Pedestrian struck

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Went to OR (angio would take 30-40 min to setup on a Saturday) for
laparotomy.
Massive bleeding from within pelvis. Aortic clamping. Both internal iliac
veins and right internal iliac artery ligated. Packing of pelvis.
Rectum completely torn 5 cm above anus; colostomy.
Bladder and prostate avulsed from pelvic floor; deviating catheter.
VAC abdominal dressing.
Ex fix placed on pelvis (don't need ortho for that, we also do the pelvic
and extremity fracture care).
Packing of large venous bleeding from deglovement right femur/gluteal
region.
Still hypotensive at the end of procedure despite massive transfusion,
rfVIIa etc.
To angio to check for other sources of bleeding; embolization of branches of
left internal iliac artery.
Stabilized on ICU afterwards. Second look, removal of packing and washout of
pelvis on day 2 and is still improving.

So, we've had the basics. Now what to do with the ischemic buttock/gluteus
after bilateral int. iliac ligation/embo? Wait for demarcation with risk of
(pelvic) sepsis? Timing of osteosynthesis? Other suggestions?


----- Original Message ----- 
From: "J.C. Goslings" <j.c.goslings at amc.uva.nl>
To: <trauma-list at trauma.org>
Sent: Monday, May 30, 2005 6:38 PM
Subject: Pedestrian struck


This guy just came in:
36 year old male, truck driven over pelvis and abdomen
A: free, stifneck placed
B: normal
C: grade III/IV hypovolemic shock, syst. blood pressure 60, pelvic binder
placed on scene
D: alert and awake at the scene, now intubated/ventilated
E: open pelvic fracture through rectum and scrotum, multiple severe
deglovements torso and right leg
chest X-ray: normal
FAST: some free intraabdominal fluid
pelvic X-ray: attached

What would you do?
Thank you,
Carel Goslings and Karine van Scherpenzeel
Trauma Unit AMC
Amsterdam, Netherlands


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