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

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

4. 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

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

8. Multi-disciplinary Polytrauma Management
ATLS
Pelvic Fracture call activated

9. 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)

10. X-ray of Trauma series Comminuted unstable pelvi-acetabular fracture
Fracture ribs with pneumothorax

11. What else would you apply in A&E?
Chest drain was inserted and intubation commenced

12. Early Use of Pelvic Binder “R” room

13. Name the pelvic binder you are currently using.
e.g. SAM sling or T –POD
How to apply?

14. 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

15. 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

16. 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.

17. Hemostatic resuscitation
Consider early blood transfusion
Massive transfusion protocol MTP
What are the problems of massive transfusions?

18. Massive transfusion problems
Coagulopathy ,Hypothermia and Acidosis
Thrombocytopenia
Hypocalcaemia, Hyperkalaemia
Blood Volume Replacement
Acute Respiratory Distress Syndrome (ARDS)

19. Massive transfusion protocol & Tranexamic Acid ( optimal blood product ratio ??1:1:1 plasma, platelet and FFP )

20. 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

21. 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

22. AFTER application of pelvic binder
Pelvic volume is effectively controlled temporarily

23. 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

24. 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 !

25. Pelvic Damage Control 3-Phase Approach
Initial life saving procedures with control of bleeding
ICU stabilization
Definite treatment later

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

27. 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

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

29. 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

30. 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

31. 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)

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

33. 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

34. 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

35. 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

36. Thank You