9Physical examination GCS 15/15 in agony PEAR Chest : AE fair due to painAbdomen:Soft, mild distension and tender over lower abdomenPR: tone and perianal sensation intact, prostate not high riding , no blood at meatus( what does this imply?)Fast scan –veHb 15 ( ?good sign)
10X-ray of Trauma series Comminuted unstable pelvi-acetabular fracture Fracture ribs with pneumothorax
11What else would you apply in A&E? Chest drain was inserted and intubation commenced
13Name the pelvic binder you are currently using. e.g. SAM sling or T –PODHow to apply?
14Pelvic binder should be centered at the level of greater trochanter Properly applied pelvic binder should NOT obscure the surgical fieldPelvic binder should be centered at the level of greater trochanter
15Damage control resuscitation (DCR) Permissive hypotension ?What is the Target SBPWhat is the reason behind?Hemostatic resuscitation ? MTPDamage control operation or surgery (DCO/DCS)e.g. bleeding control ,decontamination , quick body cavity closure to rewarm patient ,planned reoperation for definite repair when physiology normalized
16Permissive hypotension What is the target SBP in permissive hypotension?SBP around 80 to 90mmHgTo minimize the risk of hydrostatic dislodgement of the temporary clot in bleeding vessels prior to operation to stop internal bleeding.
17Hemostatic resuscitation Consider early blood transfusionMassive transfusion protocol MTPWhat are the problems of massive transfusions?
19Massive transfusion protocol & Tranexamic Acid ( optimal blood product ratio ??1:1:1 plasma, platelet and FFP )
20Transamin (Tranexamic Acid) There are increasing evidences to support use of transaminSome recommendTranexamic acid (transamin) is to be administered to all trauma patients (age>18 years old) fulfilling the following 3 criteria:1) within 3 hours of injury 2 with significant hemorrhage or considered to be at risk of significant hemorrhage with compensated shock e.g. in # pelvis, massive hemothorax, +ve FAST/hemoperitoneum3) with no contraindication to tranexamic acid e.g. no allergy to transamin or DIC
21Whole Body CT at 16:46 Haemoperitoneum in pelvis Brain: no ICH Extensive haematoma and active contrast extravasation at pelvic cavityBeware CT as tunnel to death in unstable patientIrradiation ALARA ( as low as reasonably achievable)Short AED duration saves life, consider resuscitation procedure and XR at same time by wearing lead apron
22AFTER application of pelvic binder Pelvic volume is effectively controlled temporarily
23Pelvic Damage Control Pelvic External Fixation 3 in 1 Pelvic Damage ControlPelvic External Fixation+ Packing + EmbolizationPelvic Damage ControlPersistent hemorrhagic shockBP: 80/40To OT directly after CT
24Haemodynamically Unstable (Exsanguinating) Pelvic Fracture Extremely high mortality (40-60%) Associated with polytrauma with multiple concomitant injuries (up to 90%) Survival mainly depends on timely bleeding controlBleed todeath !
25Pelvic Damage Control 3-Phase Approach Initial life saving procedures with control of bleedingICU stabilizationDefinite treatment later
26Is both Vascular and Bone Injury !! Bony surfaceRetroperitoneal Venous plexusArterial 15%85% of # pelvis bleedingIs both Vascular and Bone Injury !!
27Any Fracture Pattern can Bleed to Death ! Concomitant injuries make the situation even more complicated !!!Massive bleeding can happen in any type of fracture difficult to differentiate the sources in the golden hour
28Control of Hemorrhage Pelvic binder External fixation Retro-peritoneal pelvic packingTrans-catheter arterial embolizationDirect surgical hemostasisControl of Hemorrhage
29How to Control the Bleeding: 3 in 1 Pelvic Damage Control Embolization ArterialPelvic Packing VenousExternal Fixation BonyHow to Control the Bleeding: 3 in 1 Pelvic Damage ControlOR ( Ext. Fix. Packing ) IRMulti-disciplinary:each part plays a role
30Exsanguinating Pelvic Fracture since July 2008 YesPelvic FractureShockFAST Scan/ Diagnostic Peritoneal LavagePelvic binderExternal FixationPelvic PackingLaparotomySustained Response toInitial Resuscitation?StableICU +/- CT scanNoUnstable or Ongoing Bleeding+/- on table angiographic embolizationGrossly PositiveGrossly NegativeICUAngiographyYesNo
32Our Protocol- A Three-in-one Approach In Order and In OT within same OT table Radiolucent tableEndovascular Operating Room (EVOR)32
33The First Clot is the Best Clot Protect the clotNurture the clotPelvic binder at the level of greater trochanterShould apply pelvic binder before CTMassive Transfusion Protocolblood: FFP: Platelet conc in 1:1:1
34The Strength External Fixation: - done before pelvic packing to re-establish a stable bony pelvic and to limit the pelvic volumeAngiographic Embolization :Set up during ex-fix & pelvic packing ~ 30mins, to minimal time wastingIndication depends on clinical condition after pelvic packing
35The Strength Address all 3 major bleeding sources in one order consecutivelyat the same theatrewithin the Golden HourMinimal time wasted on prioritizing intervention procedures, doing unnecessary investigation and transferring patientFlexibility of laparotomy or concomitant procedures for other associated injuries35