1. LOGO Hemorrhage in Pelvic Fractures…Where To Go Dr. Dora Tai

2. Introduction

4. Bleeding from Pelvic Fractures  Three bleeding sources: 1.Arteries (10-15%) 2.Low-pressure venous plexus (80-90%) 3.Fractured cancellous bone surfaces Giannoudis PV, Pape HC. Damage control orthopaedics in unstable pelvic ring injuries. Injury, Int. J.Care Injured 2004;35:671-677. Geeraerts T, Chhor V, Cheisson G, Martin L, Bessoud B, Ozanne A, Duranteau J. Clinical review : Initial management of blunt pelvic trauma patients with haemodynamic instability. Critical Care 2007; 11:204-212. White CE, Hsu JR, Holcomb JB. Haemodynamically unstable pelvic fractures. Injury, Int. J.Care Injured 2009; 40: 1023-1030.

5. External Pelvic Stabilization 1 Reduce pelvic volume ↓ ↓ blood loss promotes tamponade effect 2 Return bony pelvic components back into apposition ↓ Haemostatic pathways to control venous bleeding 3 ↓ clot dislodgement ↓ elimination of thrombotic process ↓ consumption of clotting factors Miller PR, Moore PS, Mansell E, Meredith W, Chang MC. External fixation or arteriogram in bleeding pelvic fracture : Initial therapy guided by markers of haemorrhage. J Trauma 2003; 54(3):437-443. DiGiacomo JC, Bonadies JA, Cole FJ, Diebel L, Hoff WS, Holevar M, Malcynski J, Scalea T. Practice management guidelines for haemorrhage in pelvic fracture. Eastern Association for the Surgery of Trauma 2001; 1-15.

6. Pelvic Binder Non-invasive, inexpensive Easy to apply Access to abdomen White CE, Hsu JR, Holcomb JB. Haemodynamically unstable pelvic fractures. Injury, Int. J.Care Injured 2009; 40: 1023-1030.

7. External Fixator Mohanty K, Musso D, Powell JM, Kortbeek JB, Kirpatrick AW. Emergent management of pelvic ring injuries: An update. Can J Surg 2005; 48(1):49-55. DiGiacomo JC, Bonadies JA, Cole FJ, Diebel L, Hoff WS, Holevar M, Malcynski J, Scalea T. Practice management guidelines for haemorrhage in pelvic fracture. Eastern Association for the Surgery of Trauma 2001; 1-15.

8. Posterior C clamp Mohanty K, Musso D, Powell JM, Kortbeek JB, Kirpatrick AW. Emergent management of pelvic ring injuries: An update. Can J Surg 2005; 48(1):49-55. DiGiacomo JC, Bonadies JA, Cole FJ, Diebel L, Hoff WS, Holevar M, Malcynski J, Scalea T. Practice management guidelines for haemorrhage in pelvic fracture. Eastern Association for the Surgery of Trauma 2001; 1-15.

9. External Fixator  Indications:  If laparotomy or packing is needed for unstable pelvic fracture Heetveld MJ, Harris I, Schlaphoff G, Sugrue M. Guidelines for the management of haemodynamically unstable pelvic fracture patients. ANZ J.Surg 2004; 74: 520-529. Suzuki T, Smith WR, Moore EE. Pelvic packing or angiography : Competitive or complementary? Injury, Int. J.Care Injured 2009; 40: 343-353.

10. Arterial Bleeding White CE, Hsu JR, Holcomb JB. Haemodynamically unstable pelvic fractures. Injury, Int. J.Care Injured 2009; 40: 1023-1030.

11. Arterial Bleeding  Indicators of significant arterial bleeding: 1.Lack of response to initial resuscitation 2.Contrast material extravasation (blush) on CT scan  Sensitivity 80-84%  Specificity 85-98% Yoon W, Kim JK, Jeong YY, Seo JJ, Park JG, Keun HK. Pelvic arterial hemorrhage in patients with pelvic fractures : Detection with contrast-enhanced CT. RadioGraphics 2004;24:1591-1606. Miller PR, Moore PS, Mansell E, Meredith W, Chang MC. External fixation or arteriogram in bleeding pelvic fracture : Initial therapy guided by markers of haemorrhage. J Trauma 2003; 54(3):437-443.

12. CT Scan Axial CT scan shows pelvic haematoma (white arrows) with extravasation of contrast medium (arrowhead).

13. Angiography and Embolization Digital angiography of the left internal iliac artery with extravasation of contrast Geeraerts T, Chhor V, Cheisson G, Martin L, Bessoud B, Ozanne A, Duranteau J. Clinical review : Initial management of blunt pelvic trauma patients with haemodynamic instability. Critical Care 2007; 11:204-212. Heetveld MJ, Harris I, Schlaphoff G, Sugrue M. Guidelines for the management of haemodynamically unstable pelvic fracture patients. ANZ J.Surg 2004; 74: 520-529.

14. Angiography and Embolization  Indications: 1.Persistent haemodynamic instability 2.Ongoing bleed despite pelvic packing 3.Arterial extravasation of contrast Heetveld MJ, Harris I, Schlaphoff G, Sugrue M. Guidelines for the management of haemodynamically unstable pelvic fracture patients. ANZ J.Surg 2004; 74: 520-529. Balogh Z, Caldwell E, Heetveld M, Amours SD, Schlaphoff G, Harris I, Sugrue M. Institutional practice guidelines on management of pelvic fracture-related haemodynamic instability : Do they make a difference ? J Trauma 2005; 58:778-782. Suzuki T, Smith WR, Moore EE. Pelvic packing or angiography : Competitive or complementary? Injury, Int. J.Care Injured 2009; 40: 343-353.

15. Pelvic Packing Preperitoneal space White CE, Hsu JR, Holcomb JB. Haemodynamically unstable pelvic fractures. Injury, Int. J.Care Injured 2009; 40: 1023-1030. Giannoudis PV, Pape HC. Damage control orthopaedics in unstable pelvic ring injuries. Injury, Int. J.Care Injured 2004;35:671-677. Gansslen A, Giannoudis P, Pape HC. Haemorrhage in pelvic fracture: Who needs angiography ? Curr Opin Crit Care 2003; 9:515-523.

16. Pelvic Packing White CE, Hsu JR, Holcomb JB. Haemodynamically unstable pelvic fractures. Injury, Int. J.Care Injured 2009; 40: 1023-1030. Giannoudis PV, Pape HC. Damage control orthopaedics in unstable pelvic ring injuries. Injury, Int. J.Care Injured 2004;35:671-677. Gansslen A, Giannoudis P, Pape HC. Haemorrhage in pelvic fracture: Who needs angiography ? Curr Opin Crit Care 2003; 9:515-523.

17. Pelvic Packing  Indications:  Ruptured pelvic haematoma at laparotomy (transperitoneal)  Unresponsive to embolization/initial resuscitation  No angiography facilities available Heetveld MJ, Harris I, Schlaphoff G, Sugrue M. Guidelines for the management of haemodynamically unstable pelvic fracture patients. ANZ J.Surg 2004; 74: 520-529. White CE, Hsu JR, Holcomb JB. Haemodynamically unstable pelvic fractures. Injury, Int. J.Care Injured 2009; 40: 1023-1030.

18. CROSS-ROAD SITUATION: ANGIO or PACKING

19. Angiography +/- embolisation External fixationPelvic Packing Advantages Less invasive High success rate Can stop arterial bleeding Quick to perform Does not limit access to abdomen Can be placed in the AED Quick to perform Does not require special technology Stabilize patient for angiography Disadvantages/ Complications Time consuming Requires interventional radiologist Haematoma Pin site infection Nerve and vascular injuries (C-clamp) Invasive Intrapelvic infection May not be effective for treatment of arterial bleeding Removal required Suzuki T, Smith WR, Moore EE. Pelvic packing or angiography : Competitive or complementary? Injury, Int. J.Care Injured 2009; 40: 343- 353. Papakostidis C, Giannoudis PV. Pelvic ring injuries with haemodynamic instability : Efficacy of pelvic packing, a systematic review. Injury, Int. J.Care Injured 2009; 40S4: S53-S61. Comparison of Interventions

21. Time to intervention Time to intervention: PACKING group vs ANGIO group (45mins vs 130mins)(p=0.01) Blood transfusion in the first 24 hours Blood transfusion in the first 24 hours:,less in the PACKING group (6.9 unit vs 10.1 units ; p=0.01) Mortality Mortality: PACKING group 4/20 vs ANGIO group 6/20 (p = 0.48)

22. Early mortality rate: 10% (95% CI: 3−18%) Late mortality rate: 13% (95% CI: 5−22%) Overall mortality: 28% (95% CI: 16.8−39.4%) Increase in SBP after EPP (p=0.002) Mortality : 28%

23. QEH Data 2005200620072008 2009 (8 mth) Total no. of trauma cases 401351371447402 No of pelvic injury cases (%) 27 (7%) 38 (11%) 36 (10%) 45 (10%) 27 (7%)

24. Grossly NegativeGrossly Positive QEH Protocol 2004-2008 No Yes No YesNo Pelvic Fracture Hypotension FAST Scan/ Diagnostic Peritoneal Lavage Wrap Pelvis with Sheet/Binder Laparotomy + External Fixation Laparotomy + External Fixation Stable Angiography + Embolization Angiography + Embolization Amenable to External Fixation Yes External Fixation ICU ICU+CT Sustained Response to Initial Resuscitation? Sustained Response to Initial Resuscitation? Angiography + Embolization Angiography

25. QEH Protocol 2008-2009 Yes Pelvic Fracture Shock FAST Scan/ Diagnostic Peritoneal Lavage Wrap Pelvis with Sheet/Binder Pelvic Fixation Pelvic Packing Laparotomy Pelvic 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 External Fixation Pelvic Packing No Yes Grossly Positive Grossly Negative ICU Angiography ICU

26.  Study period : June 2007- End of 2009  Number of patients: 24  Aim: To compare the mortality rate between the 2 protocols  Previous protocol : (Angiogram +/- Embolization) Feb 2004 – June 08  Current protocol : (Packing +/- Angiogram +/- Embolization) Jun 08 onward Retrospective Review for Unstable Pelvic Fractures

27.  Male : Female 15:9  Age: mean 47.7yrs, median 45yrs, range:18-84yrs  Mechanism of injury: Blunt trauma  Road traffic accident: 13  Fell from height: 11  Trauma score (Median / Mean) : ISS 41.2/ 43  Overall mortality : 58.3% (14/24) Retrospective Review for Unstable Pelvic Fractures

28. QEH Data N= 24ANGIO N= 13 PACKING N=11 P value Age44.8 (+/- 23.7)51.2 (+/- 19.6)0.464 Blood transfusion in AED (units) 3.3 (+/-4.4)2.7 (3.37)0.338 Combination of treatment 0/135/110.002 Time spent in AED (mins) 61.9 (+/- 33.5)69.7 (+/- 15.6)0.711 Systolic pressure on arrival (mmHg) 61.2 (+/- 15.5)99.0 (+/- 32.6)0.060 ISS40.0 (+/- 12.7)42.3 (+/- 18.1)0.724 RTS5.52 (+/- 2.4)6.92 (+/- 2.0)0.139 TRISS0.45 ( +/- 0.3)0.73 (+/- 0.2)0.050 Mortality 10/13 (77% ) 4/11 (36%) 0.095

29. The Golden Hour…every second counts!

30. Acknowledgements  Dr. Li Wing Hong  Dr. Lee Kin Bong  Dr. Lee Kin Yan  Dr. Tang Lap Fai  Dr. Ho Hiu Fai  Ms Annice Chang