Author Dr. Chan Chun Man Oct., 2013 HKCEM College Tutorial Fracture Pelvis Author Dr. Chan Chun Man Oct., 2013

You heard that a case will be transferred to your under primary trauma diversion. Can you name the primary trauma diversion criteria?

Severe pelvic pain & deformity Arrive A&E at 16:12 BP:90/50, P:150 SaO2 100 % (100 % O2) GCS: 15/15 (E4V5M6) Severe pelvic pain & deformity Left LL deformed Multiple crush marks and abrasions over both LL Scalp haematoma

Activate Trauma Call? What are the criteria for Trauma Activation?

Multi-disciplinary Polytrauma Management ATLS Pelvic Fracture call activated

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

Early Use of Pelvic Binder “R” room

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

Pelvic binder should be centered at the level of greater trochanter 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 problems Coagulopathy ,Hypothermia and Acidosis Thrombocytopenia Hypocalcaemia, Hyperkalaemia Blood Volume Replacement
Acute Respiratory Distress Syndrome (ARDS)

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 Pelvic External Fixation 3 in 1 Pelvic Damage Control Pelvic External Fixation + Packing + Embolization 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

Is both Vascular and Bone Injury !! Bony surface Retroperitoneal Venous plexus Arterial  15% 85% of # pelvis bleeding Is both Vascular and Bone Injury !!

Any 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

Control of Hemorrhage Pelvic binder External fixation Retro-peritoneal pelvic packing Trans-catheter arterial embolization Direct surgical hemostasis Control of Hemorrhage

How to Control the Bleeding: 3 in 1 Pelvic Damage Control Embolization  Arterial Pelvic Packing  Venous External Fixation  Bony How to Control the Bleeding: 3 in 1 Pelvic Damage Control OR ( Ext. Fix.  Packing )  IR Multi-disciplinary: each part plays a role

Exsanguinating Pelvic Fracture since July 2008 Yes Pelvic Fracture Shock FAST Scan/ Diagnostic Peritoneal Lavage Pelvic binder External Fixation Pelvic Packing Laparotomy Sustained Response to Initial Resuscitation? Stable ICU +/- CT scan No Unstable or Ongoing Bleeding +/- on table angiographic embolization Grossly Positive Grossly Negative ICU Angiography Yes No

QEH Protocol Persistent Shock  OT Pelvic fracture ? Pelvic binder Yes Responder ? MTP No OT Ex-Fix  Pelvic Packing (OR)  +/- Laparotomy  On Table Angiogram & Embolization (IR)

Our Protocol- A Three-in-one Approach In Order and In OT within same OT table Radiolucent table Endovascular Operating Room (EVOR) 32

The First Clot is the Best Clot Protect the clot Nurture the clot Pelvic binder at the level of greater trochanter Should apply pelvic binder before CT Massive Transfusion Protocol blood: FFP: Platelet conc in 1:1:1

The Strength External Fixation: - done before pelvic packing to re-establish a stable bony pelvic and to limit the pelvic volume Angiographic Embolization : Set up during ex-fix & pelvic packing ~ 30mins, to minimal time wasting Indication depends on clinical condition after pelvic packing

The Strength Address all 3 major bleeding sources in one order consecutively at the same theatre within the Golden Hour Minimal time wasted on prioritizing intervention procedures, doing unnecessary investigation and transferring patient Flexibility of laparotomy or concomitant procedures for other associated injuries 35

Thank You