Circumferential pelvic antishock sheeting: a temporary resuscitation aid

Pelvic ring injuries: recent advances in diagnosis and treatment

Pelvic ring injuries typically occur from high-energy trauma and are often associated with multisystem injuries. Prompt diagnosis of pelvic ring injuries is essential, and timely initial management is critical in the early resuscitation of polytraumatized patients. Definitive management of pelvic ring injuries continues to be a topic of much debate in the trauma community. Recent studies continue to inform our understanding of static and dynamic pelvic ring stability. Furthermore, literature investigating radiographic and clinical outcomes after nonoperative and operative management will help guide trauma surgeons select the most appropriate treatment of patients with these injuries.

Preperitoneal Pelvic Packing for Hypotension Has a Greater Risk of Venous Thromboembolism Than Angioembolization: Management of Refractory Hypotension in Closed Pelvic Ring Injury

BACKGROUND

Patients with traumatic pelvic ring injury may present with hypotension secondary to hemorrhage. Preperitoneal pelvic packing (PPP) and angioembolization (AE) are alternative interventions for management of hypotension associated with pelvic ring injury refractory to resuscitation and circumferential compression. We hypothesized that PPP may be independently associated with increased risk of venous thromboembolism (VTE) compared with AE in patients with hypotension and pelvic ring injury.

METHODS

Adult patients with pelvic ring injury and hypotension managed with PPP or AE were retrospectively identified in the Trauma Quality Improvement Program (TQIP) database from 2015 to 2019. Patients were matched on a propensity score for receiving PPP based on patient, injury, and treatment factors. The primary outcome was the risk of VTE after matching on the propensity score for treatment. The secondary outcomes included inpatient clinically important deep vein thrombosis, pulmonary embolism, respiratory failure, mortality, unplanned reoperation, sepsis, surgical site infection, hospital length of stay, and intensive care unit (ICU) length of stay.

RESULTS

In this study, 502 patients treated with PPP and 2,439 patients treated with AE met inclusion criteria. After propensity score matching on age, smoking status, Injury Severity Score, Tile B or C pelvic ring injury, bilateral femoral fracture, serious head injury, units of plasma and platelets given within 4 hours of admission, laparotomy, and level-I trauma center facility designation, 183 patients treated with PPP and 183 patients treated with AE remained. PPP, compared with AE, was associated with a 9.8% greater absolute risk of VTE, 6.5% greater risk of clinically important deep vein thrombosis, and 4.9% greater risk of respiratory failure after propensity score matching.

CONCLUSIONS

PPP for the management of hypotension associated with pelvic ring injury is associated with higher rates of inpatient VTE events and sequelae compared with AE.

LEVEL OF EVIDENCE

Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Resuscitative endovascular balloon occlusion of the aorta in pelvic ring fractures: The Denver Health protocol

Patients presenting with hemodynamic instability associated with pelvic fractures continue to have very high mortality and surgeons continue to seek damage control strategies that may improve survival. Strategies usually require massive transfusion, immediate pelvic stabilization and another adjunctive maneuver's such as angioembolization or preperitoneal pelvic packing to prevent hemorrhagic death. One current intervention that has regained some popularity in lieu of resuscitative thoracotomy is the Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA). This requires some manner of femoral arterial access to insert a balloon into the aorta and increase central blood pressure (cardiac and cerebral perfusion) and control active pelvic bleeding. Based on several animal models and an increasing number of publications, many US level I trauma centers have now opted to use REBOA in carefully selected patients showing signs of near cardiac arrest from non-compressible torso hemorrhage. Description of the current advances in aortic occlusion using catheter-based technology in the setting of severe shock for non-compressible torso hemorrhage from pelvic ring fracture is the purpose of this report.

Evaluation of Pelvic Circular Compression Devices in Severely Injured Trauma Patients with Pelvic Fractures

Background: The role of pelvic circumferential compression devices (PCCD) is to temporarily stabilize the pelvic ring, reduce its volume and to tamponade bleeding. The purpose of this study was to evaluate the effect of PCCDs on mortality and bleeding in severely injured trauma patients, using a large registry database.Methods: We performed a retrospective analysis of all patients registered in the Trauma Register DGU® between 2015 and 2016. The study was limited to directly admitted patients who were alive on admission, with an injury severity score (ISS) of 9 or higher, with an Abbreviated Injury Scale AIS_pelvis of 3-5, aged at least 16, and with complete status documentation on pelvic circular compression devices (PCCD) and mortality. A cohort analysis was undertaken of patients suffering from relevant pelvic fractures. Data were collected on mortality and requirements for blood transfusion. The observed outcome was compared with the expected outcome as derived from version II of the Revised Injury Severity Classification (RISC II) and adjusted accordingly. A Standardized Mortality Ratio (SMR) was also calculated.Results: A total of 9,910 patients were included. 1,103 of 9,910 patients suffered from a relevant pelvic trauma (AIS_pelvis = 3-5). Only 41% (454 cases) of these received a PCCD. PCCD application had no significant effect on mortality and did not decrease the need for blood transfusion in the multivariate regression analysis. However, in this cohort, the application of a PCCD is a general indicator for a critical patient with increased mortality (12.0% no PCCD applied vs. 23.2% PCCD applied prehospital vs. 27.1% PCCD applied in the emergency department). The ISS was higher in patients with PCCD (34.12 ± 16.4 vs. 27.9 ± 13.8; p < 0.001).Conclusion: PCCD was applied more often in patients with severe pelvic trauma according to ISS and AIS_pelvis as well with deterioration in circulatory status. PCCDs did not reduce mortality or reduce the need for blood transfusion.Trial registration: TR-DGU ID 2017-003, March 2017; German clinical trial register DRKS00024948.

Management of Pelvic Ring Injury Patients With Hemodynamic Instability

Pelvic ring injuries (PRI) are among the most difficult injuries to deal with in orthopedic trauma. When these injuries are accompanied by hemodynamic instability their management becomes significantly more complex. A methodical assessment and expeditious triage are required for these patients followed by adequate resuscitation. A major triage decision is whether these patients should undergo arterial embolization in the angiography suit or prompt packing and pelvic stabilization in the operating room. Patient characteristics, fracture type and injury characteristics are taken into consideration in the decision-making process. In this review we discuss the acute evaluation, triage and management of PRIs associated with hemodynamic instability. An evidence based and protocol driven approach is necessary in order to achieve optimal outcomes in these patients.

Potentially serious adverse effects from application of a circumferential compression device for pelvic fracture: A report of three cases

Pelvic circumferential compression devices (PCCDs) have gained wide acceptance in the management of patients with pelvic fracture. These devices are considered safe due to their noninvasive nature and significant hazards associated with the use of PCCDs have not been reported previously. However, we present herein the cases of three patients who received PCCD application and eventually developed major complications presumably caused by PCCDs. As a result, one patient developed surgical site infection following internal fixation and required several debridements. Another patient ended up with a walking disability. The remaining patient eventually died from exsanguination following application of the PCCD. Clinicians should be aware of the potential for deleterious effects, including bladder rupture, muscle necrosis, and vessel injuries. In particular, application for acetabular fractures and prolonged application of PCCDs should be avoided.

Initial experience with the T-Clamp for temporary fixation of mechanically and hemodynamically unstable pelvic ring injuries

In polytrauma patients with unstable pelvic ring injuries, pelvic binders interfere with femoral arterial access and are frequently removed for emergent endovascular and abdominal procedures. The 'trochanteric C-clamp' (T-clamp) is a novel technique described for rapid stabilization of the pelvis without fluoroscopic imaging, while ensuring adequate access to the groin. This case series reports the feasibility and safety following T-clamp application for unstable pelvic ring injuries in patients requiring simultaneous endovascular intervention. Between May 2018 - May 2019, seventeen patients with unstable pelvic ring injuries were treated with a T-clamp in conjunction with other emergent endovascular or intra-abdominal procedures. Nine presented with unstable APC injuries, seven with unstable LC injuries and one with a vertical shear pattern. Complications related to the T-clamp were prospectively collected. Following T-clamp application, there were two cases of intraoperative over-reduction, one of which required exchange for an anterior external fixator. This was the result of a concomitant acetabulum fracture leading to iatrogenic acetabular protrusion secondary to the T-clamp. Twelve cases maintained the T-clamp fixation postoperatively ranging from 1-3 days. One postoperative loss of reduction was noted and required exchange for anterior external fixator. In hemodynamically unstable patients who require emergent endovascular procedures, such as pelvic angiography and REBOA, T-clamp application offers a reasonably safe and effective method for expeditious stabilization of the pelvis while allowing unimpeded access to the abdomen, groin and pelvis. Caution should also be applied in patients with concomitant acetabulum fracture for risk of malreduction. Additionally, its prolonged postoperative use should be limited to patients who are not immediately suitable for fixation of the pelvis.

Haemodynamics as a determinant of need for pre-hospital application of a pelvic circumferential compression device in adult trauma patients

INTRODUCTION

Pelvic ring fractures are common following high-energy blunt trauma and can lead to substantial haemorrhage, morbidity and mortality. Pelvic circumferential compression devices (PCCDs) improve position and stability of open-book type pelvic fracture, and can improve haemodynamics in patients with hypovolaemic shock. However, PCCDs may cause adverse outcomes including worsening of lateral compression fracture patterns and routine use is associated with high costs. Controversy regarding indication of PCCDs exists with some centres recommending PCCD in the setting of hypovolaemic shock compared to placement for any suspected pelvic injury.

OBJECTIVE

To assess the need for PCCD application based on pre-hospital vital signs and mechanism of injury.

METHODS

A retrospective cohort study was conducted in a single adult major trauma centre examining a 2-year period. Patients were sub-grouped based on initial pre-hospital and emergency department observations as haemodynamically normal (heart rate <100 bpm, systolic blood pressure ≥100 mmHg and Glasgow Coma Scale ≥13) or abnormal. Diagnostic accuracy of pre-hospital haemodynamics as a predictor of pelvic fracture requiring intervention within 24 h was assessed.

RESULTS

There were 376 patients with PCCD in-situ on hospital arrival. Pelvic fractures were diagnosed in 137 patients (36.4%). Of these, 39 (28.5%) were haemodynamically normal and 98 (71.5%) were haemodynamically abnormal. The most common mechanisms of injury were motor vehicle collision (57.7%) and motorcycle collision (13.8%). Of those with fractures, 40 patients (29.2%) required pelvic intervention within 24 h of admission; of these, 8 (20%) were haemodynamically normal and 32 (80%) were haemodynamically abnormal. As a test for pelvic fracture requiring intervention within 24 h, abnormal pre-hospital haemodynamics had a sensitivity of 0.80 (95% CI 0.64-0.91), specificity of 0.32 (95% CI 0.27-0.38) and negative predictive value (NPV) of 0.93 (95% CI 0.88-0.96). Combined with absence of a major mechanism of injury, normal haemodynamics had a sensitivity 1.00, specificity 0.51 (95% CI 0.36-0.66) and NPV of 1.00 for pelvic intervention within 24 h.

CONCLUSION

Normal haemodynamic status, combined with absence of major mechanism of injury can rule out requirement for urgent pelvic intervention. Ongoing surveillance is recommended to monitor for any adverse effects of this change in practice.

Treatment Discrepancy for Pelvic Fracture Patients With Urethral Injuries: A Survey of Orthopaedic and Urologic Surgeons

OBJECTIVES

In patients with traumatic pelvic fracture urethral injuries (PFUI), the interaction between urethral management and orthopaedic decision making remains unknown. We aimed to survey orthopaedic and urologic surgeons to assess interdisciplinary interactions in the management of PFUI.

METHODS

An anonymous cross-sectional survey of members of the Orthopaedic Trauma Association (OTA) and the Society of Genitourinary Reconstructive Surgeons (GURS) was conducted between September 2017 and August 2018. Participants were queried regarding the impact of urethral injuries and their management on orthopaedic operative decision making.

RESULTS

Fifty-three GURS and 64 OTA members responded (17% response rate). For urethral injury management, 73% of OTA respondents preferred that suprapubic tubes (SPTs) were not placed for urethral injury management, whereas 43% of GURS respondents preferred SPTs (P = 0.08). Ninety-two percent of OTA respondents stated that SPTs increase hardware infection risks in patients undergoing pelvic open reduction with internal fixation (ORIF), whereas only 8% of GURS respondents agreed (P < 0.01). Although 66% of GURS respondents reported not considering the operative plans of orthopaedics when determining urethral management, 75% of OTA respondents reported that they were less inclined to proceed with ORIF, and 70% would perform external fixation in the setting of an SPT, despite 78% believing that this resulted in an inferior outcome for the patient.

CONCLUSIONS

There is discordance between urologists and orthopaedists as to the optimal management of PFUI patients, with significant disagreement regarding the infectious risks of SPT in the setting of ORIF. Improved data and interdisciplinary dialogue are required to maximize patient outcomes.

LEVEL OF EVIDENCE

Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence.

Trends and efficacy of external emergency stabilization of pelvic ring fractures: results from the German Pelvic Trauma Registry

PURPOSE

External emergency stabilization (EES) of unstable pelvic fractures reduces haemorrhage and mortality. Available are non-invasive procedures (sheet sling and pelvic binder) and invasive procedures (external fixator and pelvic C-clamp). Nevertheless, there is no recommended standard as to which procedure for EES should be used.

METHODS

Prospectively collected data between 2007 and 2016 from the German Pelvic Trauma Registry were used to evaluate 989 patients with in-hospital EES. Besides age, gender and injury severity score (ISS), the fracture classification was evaluated. Furthermore, the frequency of used EES, time to application, their reported efficacy and the frequencies of change to another EES were investigated.

RESULTS

The use of pelvic binders increased up to 40% while all other procedures decreased in frequency over the 10-year period. The ISS was highest in patients treated with a pelvic C-clamp or combination of pelvic C-clamp and external fixator (p < 0.05). Non-invasive stabilization was applied significantly faster than invasive procedures (p < 0.0001). Overall, the reported efficacy was good (at least 70%) for all procedures but with poorest results for the pelvic binder and best for the external fixator (p < 0.00001). Most change to another EES was found for the sheet sling and pelvic binder.

CONCLUSION

In case of suspected unstable pelvic fracture, an EES should be performed, in case of doubt with a non-invasive EES until imaging and final diagnosis. Which method should be used depends on the individual situation and the available information about the overall injury pattern. Invasive EES are preferable for treatment according to Damage Control Orthopaedics.

Pelvic trauma mortality reduced by integrated trauma care

OBJECTIVES

A multidisciplinary approach that emphasised improved triage, early pelvic binder application, early administration of blood and blood products, adherence to algorithmic pathways, screening with focused sonography (FAST), early computed tomography scanning with contrast angiography, angio-embolisation and early operative intervention by specialist pelvic surgeons was implemented in the last decade to improve outcomes after pelvic trauma. The manuscript evaluated the effect of this multi-faceted change over a 12-year period.

METHODS

A retrospective cohort study was conducted comparing patients presenting with serious pelvic injury in 2002 to those presenting in 2013. The primary exposure and comparator variables were the year of presentation and the primary outcome variable was mortality at hospital discharge. Potential confounders were evaluated using multivariable logistic regression analysis.

RESULTS

There were 1213 patients with a serious pelvic injury (Abbreviated Injury Scale ≥3), increasing from 51 in 2002 to 156 in 2013. Demographics, injury severity and presenting clinical characteristics were similar between the two time periods. There was a statistically significant difference in mortality from 20% in 2002 to 7.7% in 2013 (P = 0.02). The association between the primary exposure variable of being injured in 2013 and mortality remained statistically significant (adjusted odds ratio 0.10; 95% confidence interval: 0.02-0.60) when adjusted for potential clinically important confounders.

CONCLUSIONS

Multi-faceted interventions directed at the spectrum of trauma resuscitation from pre-hospital care to definitive surgical management were associated with significant reduction in mortality of patients with severe pelvic injury from 2002 to 2013. This demonstrates the effectiveness of an integrated, inclusive trauma system in achieving improved outcomes.

Intra-pelvic pressure changes after pelvic fracture: A cadaveric study quantifying the effect of a pelvic binder and limb bandaging over a bolster

INTRODUCTION

Unstable pelvic fractures can be life-threatening due to catastrophic haemorrhage. Non-invasive methods of reducing and stabilising these injuries include pelvic binder application and also lower limb bandaging over a knee-flexion bolster. Both of these methods help close the pelvic ring and should tamponade bleeding. This study aimed to quantify the intra-pelvic pressure changes that occurred with 3 different manoeuvres: lower limb bandaging over a bolster; a Trauma Pelvic Orthotic Device (T-POD) pelvic binder, and a combination of both.

METHODS

Following a pilot study with 2 soft embalmed cadavers, a formal study with 6 unembalmed cadavers was performed. For each specimen an unstable pelvic injury was created (OA/OTA 61-C1) by dividing the pelvic ring anteriorly and posteriorly. A 3-4cm manometric water-filled balloon was placed in the retropubic space and connected to a 50ml syringe and water manometer via a 3-way tap. A baseline pressure of 8cmH₂O (equating to the average central venous pressure) was used for each cadaver. Steady intra-pelvic pressures (more reliably reflecting the pressures achieved following an intervention) were used in the subsequent statistical analysis, using R statistical language and Rstudio. Paired t-test or Wilcoxon's rank sum test were used (depending on the normality of the dataset) to determine the impact of each intervention on the intra-pelvic pressure.

RESULTS

The mean steady intra-pelvic pressures were significantly greater than the baseline pressure for each intervention. The binder and limb bandaging over a bolster alone increased the mean steady pelvic pressures significantly to 24 (SE=5) (p<0.036) and 15.5 (SE=2) (p<0.02)cmH₂O respectively. Combining these interventions further increased the mean steady pressure to 31 (SE=7)cmH₂O. However, this was not significantly greater than pressures for each of the individual interventions.

DISCUSSION

Both lower limb bandaging over a bolster and pelvic binder application significantly increased intra-pelvic pressure above the baseline pressure. This was further increased through combining these interventions, which could be useful clinically to augment haemorrhage control in these fractures.

CONCLUSION

Lower-limb bandaging over a bolster, and pelvic binder application, both significantly increased intra-pelvic pressures, and were greatest in combination. These findings support the use of these techniques to facilitate non-surgical haemorrhage control.

Prehospital control of life-threatening truncal and junctional haemorrhage is the ultimate challenge in optimizing trauma care; a review of treatment options and their applicability in the civilian trauma setting

Introduction

Exsanguination following trauma is potentially preventable. Extremity tourniquets have been successfully implemented in military and civilian prehospital care. Prehospital control of bleeding from the torso and junctional area’s remains challenging but offers a great potential to improve survival rates. This review aims to provide an overview of potential treatment options in both clinical as preclinical state of research on truncal and junctional bleeding. Since many options have been developed for application in the military primarily, translation to the civilian situation is discussed.

Methods

Medline (via Pubmed) and Embase were searched to identify known and potential prehospital treatment options. Search terms were|: haemorrhage/hemorrhage, exsanguination, junctional, truncal, intra-abdominal, intrathoracic, intervention, haemostasis/hemostasis, prehospital, en route, junctional tourniquet, REBOA, resuscitative thoracotomy, emergency thoracotomy, pelvic binder, pelvic sheet, circumferential. Treatment options were listed per anatomical site: axilla, groin, thorax, abdomen and pelvis Also, the available evidence was graded in (pre) clinical stadia of research.

Results

Identified treatment options were wound clamps, injectable haemostatic sponges, pelvic circumferential stabilizers, resuscitative thoracotomy, resuscitative endovascular balloon occlusion of the aorta (REBOA), intra-abdominal gas insufflation, intra-abdominal self-expanding foam, junctional and truncal tourniquets. A total of 70 papers on these aforementioned options was retrieved. No clinical reports on injectable haemostatic sponges, intra-abdominal insufflation or self-expanding foam injections and one type of junctional tourniquets were available.

Conclusion

Options to stop truncal and junctional traumatic haemorrhage in the prehospital arena are evolving and may offer a potentially great survival advantage. Because of differences in injury pattern, time to definitive care, different prehospital scenario’s and level of proficiency of care providers; successful translation of various military applications to the civilian situation has to be awaited. Overall, the level of evidence on the retrieved adjuncts is extremely low.

The early management of gunshot wounds Part II: the abdomen, extremities and special situations

The management of gunshot wounds of the abdomen and extremities is evolving with centres who treat large volumes of such injuries tending to the application of a policy of selective non-operative management. This article discusses the management of gunshot wounds to the abdomen and extremities and reviews the evidence supporting these changing practices. Special situations such as wounding by shotguns or air rifles are also examined as are the special considerations needed when dealing with the gunshot injured pregnant women or in a child.

Kendrick's extrication device and unstable pelvic fractures: Should a trochanteric belt be added? A cadaveric study

INTRODUCTION

Pre-hospital pelvic stabilisation is advised to prevent exsanguination in patients with unstable pelvic fractures (UPFs). Kendrick's extrication device (KED) is commonly used to extricate patients from cars or crevasses. However the KED has not been tested for potential adverse effects in patients with pelvic fractures. The aim of this study was to examine the effect of the KED on pubic symphysis diastasis (SyD) with and without the use of a trochanteric belt (TB) during the extraction process following a MVC.

MATERIALS AND METHODS

Left-sided "open-book" UPFs were created in 18 human cadavers that were placed in seven different positions simulating pre-extraction and extraction positions using the KED with and without a TB in two different positions (through and over the thigh straps). The SyD was measured using anteroposterior radiographs. The effects of the KED with and without TB, on the SyD, were evaluated.

RESULTS

The KED alone resulted in a non-significant increase of the SyD compared to baseline, whereas the addition of a TB to the KED resulted in a significant reduction of the SyD (p<0.001). The TB through the straps provided a significantly better reduction than the TB over the straps in the extracted position (p<0.05).

CONCLUSION

Our study demonstrated that a TB in combination with the KED on UPFs is an effective way to achieve early reduction. The addition of the TB in combination with the KED could be considered for Pre-Hospital Trauma Life Support (PHTLS) training protocols.

The Role of Pelvic Packing for Hemodynamically Unstable Pelvic Ring Injuries

In patients with severe pelvic fractures, exsanguinating hemorrhage represents the major cause of death within the first 24 hours. Recently, multiple management algorithms have been proposed; however, the optimal treatment modalities, in particular, in the hemodynamically unstable patient with pelvic fracture are still a matter of debate. Mechanical pelvic stabilization by pelvic binder, anterior external fixator, and/or pelvic C-clamp constitutes the first treatment option in the hemodynamically unstable patient with pelvic fractures. The mechanically stabilized pelvic ring provides the basis for pelvic packing through a minimal extraperitoneal approach, which effectively controls venous bleeding and bleeding from the fractured bony surface. Patients with persistent hypotension and/or transfusion requirements should undergo angiography and selective embolization for definitive arterial control if necessary. This review article describes the current trend in the initial management of patients with pelvic fractures and hemodynamic instability, and focuses on the role of pelvic packing.

Strategies for the management of haemorrhage following pelvic fractures and associated trauma-induced coagulopathy

Exsanguination is the second most common cause of death in patients who suffer severe trauma. The management of haemodynamically unstable high-energy pelvic injuries remains controversial, as there are no universally accepted guidelines to direct surgeons on the ideal use of pelvic packing or early angio-embolisation. Additionally, the optimal resuscitation strategy, which prevents or halts the progression of the trauma-induced coagulopathy, remains unknown. Although early and aggressive use of blood products in these patients appears to improve survival, over-enthusiastic resuscitative measures may not be the safest strategy. This paper provides an overview of the classification of pelvic injuries and the current evidence on best-practice management of high-energy pelvic fractures, including resuscitation, transfusion of blood components, monitoring of coagulopathy, and procedural interventions including pre-peritoneal pelvic packing, external fixation and angiographic embolisation.

Early Total Care versus Damage Control: Current Concepts in the Orthopedic Care of Polytrauma Patients

The management of the polytraumatized orthopedic patient remains a challenging issue. In recent years many efforts have been made to develop rescue techniques and to promote guidelines for the management of these patients. Currently controversies persist between two orthopedic approaches: the Early Total Care and the Damage Control Orthopedics. An overview of the current literature on the orthopedic management of polytrauma patient is provided. Subsequently, femoral shaft fractures, representing extremely common lesions, and pelvic ring injuries, that are associated with a high mortality rate, are analyzed in detail.

Orthopaedic management in the polytrauma patient

The past century has seen many changes in the management of the polytraumatized orthopaedic patient. Early recommendations for non-operative treatment have evolved into early total care (ETC) and damage control orthopaedic (DCO) treatment principles. These principles force the treating orthopaedist to take into account multiple patient parameters including hypothermia, coagulopathy and volume status before deciding upon the operative plan. This requires a multidisciplinary approach involving critical care physicians, anesthesiologists and others.

Eastern Association for the Surgery of Trauma practice management guidelines for hemorrhage in pelvic fracture--update and systematic review

BACKGROUND

Hemorrhage from pelvic fracture is common in victims of blunt traumatic injury. In 2001, the Eastern Association for the Surgery of Trauma (EAST) published practice management guidelines for the management of hemorrhage in pelvic trauma. Since that time there have been new practice patterns and larger experiences with older techniques. The Practice Guidelines Committee of EAST decided to replace the 2001 guidelines with an updated guideline and systematic review reflecting current practice.

METHODS

Building on the previous systematic literature review in the 2001 EAST guidelines, a systematic literature review was performed to include references from 1999 to 2010. Prospective and retrospective studies were included. Reviews and case reports were excluded. Of the 1,432 articles identified, 50 were selected as meeting criteria. Nine Trauma Surgeons, an Interventional Radiologist, and an Orthopedic Surgeon reviewed the articles. The EAST primer was used to grade the evidence.

RESULTS

Six questions regarding hemorrhage from pelvic fracture were addressed: (1) Which patients with hemodynamically unstable pelvic fractures warrant early external mechanical stabilization? (2) Which patients require emergent angiography? (3) What is the best test to exclude extrapelvic bleeding? (4) Are there radiologic findings which predict hemorrhage? (5) What is the role of noninvasive temporary external fixation devices? and (6) Which patients warrant preperitoneal packing?

CONCLUSIONS

Hemorrhage due to pelvic fracture remains a major cause of morbidity and mortality in the trauma patient. Strong recommendations were made regarding questions 1 to 4. Further study is needed to answer questions 5 and 6.

Transcatheter embolization in the treatment of hemorrhage in pelvic trauma

Massive hemorrhage related to pelvic trauma is relatively rare, but when it occurs rapid triage to therapeutic intervention is essential for survival. Traditional surgical repairs had limited success. Anatomic and clinical studies indicate that arterial hemorrhage is often identified in patients with hemodynamic instability that do not respond to initial resuscitation. Transcatheter angiography directly identifies arterial injury, and embolization can control retroperitoneal arterial hemorrhage. Stent-graft technology extends the scope of interventional therapy to include rapid and definitive repair of nonexpendable artery injury. Successful management requires coordination between multiple services and the continuation of resuscitative procedures in the angiography suite.

Effect of a new pelvic stabilizer (T-POD®) on reduction of pelvic volume and haemodynamic stability in unstable pelvic fractures

BACKGROUND

Pelvic fractures, often the result of high energy blunt trauma, are associated with severe morbidity and mortality. A new pelvic stabilizer (T-POD®) provides secure and effective simultaneous circumferential compression of the pelvis.

METHODS

In this study we describe 15 patients with a prehospital untreated unstable pelvic fracture with signs of hypovolaemic shock with the T-POD®. Before and 2 min after applying the T-POD®, heart rate and blood pressure were measured. An X-ray before and directly after applying the T-POD® was made to measure the effect on reduction in symphyseal diastasis.

RESULTS

Application of the T-POD® reduced the symphyseal diastasis with 60% (p = 0.01). The mean arterial pressure (MAP) increased significant from 65.3 to 81.2 mm Hg (p = 0.03) and the heart rate declined from 107 beats per minute to 94 (p = 0.02). Out of ten patients in whom the circulatory response before and after the T-POD® was recorded, seven were good responders, one had a transient response and two responded poor.

CONCLUSION

In the acute setting, the T-POD® device has a clear compressive effect on the pelvic volume in unstable pelvic fractures. The T-POD® is therefore an effective and easy to use device in (temporarily) stabilizing the pelvic ring in haemodynamically unstable patients.

Traction vertical shear pelvic ring fracture: a marker for severe arterial injury? A case report

Vertical shear pelvic ring fractures have been described as being produced only by a force directed cephalad, typically from falls or motor vehicle collisions. We report a seemingly similar vertical injury with the displacement of the hemipelvis being caudad rather than cephalad. Caudad displacement of the hemipelvis might disrupt the pelvic floor and vasculature far more than a standard vertical shear injury would and might be more prone to vascular injury. The clinical examination of the pelvic wound in our patient was not impressive and the magnitude of displacement seen on the admission radiograph was not different from that seen with a typical vertical shear injury. It is the caudal direction of the displacement that we think should alert the surgeon to the possibility of massive vascular injury and potential for limb loss.