TRAUMA.ORG

The Case Presentation

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Image from DEKRA & Winterthur
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On Scene: pulse 120, systolic blood pressure 90, Resp 16, GCS 8.

PreHospital Questions:

• This patient is obviously in shock. How do you define haemodynamically instability?
  Adam Starr
     
• How do you diagnose an unstable pelvic fracture in the street? Is clinical examination valuable? Is it harmful?
     
• The Right iliac wing is mobile to exam. Do you stabilize this on scene?
  (e.g. London splint, Geneva belt, Dallas binder, Kendrick extrication device, PASG, etc)
     
• The nearest community hospital is 30 minutes away.
  The nearest Level II Trauma Center is 60 min.
  Level I Trauma Center is 90 min.
  To which hospital should this patient be transported?
  Both the Kellam and the Routt algorithms address the transfer question.
     
• If the patient is taken first to a community hospital, what should be done there prior to transfer?
     
• Most algorithms (e.g. Agolini ) call for fluid resuscitation. (Not Brohi)
  How much fluid should this patient receive? Ken Mattox

On Arrival - Level I trauma center
Intubated and ventilated, saturations 99%
Pulse 160, blood pressure 70/40,
Patient immobilized to long backboard.
2 large bore iv's running LR.

Chest Xray - Left hemopneumothorax.
Lt Chest tube placed.

AP pelvic Xray obtained.

Image courtesy of Kenneth Johnson MD,
Vanderbilt Univ Med Ctr, Nashville

Emergency Room Questions:

• Is the AP pelvic X-rays as a priority? Do you order them on everybody?
     
• Is there anything wrong with this pelvic X-ray?
     
• Are the orthopaedic Tile and Burgess-Young pelvic injury classifications useful in this situation?

Image courtesy of Karim Brohi FRCS FRCA,
Royal London Hospital / Trauma.Org

A sheet was immediately wrapped around the pelvis in the emergency room.
Blood pressure improved to 90/60 with tachycardia of 130/min.

Image courtesy of Paul Tornetta III MD,
Boston University Medical Center

More Emergency Room Questions:

• The Kellam, Brohi and Routt algorithms call for non-invasive pelvic stabilization. Do you institute or continue non-invasive stabilization in the ER?
     
• Can the haemodynamic response response to non-invasive stabilisation be used to predict the need for further interventions (external fixation / angiography etc.)
     
• Where is this patient bleeding from?
     
• How do you want to investigate this further and where?
  (Evers and Pohlemann have already taken the patient to the OR.)
     

The patient has received 3L crystalloid, the 4 units of PRBC's and 4 units of FFP .

Abdominal ultrasound shows hypoechoic stripe in the hepatorenal space.
(positive for free intraperitoneal fluid).

Image courtesy of Karim Brohi FRCS FRCA,
Royal London Hospital / Trauma.Org

FAST vs DPL Questions:

• Is this a positive FAST? If so, do you trust it?
  
  
• Is FAST accurate in the presence of a pelvic fracture / retroperitoneal haematoma?
     
• Is there still a place for Diagnostic Peritoneal Lavage?
     
• What if this patient were FAST Negative? - there's no intraperitoneal injury.
  What do you want to do now?

Prior to laparotomy, the sheet & towel clip were replaced with a pelvic clamp.
Application time was 35 minutes.

Image courtesy of Kenneth Johnson MD,
Vanderbilt University Medical Center, Nashville

Ex Fix Questions:

• Is there any point in applying an external fixation device over and above the non-invasive belts?
  The surgeons (e.g. Scalea, Brohi, Agolini) want to perform an immediate laparotomy.
     
• It appears that pelvic external fixation
  • does not significantly tamponade retroperitoneal hemorrhage,
  • does not significantly reduce intrapelvic volume, and
  • frequently increases posterior pelvic displacement - in the vicinity of major sources of venous and arterial hemorrhage.
    
    Is there any evidence to support the use of the external fixator?
    
    
• Which method of external stabilization is best? When should it be applied?

Operating Room

On OR Arrival: BP 90/50 pulse 140.

At laparotomy - an extensive liver laceration is found and is controlled with packing. A large pelvic retroperitoneal haematoma is present.

BP 90/60, pulse 140, urine output 300 ml.

The patient is transferred to the angiography suite.

Angiography:
Haemorrhage from the left obturator artery is identified and embolized.
BP 100/70, pulse 100

Image courtesy of Steven Olson MD,
UC Davis, Sacramento

Angiography Questions:

• In retrospect should angiography have been performed first?
     
• Can angiography control intraperitoneal haemorrhage avoiding the need for laparotomy?
     
• Should the operating room and angiography be the same place?

After sustained hemodynamic improvement in angiography, iliosacral screws are placed under fluoroscopy to supplement the pelvic internal fixation.

Image courtesy of Kenneth Johnson MD,
Vanderbilt University Medical Center, Nashville

Definitive Fixation Questions:

• How and when should definitive fixation be instituted?
     
• Would you do this without a CT scan?

The patient subsequently underwent a CT scan of his head which revealed a small left subdural hematoma and diffuse brain injury with tight basal cisterns.

Initial intracranial pressures of approximately 35 mm Hg increased relentlessly over the ensuing 48 hours despite aggressive management.

Eventually ICP topped 100 mm Hg pressure.
Pupils became fixed and dilated.
A day later life support was withdrawn.

Image courtesy of Eric Frykberg MD,
Shands, UF Jacksonville

Traumatic Brain Injury Questions:

• Does management of the pelvic injury affect neurological outcome?