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Sun Oct 28 14:12:45 GMT 2007

Technically this is a very simple method. We have described it in a recent
issue of Journal of Trauma(1).The Denver group presented their results in
the same issue. 

We are doing the procedure in the ER. We have embolization as the main
method for controlling bleeding for pelvic bleeding. However, our angio
suite is located far from ER and for patients in shock embolization is no
option as such patients will die during transfer – even though we have
intervention services on call 24hrs/365. So packing is for patients that
otherwise would exanguinate. 

Pelvic packing is done with the sheet or pelvic binder placed around the
trochanter regions and the extremities internally rotated. A short midline
incision from the symphysis to 4- 5 cm below the umbilicus is made. The
haemotoma makes  the surgical dissection easy as the bleed is
extraperitoneal. The bladder is held cranially and then you just go
laterally along the pelvic brim under the external illac vessels and the
psoas muscle. The pelvic bleeding is controlled by a minimum of 3-4 large
swabs on each side in the interspace between the bony pelvic ring and the
peritoneum, starting from caudal and posterior at the ileosacral joint and
advancing anteriorily to the symphysis. The swabs are directed toward
branches of the internal iliac artery and the pelvic venous plexus situated
in the retroperitoneal space. Usually access to the site of bleeding is
simple as haematoma has already dissected the retroperitoneal space. To
obtain maximum compression the contra-lateral side is packed in the same
manner. In unstable pelvic fractures (vertical shear and major open book
injuries – C and B1) the muscles and ligaments of the pelvic floor may be
torn. This increases the volume of the true pelvis and more swabs may be
needed. After completing pelvic packing the linea alba is closed with
continuous sutures in order to achieve additional tamponading effect. No
wound drains are left. 

The swabs are left for 48 hours. Usually definitive internal fixation can be
performed at the time of swab removal.  However, if the patients starts to
rebleed at the time of swab removal the EPP is repeated and swabs left for
another 48 hours. 

This procedure is done by the resident on call. We have established a
systematic training for the trauma team leaders at the lab of pathology. The
residents are not allowed to serve as a team leader without knowing the
procedure. 

The procedure is very simple and can easily be learned by any surgeon. You
will be able to do this in just few minutes. 

Reference;

1.    Totterman A, Madsen JE, Skaga NO, Roise O. Extraperitoneal pelvic
packing: a salvage procedure to control massive traumatic pelvic hemorrhage.
J Trauma. 2007 Apr;62(4):843-52.  

Olav

Olav Røise
Chairman, MD, Ph.D

Division of Neuroscience and Muscoloskeletal Medicine, Ullevaal University
Hospital

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 Robert F. Smith
Sent: 28. oktober 2007 12:37
To: 'Trauma &amp; Critical Care mailing list'
Subject: RE: Pelvic fracture

Doesn't work for me either even if I cut and paste. 

How does one technically do this? Do you worry about violating expanding

hematoma?

Rob Smith

-----Original Message-----

From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]

On Behalf Of Richard Wigle MD FACS

Sent: Saturday, October 27, 2007 10:19 PM

To: Trauma &amp, Critical Care mailing list

Subject: RE: Pelvic fracture

Having had the opportunity to hear Dr Moore speak on this

topic I would very much like to have access to this

presentation. This link- and the previous link- are,

however not working for me despite my trying all the usual

tricks to milk reticent data from web sites. Any other

suggestions?

R Wigle

--- Stephen Luk <Sluk at harthosp.org> wrote:

> A presentation by Dr. Moore from the Panamerican Trauma

> Society meeting

> on Pelvic Packing.  

> 

> 

http://www.panamtrauma.org/Lectures/Pelvic%20Retroperitoneal%20Packing%20Rel

ated%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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Pelvic fracture