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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
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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.
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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.
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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.
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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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