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Exsanguinating Pelvic Trauma

Introductory Cases

Case One

We recently had a case of a pedestrian run over by her own car and suffered major pelvic fractures (anterior and posterior), a liver laceration and major chest injuries. The Surgical team decided that there was no major thoracic or abdominal souce of bleeding although a FAST (Focussed Abdominal Sonography for Trauma) or DPL (Diagnostic Peritoneal Lavage) was not done.

The Orthopaedic team decided that pelvic angiography and embolisation was the way to go for control of the major pelvic bleeding. The patient was initially stable after intubation, fluid and blood resuscitation, but became very unstable in the Angio suite and had a hypovolaemic arrest in radiology. She was resuscitated with fluids, blood and adrenaline and the radiologist was then able to complete the angio ( after about an hour) and successfully embolise 2 major arterial bleeders.

She then went to the OT and had external fixation appllied and eventually had a laparotomy which revealed a liver laceration, which the surgeons tell me was not a major source of blood loss. Unfortunately she had a further cardiac arrest on the operating table and was not able to be resuscitated.


Case Two

25 year old motorcyclist was brought to our unit via our Helicopter Emergency Medical Service. She was persistently hypotensive throughout her prehospital course and on arrival in the emergency department had a blood pressure of 70/50 and pulse rate of 130/min. She was alert, orientated and conversing normally.

Her airway was clear and examination of the chest was normal. Her abdomen was obviously distended and pelvis very unstable to clinical examination. Blood pressure improved to 90/50 with infusion of 2 litres of crystalloid and 4 units warmed O-egative blood through a rapid infusion system. She was log-rolled to examine her back but immediately lost her blood pressure and only had a palpable carotid pulse. Blood pressure returned to around 80/40 after further fluid and blood transfusion.

Pelvic X-ray showed pubic rami fractures and a left sacral fracture.

Ultrasound scan of her abdomen showed intraperitoneal free fluid in the hepatorenal space and pelvis.

She remained shocked and unresponsive to fluid resuscitation and was taken to the operating room. The decision was taken to place an external fixator prior to performing the laparotomy. Anaesthesia was induced and an incision made over the iliac crest. Unfortunately this entered the retroperitoneal haematoma and the patient began to haemorrhage from this wound. Packing was applied an the external fixator quickly completed.

A laparotomy was carried out through a midline incision. The right lobe of the liver had a deep laceration not extending into the hepatic veins. There was a large pelvic retroperitoneal haematoma which was leaking into the intraperitoneal space. The haemorrhage from the liver laceration was controlled with ligation of bleeding arteries and packing. As the haematoma was expanding and leaking, attempts were made to control the retroperitoneal haemorrhage.

The retroperitoneum was opened. This lead to significant haemorrhage from the general pelvic area. Both internal iliac arteries were identified and ligated. Further attempts were made to control venous haemorrhage by placing fogarty balloon catheters via the femoral veins. The patient became progressively cold, acidotic and coagulopathic despite administration of clotting factors and the use a rapid infuser go transfuse warmed fluids. All attempts to control haemorrhage were unsuccessful and the patient died on the table.

Following this case we reviewed our management of pelvic injuries. We looked at all patients arriving with unstable pelvic fractures. Overall mortality was 6%. When there was a significant concomittant intra-abdominal injury (Abbreviated Injury Scale 3 or more) mortality rose to 50% (median injury severity score - ISS - for this group was 56). For those patients who arrived in hypovolaemic shock with a systolic blood pressure below 90mmHg, with combined intraperitoneal injury and unstable pelvic fracture the mortality was 100% (median ISS 63).

Management of these patients was altered, based on the principles of protecting the primary clot, prevention of the hypothermia-acidosis-coagulopathy syndrome and early control of haemorrhage using damage control techniques.


Case Three

33yr old male driver of a car, lateral impact with another car and then head-on into a bus. At scene pulse 130, BP 80/40. GCS 14. Open pelvic fracture involving the rectum.

At scene:
Airway was clear, seat-belt mark to chest but lung fields appeared clear. No manual testing of pelvic stability. Pelvic splint applied. Minimal log-rolling. Scoop stretcher & vacuum mattress applied for transport. IV Access for analgesia. A total of 100 mls of warmed Ringer's lactate given in prehospital phase.

Emergency Department:
Arrived with pulse of 130, BP 70/50, cool peripheries.

Chest X-ray showed a large diaphragmatic tear with haemothorax.

Pelvic X-ray showed a complex unstable pelvic injury.


Intraperitoneal free fluid on abdominal ultrasound (FAST) .

The pelvic splint was left on. A further 300 mls warmed RInger's given in emergency department. Right chest tube placed. 700 mls blood evacuated. Blood, platelets, fresh frozen plasma and cryoprecipitate was ordered.

Operating Room:
At laparotomy there was a large right diaphragmatic tear with liver herniation and a laceration to the right lobe of the liver extending into the retrohepatic inferior vena cava. There was a laceration to the upper pole of the spleen. There was a large retroperitoneal haematoma centrally in the upper abdomen and in the pelvis.

The liver and vena cava were packed, a splenectomy performed and the pelvis packed (pelvic splint remains in place). The right diaphragm was repaired. The abdomen was closed and angiography was then performed on the table in the operating room. Obturator and internal pudendal arteries were embolized. Branches of the hepatic artery were also embolized.

Once the major haemorrhage had been controlled, crystalloid, blood and clotting factors were administered to correct the base deficit. The patient was transferred to the intensive care unit and warmed. The following morning he developed an abdominal compartment syndrome and the abdomen was opened and the packs removed. The caval injury was re-packed.

48 hours later all packs were removed and the abdomen closed primarily.



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