Major Pelvic Trauma

Evidence Based Management Guidelines

Dr Sashi Kumar MBBS DLO FACEM Senior Staff Specialist Emergency Medicine The Canberra Hospital AUSTRALIA

THE CANBERRA HOSPITAL

EMERGENCY DEPARTMENT

Major Pelvic Trauma

Major Pelvic Trauma

What is the problem ?

What is the problem ?

Major source of Blood loss (BIG Bones, muscles and veins ) Associated Intra abdominal bleeding is about 32 % (Level III- 3 ) Needs Multi disciplinary approach for best results (General Surgeon ,Emergency Physician Orthopaedic Surgeon ,Interventional Radiologist ICU specialist , Nursing staff and Blood Bank ) ( Level IV )
ITIM

Evidence based What is it ?

Conscientious, explicit and judicious use of current best evidence in making decisions Effectiveness and Efficiency Random Reflections on Health Services -Cochrane 1972 Centre for Evidence based Medicine (www.cebm.net ) Levels of evidence varies from country to country

Professor Archie Cochrane 1909-1988

Levels of Evidence U.K.

Level A RCT ,cohort study, clinical decision rule Level B Retrospective cohort, Exploratory cohort, case control, outcomes research Level C- Case series Level D Expert opinion , critical appraisal, bench research
- Oxford Centre for Evidence based Medicine

Levels of Evidence - USA

Level I - at least 1 properly designed RCT Level II - 1 well designed trials not randomised Level II - 2 well designed cohort /case control Level II - 3 multiple time series with or without intervention Level III - Opinions, clinical experience, descriptive studies ,reports from expert committees -U.S. of Statistics Source: Australian BureauPreventive Services Task Force

Levels of Evidence -Australia

Level I Level II Systematic review of all RCT s One properly designed RCT

Level III 1- Well designed pseudo randomised controlled 2- Comparative studies with concurrent controls or case control studies not randomised 3 Comparative with historical control

Level IV -Case series , post test or pre and post test

NHMRC Australia 1999

YOUNG and BURGESS

Management of bleeding following major trauma European guidelines

-D. Spahn et al Critical Care 2007

Urgent surgical bleeding control - Grade I Damage control surgical approach and packing of pelvis Pelvic ring disruptions should be closed and stabilised FAST /CT to identify bleeding Urgent angiogram and embolisation if unstable

EAST Guidelines - USA

Level I - NIL Level II Early external immobilisation for unstable pelvic fractures with hypotension External immobilisation prior to Laparotomy Early Angiography and Embolisation when bleeding cannot be controlled at laparotomy or when iv contrast arterial extravasation on CT
-Eastern Association for the Surgery in Trauma - 2001

EAST Guidelines
Level III Early external stabilisation for Unstable pelvic fractures without hypotension but requiring steady and ongoing resuscitation No level III recommendations as to who requires urgent Angiography and Embolisation or urgent Laparotomy
Eastern Association for the Surgery in Trauma - 2001

Management of Exsanguinating pelvic injuries

Do not test for pelvic stability Do early x rays Do not remove pelvic binders until permanent fixation is applied If Unstable after Pelvic Binder is applied must have arterial bleeding and needs operative / angiographic intervention

www.trauma.org - July 2008

Management

trauma. org July 2008

Stable after pelvic binder can proceed to CT

Early CXR and ICC if required Early FAST or DPA
minimal significant

Management
IF Angiogram and embolisation not available within 30 mins - O.R. for haemorrhage control Pack external wounds Extra peritoneal packing Damage control laparotomy

Trauma. org July 2008

Angio - embolisation
Major active bleeding is from branches of Internal Iliac artery Aggressive resuscitation with blood and blood products during the procedure Trauma team in attendance at the Angio suite Future - CT scans in Resuscitation Room and Hybrid Operating Suites with Angiography facilities

Trauma. org July 2008

Trauma. org July 2008

Australian Guidelines
NSW Institute of Trauma and Injury Management (ITIM ) and Liverpool Hospital Sydney (livtrauma.org ) December 2009 updated every 5 years Recommendations based on quality evidence available right now from all over the world

How to determine source of Bleeding

External bleeding/CXR /Pelvic radiograph within 10 mins of arrival III - 3 FAST /DPA within 30 mins - III - 3 DPA is reliable III 3 FAST especially RUQ is reliable III -2 When no other source is found go for Immediate angiography - III 3

If no FAST or DPA available assume intra abdominal bleeding - Consensus

ITIM

How to stabilise the Pelvis

Rotational instability Binding III 3 Vertical instability skeletal traction III 3 Non invasive external stabilisation devices or a bed sheet but allow access to laparotomy and femoral access for angiography IV If Non invasive fails invasive anterior external fixation - IV

ITIM

Simple Pelvic Binder

1. Place folded bed sheet underneath the patient between iliac crests and Greater Trochanters

2. With two trauma team members cross the sheet across the pubic symphysis and pull the sheet firmly so it tightly fits around and stabilises
the pelvis

3. A third person should clamp the sheet at the four points shown (away from Laparotomy / angiography access points).

SAM SLING

How to control bleeding

FAST/DPA to exclude intra abdominal bleed Angiography /embolisation within 45 mins III-3 Early Non invasive External stabilisation and Traction for vertical shear to control venous and bony blood loss III 1 Immediate Laparotomy for intra abdominal bleeding III-3 If exsanguinating Laparotomy ,ligation of arteries ,pelvic packing and stabilisation of fractures IV ORIF contraindicated in unstable patient-IV
ITIM

N S
W G U I D E L I N E S

N S W
G U I D E L I N E S

SUMMARY
Very little good evidence

Early External splint is the best evidence

Look for another source of bleeding urgently Early DPA / FAST Immediate Laparotomy if positive

SUMMARY
Fix pelvis at the same time as laparotomy Hypotensive after external splint needs urgent angio /embolisation if available A Multidisciplinary TEAM approach

Thank you

Thank You !