1. Trauma– Pelvic Fractures Jay B. Baker, MD

2. Learning Objectives Understand pathology of pelvic fractures Assess and work up trauma patients for pelvic fracture Treat the unstable pelvis Disposition pelvic fractures appropriately

3. Introduction Pelvic fractures are one of the few “talk and die” cases that can totally ruin your day Associated with other severe injuries Intraperitoneal– liver, spleen Retroperitoneal– bladder, urethral Vascular injuries including aortic rupture 1 Thus hypotension may be from a source other than the pelvis in blunt trauma

4. Sources of Blood Loss Unstable pelvic fractures with hemorrhagic shock have four potential sources of blood loss– Fractured bone surfaces Pelvic venous plexus Pelvic arterial injury Up to 30% extrapelvic sources—chest, abdomen, multiple extremity, external 1

5. Classification Originally designed to predict bleeding risk, but not sensitive or specific enough 3 AP compression– “Open book” Usually from “head on” trauma Frequency is 15-20% Lateral compression Usually from “side on” trauma Pelvic volume is compressed so life-threatening hemorrhage may be less likely 60-70% Vertical shear  major pelvis instability Jumpers or “head on” MVC 5-15% 1 Combinations may occur, associated with major bleeding.

6. AP compression– Open book

7. Lateral compression

8. Vertical Shear

9. Assessment Leg-length discrepancy or rotational deformity without fracture suggests unstable pelvis fracture Motion may be detected by grasping iliac crests and pushing inward, then outward (aka compression-distraction maneuver) Weingart recommends compression only 4 Once pelvic instability is demonstrated, no further maneuvers are necessary Inspect flank, scrotum, and perianal area for bleeding including urethral meatus Inspect for lacerations in perineum, vagina, rectum, or buttocks for open pelvic fractures May defer vaginal speculum exam to OR Palpate for high-riding prostate gland in males

10. Initial Imaging AP xray of pelvis confirms clinical exam FAST is specific for intra-abdominal injury but not for retroperitoneal bleeding If positive, patient goes to OR for laparotomy If negative, patient needs CT abd/pelvis Some surgeons might perform supra- umbilical DPA to rule out intra-abdominal bleeding Not infra- to avoid possible pelvic hematoma

11. CT Abdomen and Pelvis Obtain CTAP in hemodynamically stable patient with clinical suspicion of intra- abdominal injury Defer retrograde urethrogram (RUG) in severe pelvic trauma Assessment for life-threatening injuries takes precedence IV contrast for RUG may interfere with interpretation of pelvic angiogram or CTAP 5

12. Management Splint unstable pelvis fractures with simple techniques Goal– Decrease pelvic volume prior to transfer and during resuscitation Wrap a 12” sheet around the greater trochanters and tighten down 6 Commercially available pelvic splints Other pelvis stabilizing devices e.g. ex-fix are not preferred due to time-intensive

13. Applying the Pelvic Splint

14. Sample algorithm Surgical consult Pelvic splint Evaluate for intraperitoneal gross blood If (+), then dispo patient to the OR for laparotomy If (-), then dispo to angiography 1 NB: Angioembolization may be performed concurrently with laparotomy

15. Controversy Some centers perform pre-peritoneal packing first 7 May be performed simultaneously with laparotomy if necessary A lot quicker when your surgeons are in house and your IR is still driving into the hospital Some centers reserve angioembolization for non-coagulopathic patients who continue to bleed from a pelvic source despite pre- peritoneal packing

16. Summary Unstable pelvic fractures can bleed to death as a solo injury or in association with other severe injuries Unstable pelvic fractures must be splinted immediately Unstable pelvic fractures require prompt surgical management and may require angioembolization by interventional radiology

17. References 1.Fildes J et al. Advanced Trauma Life Support Student Course Manual (8 th edition), American College of Surgeons 2008. 2.Nickson, Chris, “Trauma! Pelvic Fractures I.” Weblog entry. Life in the Fast Lane.com. April 23, 2012. http://lifeinthefastlane.com/2012/04/trauma-tribulation-027/ 3.Cullinane DC et al. Eastern Association for the Surgery of Trauma practice management guidelines for hemorrhage in pelvic fracture- update and systematic review. J Trauma 2011 Dec;71(6):1850-68. 4.Weingart, Scott, “Severe Pelvic Trauma.” Weblog entry. EMCrit blog: A discussion of the practice of ED critical care. April 30, 2012. http://emcrit.org/podcasts/severe-pelvic-trauma/ 5.Runyon MS. Blunt genitourinary trauma. In: UpToDate, Walls RM, Bachur RG (Ed), UpToDate, Waltham, MA, 2012. 6.McGonigal, Michael, “Compression Of The Fractured Pelvis With A Sheet.” Weblog entry. The Trauma Professional’s Blog. http://regionstraumapro.com/post/9038627564 7.Burlew CC, Moore EE. Definitive management of severe pelvic fractures in adults. In: UpToDate, Frankel, HL (Ed), UpToDate, Waltham, MA, 2011.

18. Simulation Training Assessment Tool– Unstable Pelvic Fracture Jay B. Baker, MD

19. CRITICAL ACTIONSMENISUSTAINIMPROVE 1° survey– recognize & treat potential hemodynamic instability FAST—recognize peritoneal fluid and begin IVF resuscitation 2° survey– recognize pelvic fracture, rectal for gross blood Apply pelvic binder– 12” wide sheet at greater trochanters Reassess VS frequently BP falls to 80/50 Transfuse w/ O(-) PRBCs, T&C 4-8 units Initial orders including portable pelvis xray Foley contraindicated, RUG deferred until after CT BP rises to 110/70 with PRBC transfusion Dispo to OR for intraabdominal injury, consult IR for angio Effective team leadership, communication and synergy TOTAL SCENARIO ALGORITHM SET UP In situ—ED resuscitation bay Sim Man 3G w/ C collar & backboard VS control by dedicated tech PRE ARRIVAL 27 yo female w/ CC: back & pelvis pain s/p thrown from horse HR 90, BP 115/70, RR 22, SPO2 98%, GCS 15 Transient hypotension en route, resolved with NS 500 cc ARRIVAL Pt in full spinal precautions 18g x1 @ LUE PRIMARY SURVEY A- Patent, speaking B- BS = bilat, RR 22 C- HR 120, BP 90/40 D- GCS 15 E- Superficial abrasions SECONDARY SURVEY C spine- C collar, nontender C spine Abdomen– TTP at LUQ Pelvis—Unstable with lateral compression (distraction contraindicated) Rectal—+gross blood GU—Perineal bruising, vaginal deferred LABS & IMAGES FAST positive at Morrison’s pouch H/H 8/24 Pelvic xray– Open book fx DISPOSITION To OR with trauma team, IR called in for angio (they will take at least 30 mins) Simulation Training Assessment Tool (STAT)– Unstable Pelvic Fracture Date:Instructor(s): Learner(s): Learning Objectives: 1.Recognize and treat pelvic fracture with hemodynamic instability 2.Recognize intraabdominal bleeding with EFAST and treat with PRBCs 3.Consult Trauma Surgery & Interventional Radiology for disposition ME = Meets Expectations; NI = Needs Improvement

20. Synopsis This case assesses the learner’s management of an unstable pelvic fracture with hemoperitoneum from likely intraabdominal injury. The setting is the ED resuscitation bay. The patient has a CC of back and pelvis pain after she was thrown from a horse and couldn’t walk due to pain. Her vitals are stable en route despite a brief SBP 85 that improved after NS 500. When the learners enter the room, they see Sim Man on a backboard and C collar w/o a monitor. The team leader (TL) must begin the 1° survey immediately and find patient is conscious, in pain, tachycardic, and mildly hypotensive. The TL must order fluid resuscitation and proceed to 2° survey while a team member performs the FAST- which is positive in Morrison’s Pouch. Secondary survey reveals TTP at LUQ, unstable pelvis, perineal ecchymosis, and positive gross blood at rectum. The pelvic binder must be applied quickly after detection. The instructor will decrease the SBP to 80– this must be detected with repeat VS. If learner fails to reassess VS, instructor may cause the patient to lose consciousness. Improvisation may be required depending on learner’s decision making if this occurs. Transfusion with emergency release PRBCs should be initiated quickly with T&C for 4 units minimum regardless if H/H is obtained. Foley is contraindicated. If PRBCs are not ordered, patient may lose consciousness as above. Patient’s BP will stabilize with transfusion. Due to hemoperitoneum, patient will dispo to the OR with general surgery consult. Interventional radiology must be considered for possible embolization. If pain control is attempted, it should begin with low doses of short acting agents e.g. fentanyl 25 mcg. The entire case should not take longer than 15 minutes. Personnel and roles Instructor assesses learners with STAT, jockeys VS through two changes Confederate nurse (possibly a Sr. resident) is helpful, not obstructive, doesn’t give away case Essential props and supply checklist 3G Sim Man w/ C collar, back board, moulage: perineal brusing and gross blood at rectum Monitor, monitor leads, O2 mask, IV x 2, IVF A pelvic binder that is stocked in your ED or a bed sheet Simulated PRBCs Debriefing Take notes with STAT to record impressions of learners’ performance with special attention to observed performance gaps. Use your notes to aid your debriefing. Begin with Reaction phase– Allow learners to blow off steam, clarify facts of case, collect insight for Teaching Phase. 1-2 minutes. Proceed into Teaching phase– Discuss each of the Critical Actions, mentioning each one in sequence. Proceed quickly where the learner performed well. Focus debriefing on areas where performance gaps were noted. 10-15 minutes. Take time to teach how to apply a pelvic splint correctly if this is needed. Summary phase– Ask learners to summarize briefly the following: What did they do well that they will do with a real patient? Briefly augment with any additional observations. What did they learn that they will do with a real patient? Briefly augment with any additional observations.

21. Images Pelvic fx film CXR Lateral C spine FAST x 4 windows w +MP

23. Nl CXR

24. Nl lateral C spine

25. Labs iSTAT Na 140 K 4.2 Cl 100 CO2 23 BUN 18 Cr 0.8 Hct 24 Hb 8.1 AnGap 19

26. ECG

27. Question 1 In patients with unstable pelvis fractures, hemorrhagic shock may be due to bleeding from all of the following except: A.Pelvic venous plexus B.Pelvic arteries C.Intrathoracic hemorrhage D.Intracranial hemorrhage

28. Question 2 Which of the following physical findings suggests pelvic fracture in the blunt trauma patient? A.Leg-length discrepancy B.Motion with compression-distraction C.Perineal bruising D.Gross rectal bleeding E.All of the above

29. Question 3 Which imaging study is not recommended in the trauma patient with a hemodynamically stable pelvic fracture? A.CT abdomen/pelvis B.Retrograde urethrogram C.AP pelvis radiograph D.FAST ultrasound

30. Question 4 Once an unstable pelvic fracture is identified, what is the next step? A.Consult orthopedics for external fixation in the OR B.Splint pelvis with a bed sheet wrapped around the greater trochanters C.Call interventional radiology for emergent angioembolization

31. Question 5 What is the disposition of the trauma patient with an unstable pelvic fracture and hemoperitoneum? A.Operating room for laparotomy only B.Angiography suite for embolization C.Operating room for laparotomy and pre- peritoneal packing D.CT suite to identify source of bleeding