009 (8 mth)
Total no. of trauma cases 401 351 371 447 402
No of pelvic injury cases (%)
27 (7%)
38 (11%)
36 (10%
)
45 (10%
)
27 (7%)
Grossly NegativeGrossly Positive
QEH Protocol 2004-2008
No Yes
No
Yes No
Pelvic FracturePelvic Fracture
HypotensionHypotension
FAST Scan/ Diagnostic Peritoneal LavageFAST Scan/ Diagnostic Peritoneal Lavage
Wrap Pelvis with Sheet/Binder
Wrap Pelvis with Sheet/Binder
Laparotomy+ External Fixation
Laparotomy+ External Fixation
StableStable
Angiography+ EmbolizationAngiography
+ Embolization
Amenable to External Fixation
Amenable to External Fixation
Yes
External FixationExternal Fixation
ICUICU
ICU+CTICU+CT
Sustained Response to Sustained Response to Initial Resuscitation?Initial Resuscitation?
Sustained Response to Sustained Response to Initial Resuscitation?Initial Resuscitation?
AngiographyAngiography++ Embolization EmbolizationAngiographyAngiography
++ Embolization Embolization
QEH Protocol 2008-2009
YesYes
Pelvic FracturePelvic Fracture
ShockShock
FAST Scan/ Diagnostic Peritoneal LavageFAST Scan/ Diagnostic Peritoneal Lavage
Wrap Pelvis with Sheet/BinderWrap Pelvis with Sheet/Binder
Pelvic FixationPelvic Packing
Laparotomy
Pelvic FixationPelvic Packing
Laparotomy
Sustained Response to Sustained Response to Initial Resuscitation?Initial Resuscitation?
Sustained Response to Sustained Response to Initial Resuscitation?Initial Resuscitation?
StableStable
ICU +/- CT scanICU +/- CT scanNoNo
YesYes NoNo
Unstable or Ongoing Bleeding
Unstable or Ongoing Bleeding
External FixationExternal FixationPelvic PackingPelvic Packing
External FixationExternal FixationPelvic PackingPelvic Packing
NoNoYesYes
Grossly PositiveGrossly Positive Grossly NegativeGrossly Negative
ICUICU
AngiographyAngiography
AngiographyAngiography ICUICU
Study period : June 2007- End of 2009
Number of patients: 24
Aim: To compare the mortality rate between the 2 protocols
Previous protocol : (Angiogram +/- Embolization) Feb 2004 – June 08
Current protocol : (Packing +/- Angiogram +/- Embolization) Jun 08
onward
Retrospective Review for Unstable Pelvic Fractures
Male : Female 15:9
Age: mean 47.7yrs, median 45yrs, range:18-84yrs
Mechanism of injury: Blunt trauma
Road traffic accident: 13
Fell from height: 11
Trauma score (Median / Mean) : ISS 41.2/ 43
Overall mortality : 58.3% (14/24)
Retrospective Review for Unstable Pelvic Fractures
QEH Data
N= 24 ANGIO
N= 13
PACKING
N=11
P value
Age 44.8 (+/- 23.7) 51.2 (+/- 19.6) 0.464
Blood transfusion in AED (units)
3.3 (+/-4.4) 2.7 (3.37) 0.338
Combination of Combination of treatmenttreatment
0/130/13 5/115/11 0.0020.002
Time spent in AED (mins)
61.9 (+/- 33.5) 69.7 (+/- 15.6) 0.711
Systolic pressure on arrival (mmHg)
61.2 (+/- 15.5) 99.0 (+/- 32.6) 0.060
ISS 40.0 (+/- 12.7) 42.3 (+/- 18.1) 0.724
RTS 5.52 (+/- 2.4) 6.92 (+/- 2.0) 0.139
TRISS 0.45 ( +/- 0.3) 0.73 (+/- 0.2) 0.050
Mortality Mortality 10/13 (77% )10/13 (77% ) 4/11 (36%)4/11 (36%) 0.0950.095