Severe Pelvic Trauma

Hemodynamically unstable pelvic fractures are a talk-and-die situation. These folks require aggressive, rapid treatment if they are going to survive the injury. Inspired by my mentor, Thomas Scalea, I discuss the management of the unstable pelvic trauma patient.

Read these Incredible Posts by Chris Nickson

Part I

Part II

Young-Burgess Shock Trauma Pelvic Fracture Classification

(J Trauma 30(7): 848-856)

from the handbook of fractures

Open Iliac Artery Clamping

Dubose and Inaba (J Trauma. 2010;69: 1507?1514)

How to Kill when Intubating

Forgot to mention on the podcast–The combination of an open-book pelvis that you have not bound yet and paralytics is a great way to cause massive bleeding. Bind the open pelvis before tubing!!!

New East Pelvic Trauma Guidelines

(J Trauma 2011;71(6):1850)

  • external fixation doesn’t limit blood loss, but reduces fracture displacement (III)
  • unstable patients should get angio (I)
  • pts with blush may require angio even if stable (I)
  • ongoing bleeding after angio should get repeat angio (II)
  • >60 y/o with major fx should get angio even if stable (II)
  • anterior fxs assoc with ant vessel injury and posterior = posterior (III)
  • Bilateral non-selective is safe, gluteal ischemia is more likely from injury not angio (III)
  • And doesn’t affect male potency (III)
  • FAST is insensitive in pelvic trauma (I)–don’t agree with this one
  • Adequate Specificity (I)
  • DPA is test of choice (II)
  • Use CT if stable (II)
  • Fracture pattern doesn’t predict need for angio (II)
  • Nor hematoma location (II)
  • Absence of ICE doesn’t exclude active hemorrhage (II)
  • Volume > 500 cm3 predicts need for angio (III)
  • Isolated acetabular fx may still need angio (III)
  • Perform cystogram after ct (III)
  • Binders reduce fx as well as definitive stabilization and decrease pelvic volume (III)
  • And they limit hemorrhage (III)
  • They work as well or better than external fixation in controlling hemorrhage (III)
  • RetroP Packing can be used to salvage after failed angio (III)
  • Can be used as primary in an integrated protocol (III)

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Comments

  1. Great stuff Scottie – and cheers for the links mate,
    Chris

  2. enjoy all the downloads, great CME

  3. Suggestion for securing sheet used for pelvic binding since I will need to transfer the patient?
    Read M. McGonigal’s blog. He mentions applying AP pressure and lateral pressure to the pelvis. You mention pushing inward. He states not to use binder if unstable with lateral pressure. Are you describing lateral or medial pressure? Can you clarify and are there times I should not place a binder with suspected pelvic trauma? I transfer all but minor trauma.

    • I’m unclear on the palpation as well. Are we talking about an even anterior-to-posterior pressure, or a bilateral lateral-to-medial compression? (There seems to be agreement not to perform a unilateral “wobble.”)

      • It is lateral to medial, but if there is actually an open book there is an inwards rotation aspect as well. Imagine closing an open textbook whose covers are sitting a little bit less than 180 at the start.

  4. Great podcast Scott. Even our big trauma centres in Oz don’t get near the volume of trauma you see, so always good to hear your thoughts. Like the pushing iliac crests in as the screening test, this gets discussed a lot at ATLS/EMST courses!

  5. My ED Crit Care buddy Xun wrote to remind me to mention:

    • Bind the pelvis before you tube, or the patient can have hemodynamic collapse
    • Always tie or tape the feet together to make the pelvic sheeting/binding effective
  6. Are there any special considerations when performing pelvic binding on patients with a gravid uterus?

    • great question. i am only postulating here, but I think it pure open book, it would be the same as you would close down the same initial volume. I would be scared if there were fracture fragments, but not really sure.

  7. DocXology says:

    Shouldn’t we make a distinction between immobilising the pelvis and ‘binding’ or ‘compressing’ the pelvis? Binders make sense in open book fractures to restore anatomy but over-exuberant tightening in lateral compression-type fractures could worsen the deformity (and possibly cause further vascular injury).

    • We only bind expanded pelvises (AC), we don’t bind LC injuries. If you accidentally do, unlikely to make the injury worse (though still not a good idea).

      • DocXology says:

        That’s why I will apply the binder firmly but not tighten it until I get some pictures. As far as binders not making LC injuries worse, do you have any evidence for this? The article from trauma.org suggests this is possible:

        http://www.trauma.org/index.php/main/article/657/


        ‘Closing the pelvis’ does not prevent this and the binder is not used to reduce the volume of the pelvis or achieve perfect anatomical alignment. .

        The pelvic binder is used to splint the bony pelvis. The binder splints the bony fracture, approximating bone ends and reducing low-pressure bleeding from bone ends and disrupted veins. As the fracture pattern is often unknown at this stage, it is possible to exacerbate certain injury patterns if excessive force is applied. This is particularly true of severe lateral compression or vertical shear injuries.

        It certainly is one reason why the C-clamp is falling out of favour. Indiscriminate application of force can be deleterious.

        • A pelvic binder is not a splint for the pelvis. We don’t place them for LC or vertical shear injuries. Their purpose is to move the pelvis not to stabilize the pelvis. If the pelvis is already closed down (VS) or compressed (LC) then there is no purpose to placing the binder.

          Karim’s article on trauma.org suggests this is possible as I eluded to, but we have not seen nor has the literature reported cases where this has occurred. I believe this is made clear by one of Karim’s absolute indications for the placement of a binder:
          “The haemodynamically unstable patient with a suspected pelvic fracture.”

          Can you please use a real name and some indication of your profession/affiliation when posting. Much thanks.

          • DocXology says:

            EMCrit says “A pelvic binder is not a splint for the pelvis.”

            The quote I provided in my previous post that argues against this is from the trauma.org site. The original article even provided the primary research that suggests the predominant mode of action of the binder is to prevent fracture movement and further vascular/clot disruption. There is reinforced by the evidence that accurate anatomical reduction (via surgery) does not actually improve the major endpoints of transfusion requirement or mortality.

            As Prof Brohi notes:

            “The pelvis does not fill with blood like water poured into a cone-shaped bucket. Pelvic haemorrhage spreads through disrupted tissue planes, extending through the retroperitoneum vertically out of the pelvis into the abdominal retroperitoneum up into the thorax, and anteriorly around the bladder the anterior abdominal wall. ‘Closing the pelvis’ does not prevent this and the binder is not used to reduce the volume of the pelvis or achieve perfect anatomical alignment. .”

            Regards,
            Dr. Derek Louey MBBS FACEM
            Flinders Medical Centres SA

  8. Derek,

    Not sure how we are disconnecting. A splint takes an existing alignment fo a bony structure and stabilizes it. If the pelvic binder was a splint we would be putting it on LC and VS injuries. We do not do this because the purpose of the pelvic binder is to move the bones; its purpose is to take an expanded AC injury and bring the bone ends into alignment. As to the mechanisms as to why this helps with hemodynamic instability and pelvic bleeding, they are debatable but I agree with Karim that we are not tamponading the bleeding simply by “closing the pelvis.” This in no way changes the fact that closing the pelvis is indeed what I and Karim are seeking to do and why we apply the binder in the first place.

    I am no longer sure what you are trying to get across. In some of your earlier comments, you elude to the dangers of binding an LC injury, now it seems you are stating that the binder should be used as a splint which would imply a utility for all pelvic trauma.

    I’m sorry if I have misunderstood.

  9. DocXology says:

    My approach:

    Prehospital (no xray available) = multi-trauma (potential pelvic #) = binder or sheet firmly applied to SPLINT pelvis and another sheet to tie knees together

    On arrival in ED = ABCs, get CXR/FAST/PXR

    If open book = consider tightening binder to improve reduction (but little evidence this makes any difference)

    If over-riding symphysis = consider relaxing binder slightly (but leaving it on) to prevent over-reduction (but little evidence this makes any difference)

    If no pelvic fracture, take binder off.

    The key point is I only see a binder has a means of stopping the fractures ends wobbling around to prevent further bleeding. If the patient is crashing despite the binder and blood then they are likely to have an arterial bleed and that ideally means angio. If you don’t have access to angio, the patient is in a real pickle. Keep the binder on, laparatomy, pack pelvis ++, stabilise enough to get an angio facility. Trying to achieving anatomical reduction (even with emergency ex fix) in this situation is not going to make any difference.

    • Derek,
      You lost me on the transition between applying the binder firmly and applying even tighter to close an open book. And then further mentioning the lack of evidence for outcome improvement in reducing the open book. There are a few things agreed to by I think all in the trauma world:
      the only situation in which a binder is of use is the open book pelvis
      in a known non-open book, the binder has no utility
      if in doubt as to which fx type you have, better to apply than not in an unstable patient.
      Not sure if we are agreeing or disagreeing about the above b/c you seem to be stating what you would do in a prehospital environment with an unknown fx pattern, where your strategy of placing a binder is in keeping with the above. I my confusion still lies with your concept of placing one level of compression for an unknown fracture pattern and a different one for a known A/C. I am very unsure of that concept and have seen nothing in the literature to go along with the idea. Both the SAM sling and the T-Pod should always be applied to generate the same amount of force to both unknown pattern and known AC open book injuries. The same is true of bed sheets and non-measured force binders.

      I suppose a further aid to understanding what you want to convey is when you are working ED shifts, are you applying binders on xray demonstrated LC or vertical shear injuries.

      • DocXology says:

        I said ‘consider’ adjusting binder depending on injury pattern. But to simplify – put the binder on correctly and firmly without excessive force (noting that not all binders have tension limiters). If there is a fracture potentially involving posterior elements, leave the binder on (regardless of AP, LS, VS).

        I repeat, the main purpose of the binder is to stop the fracture moving around (disrupting clot) – not to change the anatomy. But clearly if your binder is contributing to distortion of anatomy then maybe you need to think about adjusting it. Ultimately, making adjustments with the binder is not going to make a difference in the crashing patient, they need angio.

  10. at 10:00 the podcast discusses DPA (also termed ‘diagnostic peritoneal tap’/DPT in other literature). i’d like to learn more about the technique, but havent really dug up anything definitive online about how to do it. Ie: what size needle? are you accepting bowel puncture but regard it as insignificant with a small gauge?

    i see discussions about just doing the first part of DPL as DPA, but that seems like it would be a very involved process compared to just ‘sticking in a needle’.

    is anyone aware of something online to learn more about this technique?

    • DPA can be percutaneous or open. Perc takes a minute; open a while longer. The perc dpa kit is a blunt tip 20G or 18g. The blunt tip makes bowel perf much less likely but requires a small scalpel skin incision. The kit is just the needle with a cath over it or a needle, short wire, and small catheter.

      • that makes sense. thanks for the explanation. sounds like a veress needle would be the obvious choice- is that what you mean, or are you suggesting spinal-type blunt? (would be a nice option for folks without access to veress needles).

        i am still frustrated i cant learn more specifics online, whereas every other procedure always seems to have plenty to read up on. searching for ‘perc peritoneal tap/aspiration’ doesnt really turn up anything except studies comparing veress vs open access to place a DPL catheter (summary: veress introducers are great).

        i see Arrow has a perc DPL kit which includes the same introducer/catheter combo as they do for at least some of their CVC kits, which suggests a standard vascular needle. i woudl be pretty tense pushing an 18g cutting needle into someone’s belly..

        so much to learn.

  11. Dear Scott,

    It is my understanding that the bleeding from pelvic trauma/fractures is usually venous (80-85%), but arterial in 15-20%. If the patient is hemodynamically unstable, this points more towards an arterial injury, especially if you can rule out tamponade, tension hemo/pneumo, significant abdominal injury, etc… It is my understanding the bleeding from the pelvis leads not only to blood in the pelvis, but also tracks up into the retroperitoneum, and the peritoneum. My question is in regard to a +FAST necessitating laparotomy before/over angiography… Assuming isolated pelvic bleeding causes a +FAST in the pelvis, before it becomes + in the peritoneum (via right paracolic gutter). My question is: IS the reason that a +FAST necessitates laparotomy over angio, bc you can not rule out intra-abdominal injury? (Theoretically- and I know you could never 100% know this- IF the massive pelvic arterial bleed is causing the majority of the bleeding, and you happen to have a small liver lac causing a +FAST, You would think in that case angio would be more beneficial) Or- what if you could hypothetically be certain that the +FAST is due solely from the pelvic bleeding (arterial)? I don’t think you could ever truly be 100% certain, but if you have isolated pelvic trauma, with no other physical exam findings or trauma anywhere else above, AND you have an initially TOTALLY clean FAST everywhere in the thorax (no pneumo, no hemo, no effusion) , and totally clean everywhere in the belly EXCEPT the pelvis… in other words you very strongly suspect that the real problem is arterial bleeding from the pelvis… in this case would you take your odds and would angiography trump laparotomy despite a +FAST??

    Thanks so much,
    Sam
    EUS Fellow- CMC

Trackbacks

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