Physical examination GCS 15/15 in agony PEAR Chest : AE fair due to pain Abdomen: Soft, mild distension and tender over lower abdomen PR: tone and perianal sensation intact, prostate not high riding, no blood at meatus( what does this imply?) Fast scan –ve Hb 15 ( ?good sign)
X-ray of Trauma series Comminuted unstable pelvi-acetabular fracture Fracture ribs with pneumothorax
What else would you apply in A&E? Chest drain was inserted and intubation commenced
Pelvic Binder Name the pelvic binder you are currently using. e.g. SAM sling or T –POD How to apply? http://www.youtube.com/watch?v=KVOk1WB2yhM http://www.youtube.com/watch?v=PO-gLZXxZ_E
Properly applied pelvic binder should NOT obscure the surgical field Pelvic binder should be centered at the level of greater trochanter
Damage control resuscitation (DCR) Permissive hypotension ? What is the Target SBP What is the reason behind? Hemostatic resuscitation ? MTP Damage 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
Permissive hypotension What is the target SBP in permissive hypotension? SBP around 80 to 90mmHg To minimize the risk of hydrostatic dislodgement of the temporary clot in bleeding vessels prior to operation to stop internal bleeding.
Hemostatic resuscitation Consider early blood transfusion Massive transfusion protocol MTP What are the problems of massive transfusions?
Massive transfusion protocol & Tranexamic Acid ( optimal blood product ratio ??1:1:1 plasma, platelet and FFP )
Transamin (Tranexamic Acid) ▪ There are increasing evidences to support use of transamin ▪ Some recommend ▪ Tranexamic 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/hemoperitoneum ▪ 3) with no contraindication to tranexamic acid e.g. no allergy to transamin or DIC
Whole Body CT at 16:46 Haemoperitoneum in pelvis Brain: no ICH Extensive haematoma and active contrast extravasation at pelvic cavity Beware CT as tunnel to death in unstable patient Irradiation ALARA ( as low as reasonably achievable) Short AED duration saves life, consider resuscitation procedure and XR at same time by wearing lead apron
AFTER application of pelvic binder Pelvic volume is effectively controlled temporarily
Pelvic Damage Control Persistent hemorrhagic shock BP: 80/40 To OT directly after CT
Haemodynamically 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 control Bleed to death !
Pelvic Damage Control 3-Phase Approach Initial life saving procedures with control of bleeding ICU stabilization Definite treatment later
1.Bony surface 2.Retroperitoneal Venous plexus 3.Arterial 15% 85% of # pelvis bleeding Is both Vascular and Bone Injury !!
Massive bleeding can happen in any type of fracture difficult to differentiate the sources in the golden hour Concomitant injuries make the situation even more complicated !!!
Control of Hemorrhage 1.Pelvic binder 2.External fixation 3.Retro-peritoneal pelvic packing 4.Trans-catheter arterial embolization 5.Direct surgical hemostasis
How to Control the Bleeding: 3 in 1 Pelvic Damage Control Embolization Arterial External Fixation Bony Pelvic Packing Venous
Exsanguinating Pelvic Fracture since July 2008 No Yes Pelvic Fracture Shock FAST Scan/ Diagnostic Peritoneal Lavage Pelvic binder External Fixation Pelvic Packing Laparotomy External Fixation Pelvic Packing Laparotomy Sustained Response to Initial Resuscitation? Sustained Response to Initial Resuscitation? Stable ICU +/- CT scan No Yes No Unstable or Ongoing Bleeding External Fixation Pelvic Packing +/- on table angiographic embolization External Fixation Pelvic Packing +/- on table angiographic embolization Grossly Positive Grossly Negative ICU Angiography ICU
QEH Protocol Persistent Shock OT Pelvic fracture ? Yes Responder ? No OT Ex-Fix Pelvic Packing (OR) +/- Laparotomy On Table Angiogram & Embolization (IR) MTP Pelvic binder
Our Protocol- A Three- in-one Approach In Order and In OT within same OT table Endovascular Operating Room (EVOR)
The First Clot is the Best Clot Protect the clot Nurture the clot