pelvic trauma

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Unstable patient with pelvic fracture and positive DPL or a positive
FAST should go to the OR to insure that there is no surgical reason for
hypotention.  Then from OR directly to angio to study and embolize as
needed.  Agree with sheet - C-clamp could be used (sorry Ken), ex-fix
takes too long in the ED, but could be applied after angio.
RIG

>>> KChason at aol.com 3/8/2005 4:59:21 PM >>>
Had a difficult patient yesterday and waiting for post mortem.
 
80 yo m fell down an elevator shaft 2 stories.  About 30  minutes until
EMS 
arrival,  another 40 minutes on scene and to  reach hospital.  EMS
states 
hypotensive  on scene.  Two IV  lines placed in left upper extremity
due to 
multiple fractures in right upper  extremity with no distal pulses. 
Received 2 
liters wide open during  extrication and then scooped and ran.   
 
On arrival patient was awake and talking, GCS 15, no past medical or  
surgical history.
 
VS normotensive and mild tachycardia
c/o difficulty breathing and tenderness on movement or palpation of 
injured 
extremities
 

pulse ox 100% on non re-breather mild tachypnea
No obvious head trauma
lung sounds decreased on right
abd soft non tender
had blood at the urethral meatus
deformity right upper ext cool and no pulse, left lower extremity
shortened  
and rotated, cool no pulse pule in lower extremity returned with 
manipulation
 
 
Airway appeared stable
CXR no hemo/pneumo
 
pelvis xray right femoral neck fracture and widened symphysis
IV fluid bolus continued  

Type and crossed for 6 units
2 units O negative started received 4 more units of cross matched 
blood

 
Pressure began to drop and became more tachy
 
Some technical issues 
bp cuff and lines in same arm prevented rapid infusion with short BP 
cycling 
intervals 
 
 
 
Put in right IJ.  Femoral line not an option in pelvic  fracture Used
right 
side where decreased breath sounds despite nl chest  xray.  Plan was to

intubate prior to going to procedure/OR 
 
Do others use CVP or a-lines in the ED?  Tried an a-line but still 
only had 
one shot at one extremity
 
Trauma surgeon attempted sheet method to stabilize pelvis until  ortho

arrived 
 
DPL performed positive  not grossly but by cell count, Would a 
positive FAST 
been equal to DPL?
 
Had difficulty with ortho and trauma deciding the definitive care 
 
Unsure how quickly invasive radiology could get ready (confirmed not in
 
house)
 
So decided to attempt Ex-fixation  Patient intubated before EX  fix
with 
etomidate and succinylcholine
 
My thoughts: there were three options
 
Stay in the ED  to "stablilize" and would surely succumb
 
Go to radiology to attempt embolization or
 
go to OR for laparotomy with positive DPL
 
After ex fix patient went into cardiac arrest and was unable to be  
resuscitated
 
My question is their a good strategy for treatment for the unstable 
patient 
with known pelvic fracture and positive DPL?  We debated this but  
unfortunately did not reach the point of action for this patient.  Our
plan  was ex fix 
and then attempt embolization
 
 
 
 
 
 
 
 
 
 
 
 
 
unstabe
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