vascular injury in pelvic trauma

Vascular Injury in Pelvic trauma

Peter Giarso

Introduction

Pelvic Trauma:• Excellent knowledge of the anatomy

• Complex anatomic relation, pathway of nerves and vessels networks

• Substantial force.

• There are many organs in it.

• Connects to abdominal and retroperitoneal space.

• Rapid transportation to a trauma center, early recognition of the injuries.

• Early surgical intervention, good surgical judgment

Demetriades D, Inaba K. Capther 154 – Vascular Trauma : Abdominal . Cronenwett: Rutherford's Vascular Surgery, 7th ed.

Anatomy

Thompson JC. Netter’s Concise Atlas of Orthopaedic Anatomy

Surgical anatomy

For vascular trauma purposes: • Zone 1The midline retroperitoneum,from the aortic hiatus to the sacral promontory. The supramesocolic area and The inframesocolic area. • Zone 2 (left and right), Which includes the kidneys, paracolic gutter, and renal vessels.

• Zone 3, Which includes the pelvic retroperitoneum and contains the iliac vessels.


Surgical anatomy


Mechanism of injury

Penetrating trauma :

1. Low-velocity missiles cause direct injury to the vessel. 2. High-velocity missiles and blasts can also cause vascular trauma by

means of the shock wave and transient cavitation.

Blunt trauma (abdomen pelvis):

1. Rapid deceleration, (accidents or falls from heights) 2. Direct anteroposterior crushing, (seat belts) 3. Direct laceration of a major vessel by a bone fragment, as occurs in severe pelvic fractures.


Incidence

• Insiden antara arteri dan vena sama(1)

• Rutherford: Arterial injuries (49%) dan venous injuries (51%).• Vascular trauma book(2)

• Arteri common iliaka (40%), a. iliaka internal (30%) a.iliaka eksternal (30%).• Vena: common iliaka (48%), v. iliaka eksternal (32%), v. iliaka internal

(22%)• Blunt trauma : Paling sering vena iliaka internal (strectching atau laserasi)

1. Demetriades D, Inaba K. Capther 154 – Vascular Trauma : Abdominal . Cronenwett: Rutherford's Vascular Surgery, 7th ed.2. Rich NM, Mattox KL, Hirshberg A. Vascular Trauma. 2ed.

Clinical Presentation

• Multiple severe trauma, jejas/ VL daerah pelvis

• Tanda-tanda perdarahan: s/d syok, distensi abdomen, pulsasi a. femoralis

• Rectal bleeding, OUE bleeding, high riding prostate

• Secondary thrombosis (intimali tear): leg ischemia

• Fraktur pelvis: one examiner

1. Demetriades D, Inaba K. Capther 154 – Vascular Trauma : Abdominal . Cronenwett: Rutherford's Vascular Surgery, 7th ed.2. Rich NM, Mattox KL, Hirshberg A. Vasular Trauma. 2ed.

Clinical Presentation

• Radiologis: pada hemodinamik stabil(2)

• Proyektil

• Blunt trauma: increased risk vascular trauma:

• Presence of symphysis pubis diastisis >2.5 cm

• Sacroiliac joint disruption

• Superior and inferior rami fractures bilaterally (Butterfly fracture)(demetradee et al: undergo angiographic embolization dan massive transfusion)

• CT Scan: (1)

• USG : late abdominal vascular complication

• Angiography: site and severity, control bleeding

1. Demetriades D, Inaba K. Capther 154 – Vascular Trauma : Abdominal . Cronenwett: Rutherford's Vascular Surgery, 7th ed.2. Rich NM, Mattox KL, Hirshberg A. Vasular Trauma. 2ed.

Classification

• Radiology:

• Anatomy (leutornel, Dennis, Tile, OTA)

• Mechanism: (Young and Burgess)

• Vector of force

• Degree of bony displacement

• predict risk of blood loss and types of associated injuries

Stein DM, O’Toole R, Scalea TM. Multidisciplinary Approach for Patients withPelvic Fractures and Hemodinamic Instability. Journal of Surgery. 96: 272-80, 2007Stephen D. Management of high-energy pelvic fractures.

Classification


• Anterior-posterior compression (APC 1F3)

• APC1Fstable

• APC 2Fpartial instability

• APC 3Fcomplete instability

• Lateral compression (LC 1F3)

• LC lFstable impacted

• LC2Fposterior ring fracture without pelvic floor disruption

• LC3Fdirect rollover

• Vertical shear (VS)

• Combined mechanism injury (CMI)

• Not classifiable

Classification


• Anterior-posterior compression (APC 1F3)

• High speed crashes

• Open book fracture

• Substantial blood loss

Classification


• Lateral compression (APC 1F3)

• T-bone vehicular crashes

• Fall where lands on side

• Vascular injury may occur

• Generally not substantial blood loss

(concomitant injury)

Management

.

• Prehospital:

• Scoop and run

• Bleeding control

• Fluid resuscitation (controversy, crystalloid fluid)

• Increase rate and volume of blood loss

• Hypotension control

• Hypothermia

1. Demetriades D, Inaba K. Capther 154 – Vascular Trauma : Abdominal . Cronenwett: Rutherford's Vascular Surgery, 7th ed.2. Rich NM, Mattox KL, Hirshberg A. Vascular Trauma. 2ed.

Management

.

• Treating Pelvic Hemorrhage:

• Principle: reducing fracture

• Bed sheet:

• Greater trochanter: the compressive device is centered over the greater

trochanters of the hip, not over the iliiac crest

• Crisscrossed

• Mannually reduces the pelvis, post reduction x-ray

• MAST (military anti-shock trouser), PASG (pneumatic anti-shock garments)

• C-Clamp

1. Rich NM, Mattox KL, Hirshberg A. Vascular Trauma. 2ed2. Stein DM, O’Toole R, Scalea TM. Multidisciplinary Approach for Patients withPelvic Fractures and Hemodinamic Instability.

Journal of Surgery. 96: 272-80, 2007

Management

. 1. Rich NM, Mattox KL, Hirshberg A. Vascular Trauma. 2ed2. Stein DM, O’Toole R, Scalea TM. Multidisciplinary Approach for Patients withPelvic Fractures and Hemodinamic Instability.


Management

.

• Treating Pelvic Hemorrhage:

• Angiographic embolization

• Time, place, and personnel required

• A flush pelvic aortogram, then selected pelvic angiography

• Embolization

• Direct operative exploration



Management

. 1. Rich NM, Mattox KL, Hirshberg A. Vascular Trauma. 2ed2. Stein DM, O’Toole R, Scalea TM. Multidisciplinary Approach for Patients withPelvic Fractures and Hemodinamic Instability.


Management

.

• Operating management:

• Arterial injuries:

• Compression and control(proximal and distal)

• Iliac vessels: approach : dissection paracolic peritoneum and medial rotation

the colon.

• Proximal control: clamp> vessel tape

• Distal vessel: can be difficult, extending midline incision

• Primary repair

• Ligation the common and external iliaca should be aviod (50% limb loss)



Management

.

• Operating management:

• Venous injuries:

• More challenging: difficult exposure and air embolism

• Lateral venorraphy

• Ligation

• SE: stenosis (possb 50%), edema and compartment syndrome (from ligation)

• Individual choice



Conclusion

.

• Hemodinamically unstable patient with pelvic fracture present a unique challenge.

• Diagnosing the sources and resuscitation

• Close coordination

• Algorithm and tools to manage



vascular injury in pelvic trauma

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