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V. Axial Skeleton Injuries in an Austere Environment – II (continued)

V. Axial Skeleton Injuries in an Austere Environment (continued)

CPT Jeanne Patzkowski, M.D.
CPT Chad Krueger, M.D.

A. Describe the initial management, resuscitation, and stabilization of pelvic fractures


III. Resuscitation
            A. Mortality rates as high as 40% with hemodynamic instability
                        1. major cause of death in first 24 hours: exsanguinating hemorrhage
                        2. major cause of death after 24 hours: multiorgan failure
            B. Resuscitation starts at patient presentation, concurrent with ATLS surveys, and continues until fluid requirement is gone (see figure 7. Large resuscitation requirement; figure 8. Polytrauma resuscitation.)
                        1. prompt identification and management of life-threatening injuries is essential to achieving hemodynamic stability
                        2. IV fluid resuscitation typically initiated on presentation
                                    a. must find and provisionally halt sources of hemorrhage before large volume resuscitation initiated
                                    b. urgent hemostasis will limit detrimental effects of large volume resuscitation and ongoing shock
                        3. persistent resuscitation requirement indicates ongoing hemorrhage or missed injury
                        4. markers of resuscitation
                                    a. admission hematocrit ≤ 30 is a predictor of major pelvic hemorrhage
                                    b. once resuscitation started, hemoglobin and hematocrit are unreliable indicators of blood loss or status of resuscitation
                                    c. high base deficits and lactate levels correlate with mortality
                                                i. base deficit ≥ 5 mmol/L on arrival associated with increased mortality
                                                ii. sequential measurements of base deficit and lactate offer more rapid and reliable measures of blood loss and transfusion requirements
                                                iii. improvement in these labs signals improvement of oxygen debt and reversal of shock state
            C. Fluid resuscitation
                        1. once pelvis identified as major source of hemorrhage, limit crystalloid infusion and initiate blood transfusion
                                    a. 1:1:1: ratio of plasma red blood cells (PRBCs), fresh frozen plasma and platelet 6-packs shown to improve survival and reduce overall blood volume transfused in civilian trauma
                                    b. early transfusion of platelets to keep counts above 100K provides survival benefit
                                    c. may not have ideal ratio of blood components in theater, so avoid giving only PRBCs to decrease risk of diluting clotting factors and platelets
                                    d. adjuncts
                                                i. cryoprecipitate and recombinant factor VIIa
                                                            (A). may not be available in theater
                                                            (B). for use in coagulopathic patients
                                                            (C). trauma-induced coagulopathy increases linearly with ISS and risk of death
                                                ii. tris-hydroxymethyl aminomethane (THAM)
                                                            (A). rapidly corrects pH and acid base deficits
                                                            (B). may not be available in theater
                        2. maintain normothermia
                                    a. warm trauma bay
                                    b. warm blankets
                                    c. space blanket
                                    d. if available at current level of care, consider
                                                i. Bair Hugger®
                                                ii. warm colonic fluid lavage (FMS 2000® rapid infuser)
            D. Overall increased bleeding with higher energy fracture patterns and disruption of pelvic floor
                        1. anteroposterior (AP)-III, lateral compression (LC)-III, vertical shear (VS), combined mechanism injury (CMI)
                                    a. patients with rotationally unstable pelvis fracture more likely to have bleeding from true pelvis
                                    b. patients with rotationally stable pelvis are more likely to have bleeding from abdominal source.4
                        2. sources of bleeding
                                    a. venous
                                                i. accounts for majority of major pelvic hemorrhage
                                                ii. posterior pelvic venous plexus
                                    b. fracture surfaces - cancellous bone
                                    c. arterial
                                                i. only accounts for 10-15% of major hemorrhage
                                                ii. typically superior gluteal artery (posterior) or pudendal artery (anterior) injured at time of angioembolization
                                                iii. less than 1% incidence of disruption of major iliac trunk with fracture line across posterior sacroiliac joint (SI). Typically present in extremis
            E. Distribution of bleeding
                        1. bleeding from pelvis is not confined to “true pelvis”
                                    a. essentially bleeding into free space
                                    b. disruption of pelvic floor allows bleeding into retroperitoneum and thighs
                        2. buttock hematoma from inferior gluteal artery (IGA) laceration may cause skin necrosis, infection, and subsequent sepsis
                        3. Morel-Lavallée lesion
                                    a. degloving of lateral proximal thigh (over greater trochanter) due to subcutaneous hematoma formation
                                    b. increased risk of poor wound healing and infection
                                    c. associated with high energy acetabulum fracture
            F. Methods to stop bleeding
                        1. most patients will stop bleeding after appropriate resuscitation and pelvic stabilization, decrease pelvic volume/clot stabilization
                        2. application of a pelvic orthotic device or an external fixator decreases volume by 10-20% and helps to reduce pelvic fractures4
                                    a. sheet/binder
                                                i. easy to use, available, provides circumferential control
                                                ii. may cause skin necrosis, nerve injury, and abdominal or extremity compartment syndromes
                                                iii. limit access to soft tissue
                                                iv. sheet technique
                                                            (A). wrap longitudinally folded bedsheet circumferentially around pelvis
                                                            (B). place sheet between iliac crests and greater trochanters
                                                            (C). secure anteriorly with towel clamps
                                                v. binder technique (see figure 6. Pelvic binder clinical photofigure 9. AP pelvis with binder in proper position; figure 10Binder improperly placed over abdomen; figure 11. AP compression pelvic fracture before binder placement; figure 12APC pelvic fracture after binder placement.)
                                                            (A). center binder over greater trochanters
                                                            (B). remove once hemodynamic stability achieved and vital signs unchanged with removal
                                                            (C). do not place over abdomen as this will not stabilize pelvis and may contribute to abdominal compartment syndrome
                                    b. external fixator (see figure 13. Pelvic external fixator radiographfigure 14. Pelvic external fixator clinical photo.)
                                                i. external fixators have not shown to be more effective than binders at controlling hemorrhage or stabilizing the pelvis4
                                                ii. can be placed quickly and without C-arm
                                                iii. no skin necrosis or limited access to soft tissue if pins and bar carefully placed
                                                            (A). do not limit access to abdomen
                                                            (B). allow space for abdominal expansion
                                                iv. only provides anterior stabilization
                                                            (A). cannot stabilize posterior elements
                                                            (B). no benefit with LC-III, windswept pelvis, or VS fractures
                                                v. technique    
                                                            (A). place pins into iliac crests or supra-acetabular region
                                                            (B). slight biomechanical advantage to supra-acetabular placement, but no survival benefit
                                    c. C-clamp
                                                i. may be used for posterior stabilization
                                                ii. C-arm support preferred
                                               iii. requires specific training in technique
                                                iv. may result in fracture displacement, pin site infection, cortical perforation, and nerve injury
                                                v. technique – two pins applied to the ilium in the region of the SI joints, clamp placed anterior
                                               vi. studies have shown that C-clamps do not necessarily decrease blood loss within the pelvis after application4
                                                vii. application of the C-clamp can take upwards of an hour.4
                                    d. preperitoneal pelvic packing (PPP)
                                                i. direct tamponade
                                                ii. effective in controlling hemorrhage when used in combination with pelvic stabilization devices4
                                                            (A). particularly effective and useful when angiography is not available
                                                            (B). do not attempt to ligate bleeding vessels, as results are universally poor
                                                            (C). may have increased effectiveness if combined with some form of bony stabilization
                                                                  (I). may be external fixator or C-clamp
                                                                  (II). acute internal fixation not routinely performed in theater
                                                            (D). decreased risk of abdominal compartment syndrome as compared to trans-abdominal retroperitoneal packing
                                                            (E). risk of intrapelvic infection
                                                            (F). technique
                                                                  (I). 6-8 cm midline vertical incision starting from symphysis pubis and extending cranially; keep incision separate from laparotomy incision if one is present
                                                                  (II). linea alba incised, peritoneum left intact
                                                                  (III). remove pelvic hematoma (typically dissects pre-peritoneal and prevesical space to the presacral region)
                                                                  (IV). laparotomy sponges placed on each side of true pelvis below the pelvic brim
                                                                  (V). close fascia and skin
                                                                  (VI). remove packs at 24-48 hours
                                                            (G). if still demonstrating signs of continued hemorrhage, proceed to angiography and arterial embolization
                        3. angioembolization
                                    a. up to 76% of patients with persistent instability despite appropriate resuscitation, pelvic stabilization, and exclusion of other injuries will have arterial bleeding and should undergo angiography if immediately available3
                                    b. it is recommended that hemodynamically unstable patients or those patients with continued signs of bleeding after application of pelvic stabilization device be considered for angiography.4
                                                i. use a lower threshold to receive angiography on patients that are older than 60
                                                ii. can use bilateral angiography if needed
                                                            (A). gluteal necrosis and sexual dysfunction thought to be associated with trauma and not the embolization itself4
                                                iii. direct control of arterial hemorrhage
                                                iv. only available at echelon III and above
                                                v. facility must be ready to perform angiography immediately; if any delay, proceed to OR for urgent laparotomy with preperitoneal pelvic packing
                                               vi. if multiple arterial injuries found on initial angiogram
                                                            (A). increased risk of recurrent arterial hemorrhage after release of vasospasm with continued resuscitation
                                                            (B). leave arterial sheath in place for 48-72 hours to facilitate re-imaging in case signs of hemorrhage recur
                                               vii. if patient has continued hemodynamic instability despite a negative arteriogram, urgent laparotomy with pelvic packing or preperitoneal pelvic packing should be performed
                        4. open ligation of pelvic vessels
                                    a. universally poor results
                                    b. not recommended


The view(s) expressed herein are those of the author(s) and do not reflect the official policy or position of Brooke Army Medical Center, the U.S. Army Medical Department, the U.S. Army Office of the Surgeon General, the Department of the Army, Department of Defense or the U.S. Government.