Extraperitoneal packing at laparotomy

Excerpted from 'Early Management of polytraumatized patients with pelvic fracture'
Unfallchirurgische Klinik der Medizinischen Hochschule Hannover
T. Pohlemann, A. Gänsslen, T. Hüfner, H.Tscherne

Treatment protocol In the cases were hemodynamic stability was not achieved within 10-15 minutes after admission, a surgical exploration of the pelvic retroperitoneum is performed. When the origin of bleeding can clearly be focused to the pelvic region, a midline incision of the lower abdomen is used, leaving the peritoneum intact. In the majority of cases all parapelvic fascias are already disrupted. After incision of the skin a large paravesical cavity filled with hematoma and blood clots is usually present. A direct manual access through the right or left paravesical space down to the presacral region is therefore possible without further dissection.

Primary orientation includes the check for any obvious arterial bleeding which can be readily accessed either by clamping, ligature or a vascular repair. If there is massive bleeding, a transient clamping of the infrarenal part of the aorta can be helpful. In the majority of cases a specific source of bleeding cannot be identified. The origin of hemorrhage is diffuse - either from the venous plexus or the fracture site. In external type injuries the sources of bleeding is generally located close to the anterior pelvic ring. In this region control of bleeding by surgical hemostases, closure of the pelvic ring and paravesical packing is relatively easy. With a higher degree of pelvc instability, especially in C-type injuries, the origin of bleeding is most frequently located in the prevesical region. With all compartment borders disrupted this space is generally easy to be manually accessed. The presacral and paravesical region is packed using standard surgical lap packs. An amount of 4-8 packs will be necessary for sufficient compression in the small pelvis. When the acute situation is under control, the integrity of the bladder and urethra is inspected. An urological repair should be adaequate to the patients general situation and is generally restricted to suprapubic urine drainage, insertion of a transurethral catheter and suture of the bladder.

The effectiveness of the tamponade is checked again and all now identifiable bleeding is controlled by direct surgical means. If the quality of reduction of the posterior ring is unsatisfactory, it is now adjusted to minimize bleeding from the fracture site. This is performed by a short loosening of the clamp, and the application of manual traction and internal rotation to the leg as well as control of the reduction by direct palpation of the easily accessible posterior pelvic ring. Then the definitive packing is applied and the fascia is closed.

When the abdomen has to be left open an at least partial closure of the extraperitoneal fascia in the pelvic region is recommeded for supporting the tamponade effect. Then the patient is transferred to the intensive care unit for further stabilization.

With persistant bleeding an angiography combined with embolization can now be performed. If there is still active bleeding and need for blood transfusion, first, the body temperature has to be normalized as soon as possible for stabilization of the intrinsic hemostatic system. With normal body temperature a second attempt for hemorrhage control by changing the packing is performed.

With stabilized hemodynamics the packing is left in place for 24-48 hours. During the "second look" operation the local overview is usually significantly improved and the bleeding has completely stopped or can be controlled by local surgical hemostases. With a persitent bleeding new tamponades are inserted and a "third look" is planned 24-48 hours later.

Wolfgang Klaus Ertel, MD; Marius Keel, MD; Andreas Platz, MD
Control of Severe Hemorrhage in Multiply Injured Patients with Pelvic Ring Disruption Using C-Clamp and Pelvic Packing
1999 OTA Annual Meeting - Session VIII - Pelvis - Paper 59

Purpose: Pelvic disruption in combination with multiple injuries is associated with high mortality. Despite improved protocols for shock treatment and acute reduction and fixation of the displaced pelvis using external fixation devices, mortality of those patients has recently been reported between 33% and 58%. This study evaluates the effectiveness of a combination of C-clamp and pelvic/abdominal packing in multiply injured patients with pelvic ring disruption and severe hemorrhage. Moreover, the use of lactate blood levels for rapid recognition of "hidden" shock was studied.

Methods: From 1/97 to 12/98 14 consecutive patients (mean age: 43.1±15.7 years; [mean ± SD]; ISS: 37.2±14.9 points; APACHE II: 19.1±4.7 points) in extremis (12 units of blood/2hr or necessity of catecholamines) were enrolled. Associated injuries were head (n=6; AIS: 3.0±1.5 points), chest (n=8; AIS: 3.8±0.7 points), abdomen (n=5; AIS: 4.2±0.4 points), spine (n=3; 2.0±0.0 points), and extremities (n=11; AIS: 3.1±0.5 points). Pelvic injuries were type C fractures (n=12; C1: n=4; C2: n=1; C3: n=7) and type B fractures in 2 patients (B1: n=1;B2: n=1) All patients were treated according to ATLS guidelines. For fixation of posterior ring disruption C-clamp was used in all patients. In patients with obvious signs of torrential hemorrhage crash laparotomy and pelvic packing were carried out.

Results: C-clamp was applied in all patients within 50.9±27.7 minutes (range 5 ­ 85 min) after arrival. Eight patients (57%) underwent crash laparotomy with pelvic packing for control of hemorrhage, 2 patients (14%) additional resuscitation thoracotomy (aortic clamping n=1). Three of the laparotomized patients (38%) developed abdominal compartment syndrome followed by decompressive laparotomy. Packing was retrieved after 28.8±5.1 hours on average, definitive stabilization of pelvic ring injuries was accomplished after 2.5±2.9 days (range 1 ­ 11 days). Mean blood substitution during hospital stay was 54.6±26.9 units of packed red blood cells (range 5 ­ 89 units). Two patients died due to pelvic hemorrhage during the first 5.5±2.6 hours upon arrival, one patient because of septic MOF 23 days after injury (total mortality: 3/14; 21%). Lactate levels obtained at admission were elevated in all patients (4.6±2.7 mmol/L). However, in patients that required pelvic packing (5.6±2.9 mmol/L), lactate levels obtained at admission were markedly increased by 70% compared to patients without packing (3.3±1.8 mmol/L). In contrast, hemoglobin (6.7±2.1 g/dL versus 7.6±2.4 g/dL; -12%) and hematocrit (20.1±6.2 versus 22.5±7.2; -11%) early after admission were similar in both groups. While lactate levels normalized in all survivors, increased concentrations were observed in the two patients dying from pelvic hemorrhage.

Discussion: Pelvic packing in addition to posterior ring fixation with C-clamp reduced mortality of multiply injured patients with severe pelvic injury admitted in extremis compared to previous studies. Furthermore, measurements of arterial lactate levels early after admission may provide a more rapid and reliable estimation of the true severity of hemorrhagic shock, which may not be correctly jugded by routine clinical parameters (hemoglobin, hematocrit). Conclusion: Rapid diagnosis of "hidden" hemorrhagic shock and aggressive management of bleeding control using a combination of external fixation and pelvic/abdominal packing further reduces mortality in multiply injured patients with associated pelvic ring disruption.