List Archives

Sat Oct 27 16:19:30 BST 2007

A presentation by Dr. Moore from the Panamerican Trauma Society meeting
on Pelvic Packing.  

http://www.panamtrauma.org/Lectures/Pelvic%20Retroperitoneal%20Packing%20Related%20to%20Hemorrhage%20by%20Fractures/player.html

Stephen S. Luk, MD, FACS, FCCP
Assistant Professor of Surgery
Associate Director of Trauma
Medical Director, ATOM Course
Hartford Hospital
EMS/Trauma Program
80 Seymour Street
Hartford, CT 06102-5037
(860) 545-3766
sluk at harthosp.org 

>>> Olav Røise <olav.roise at medisin.uio.no> 10/27/2007 10:26 AM >>>
I agree with Ken Mattox. I introduced extrapelvic packing in Oslo in
1994
and it has been part of our pelvic bleeding protocol ever since.

So as the patient is haemodynamically unstable this would be the option
in
this case.  First the fracture should be stabilized with the binder or
sheet
around the trochanter region and kept in place during the surgical
procedure
of damage control. 

For the urethral injury I would not have put the catheter in before
the
urethra was cleared by an urethra-graphy.  It is known that catheter
can put
a partial rupture into a total disruption. I would not focus on the
urethra
before the pelvic bleed is under controll. 

With regard to the possible rectal injury we are doing a
rectal/sigmoidoscopy to exclude injury. We have seen false negative
contrast
exam. of the rectum. This has of low priority and should not be done
before
control of the bleed. Eventually a sigmoidotomy shoul be done - keeping
in
mind the later reconstruction of the pelvis - and talk to the pelvic
surgeon
to avoid incision conflict for later reconstruction of the pelvis 

With kind regards,

Olav

Olav Røise

Division of Neuroscience and Muscoloskeletal Medicine, Ullevaal
University
Hospital, Oslo

Cellular phone;+4790895062
E-mail;olro at uus.no or; olav.roise at medisin.uio.no 

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] 
On Behalf Of KMATTOX at aol.com 
Sent: 27. oktober 2007 15:44
To: trauma-list at trauma.org 
Cc: ccm-l at ccm-l.org 
Subject: Re: Pelvic fracture

In a message dated 10/27/2007 5:39:42 A.M. Central Daylight Time,  
hpb.surgery at gmail.com writes:

1.  Pelvic fracture + suspected ongoing retro peritoneal venous bleed, 
what
surgical strategy would you employ?
2. If a rectal tear is  suspected, without any perioneal trauma, how
would
you
de-function, loop  colostomy? Or end colostomy and mucous fistula?
Would you
try and establish  the site of perforation - on-table flexible
sigmoidoscopy
etc.?

I agree with Bjorn regarding the excessive fluid administration.  

The patient appears to be hemodynamically stable.    If  unstable, then
one 
of several tactics to impede ongoing blood loss is  indicated.   I
have
never 
been totally satisfied with arterial  embolization for control of
venous 
bleeding.    I also have not  been satisfied with external fixation to
reduce blood 
loss.   The  orthopedic community is mixed in its support of external 

fixation.    The new extra peritoneal packing as reported from  Europe
and
from a 
couple of centers in the United States bears  watching.    I might have

considered such a procedure in this  patient.   It is a temporizing
("damage
control") 
tactic.  

With the case as you describe, I would consider going to OR for an  
examination under anesthesia, looking mainly at the rectum.     For
this one
does not 
need to do a flexible sigmoidoscopy, as it is only the  rectum which is
of 
concern.     This can be done with a  straight short scope.     Even a
full 
thickness injury might  be missed, but your CT description is
suggestive of
a rectal 
 injury.     I would strongly consider a LOOP colostomy, but  to be
sure
that 
the distal stoma is totally defunctionalized, unless the patient  is
obese 
and the mesentery is foreshortened and to do a loop would create 
vascular 
compromise to the exteriorized
 segment.       If the patient's pelvis
was 
operatively repaired, and he did not become  febrile, I would study
the
distal rectum 
via the loop colostomy and if NO LEAK,  I would consider closing this
colostomy 
at the first  hospitalization.   

k

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