trauma-list Digest, Vol 52, Issue 31

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Puttin a symphysis pubis plate on can be a relatively
simple thing to do to stabilise the anterior part of
the pelvis during a lapaortomy if there is a
diastasis.  Does anybody have any experience on how
this can affect things haemodynamically if the
posterior ring (S-I joint/sacrum) is disrupted?

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> > Today's Topics:
> 
>    1. RE: [ccm-l] RE: Pelvic fracture (Stephen Luk)
>    2. Sending Power Point Presentations (Charlene M
> Morris)
>    3. RE: Pelvic fracture (Olav R?ise)
>    4. Pelvic fracture - operative findings (Saboor
> Khan)
>    5. RE: Pelvic fracture - operative findings
> (Lorick Fox, MPAS, PA-C)
>    6. RE: Pelvic fracture - operative findings (Olav
> R?ise)
>    7. RE: Pelvic fracture (Hardcastle, Tim, Dr
> <tch at sun.ac.za>)
>    8. RE: Pelvic fracture - operative findings
>       (Hardcastle, Tim, Dr <tch at sun.ac.za>)
>    9. RE: Pelvic fracture - operative findings
> (Sanjay Gupta MD)
> > From: "Stephen Luk" <Sluk at harthosp.org>
> Subject: RE: [ccm-l] RE: Pelvic fracture
> CC: ccm-l at ccm-l.org
> Date: Sun, 28 Oct 2007 08:48:41 -0400
> To: <olav.roise at medisin.uio.no>, "Dr Brahma
> Balakrishnan" <drbrahma at tm.net.my>,
> 	"'Trauma &amp; Critical Care mailing list'"
> <trauma-list at trauma.org>
> 
>  try this link - browse through the selections, the
> pelvic packing
> lecture is on the bottom of the left hand column
> 
> http://www.panamtrauma.org/Lectures/Lectures.htm 
> 
> 
> 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 
> 
> 
> >>> Dr Brahma Balakrishnan <drbrahma at tm.net.my>
> 10/27/2007 1:23 PM >>>
> Dear Stephen,
> Nothing happens when I click on the link.
> 
> Regards Dr B
> 
> Dr. Brahma Balakrishnan
> Clinical Director
> Wijaya International Medical Center
> Malaysia
> 
> -----Original Message-----
> From: ccm-l-bounces at ccm-l.org
> [mailto:ccm-l-bounces at ccm-l.org] On
> Behalf Of
> Stephen Luk
> Sent: Saturday, October 27, 2007 11:19 PM
> To: Olav Røise; 'Trauma &amp; Critical Care mailing
> list'
> Cc: ccm-l at ccm-l.org 
> Subject: [ccm-l] RE: Pelvic fracture
> 
> 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
> suppor
> t 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  
> 
=== message truncated ===> From: "Charlene M Morris"
<cvmmorris at gmail.com>
> Subject: Sending Power Point Presentations
> Date: Sun, 28 Oct 2007 08:57:06 -0400
> To: "Trauma &amp, Critical Care mailing list"
> <trauma-list at trauma.org>
> 
> for sending ppp, use www.yousendit.com. It is still
> free for the basic and
> TERRIFIC for alrge files.
> 
> Charlene Morris
> 
> 
> 
> On 10/28/07, Charles Brault <c_brault at yahoo.com>
> wrote:
> >
> > I find that
> > Goop powerpoint presentation
> > Are normaly bad reference document
> >
> > The poerpoint when well used is but a frame
> > That does not hold much without IT's presenter
> >
> > ... or take on an all other form (god or bad)
> >
> >
> > Charles
> >
> > ----- Original Message ----
> > From: "Bjorn, Pret" <pbjorn at emh.org>
> > To: "Trauma & Critical Care mailing list"
> <trauma-list at trauma.org>
> > Sent: Friday, October 26, 2007 9:14:06 PM
> > Subject: RE: Pedi Pointers and Pertinent
> Propaganda
> >
> > Just to show I tried: my slides apparently got
> confiscated at the border
> > (at least, I never saw this on the other end). 
> Still available
> > off-List, I think; but again: low expectations are
> advised.
> >
> > Pret
> >
> > -----Original Message-----
> > From: Bjorn, Pret
> > Sent: Wednesday, October 24, 2007 12:44 PM
> > To: 'Trauma & Critical Care mailing list'
> > Cc: 'Andrew J Bowman'
> > Subject: RE: Pedi Pointers and Pertinent
> Propaganda
> >
> >
> > Sorry Andrew and everybody.  Bangor can be a busy
> place, and I really
> > intended to annotate these (there's of course a
> lot of scripting that
> > wouldn't be intuitive from the slides); but that's
> not gonna happen any
> > time soon.
> >
> > Please forgive the colloquiality, and be patient
> with the format:
> > PowerPoints don't tend to travel well over the
> internet.  The fonts and
> > bullets and layouts will probably not translate
> cleanly.
> >
> > And above all, know that these were very short
> presentations for a local
> > audience, not by any means definitive or
> comprehensive.  But if there's
> > a slide or two that you can use, have at it.
> >
> > Pret Bjorn, RN
> > Bangor, ME USA
> >
> > -----Original Message-----
> > From: trauma-list-bounces at trauma.org
> > [mailto:trauma-list-bounces at trauma.org] On Behalf
> Of Andrew J Bowman
> > Sent: Sunday, October 14, 2007 5:20 PM
> > To: Trauma & Critical Care mailing list
> > Subject: Re: Pedi Pointers and Pertinent
> Propaganda
> >
> >
> > Pret,
> >
> > How did your presentation go?
> >
> > Andrew Bowman
> >
> > ----- Original Message -----
> > From: "Bjorn, Pret" <pbjorn at emh.org>
> >
> >
> >
> > I'm speaking to a group of nurse anesthetists this
> weekend who want to
> > know cool stuff about pediatric trauma.  I've got
> a couple of canned
> > lectures on my hard drive, but they (and surely I)
> could use some
> > freshening up.
> >
> > Pret Bjorn, RN
> > Bangor, ME USA
> >
> > --
> > trauma-list : TRAUMA.ORG
> > To change your settings or unsubscribe visit:
> > http://www.trauma.org/index.php?/community/
> >
> >
> > --
> > trauma-list : TRAUMA.ORG
> > To change your settings or unsubscribe visit:
> > http://www.trauma.org/index.php?/community/
> > --
> > trauma-list : TRAUMA.ORG
> > To change your settings or unsubscribe visit:
> > http://www.trauma.org/index.php?/community/
> >
> 
> > From: Olav Røise <olav.roise at medisin.uio.no>
> Subject: RE: Pelvic fracture
> Date: Sun, 28 Oct 2007 15:12:45 +0100
> To: "'Trauma &amp; Critical Care mailing list'"
> <trauma-list at trauma.org>
> 
> 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
> 
=== message truncated ===> From: "Saboor Khan"
<hpb.surgery at gmail.com>
> Subject: Pelvic fracture - operative findings
> Date: Sun, 28 Oct 2007 15:52:02 +0000
> To: "Trauma &amp, Critical Care mailing list"
> <trauma-list at trauma.org>
> 
> Thanks to those who replied: Just to mention a few
> points:
> 
> 1. I agree, with such an injury a urethrogram should
> have been performed.
> 2. Cannot comment on whether the crystalloid
> resuscitation was excessive.
> 3. The CT scan did not show a blush, however my
> (experienced) orthopaedic
> colleague, who has an interest in pelvic trauma, was
> concerned because of
> his hypotension - and wondered about packing - I
> hadn't performed one
> before!). I did not think that there was substantive
> evidence of a bleed.
> 4. A rigid sigmoidoscopy was performed, pre-op and
> he had blood in the
> rectum.
> 5. Just curious, what is a 'VOMIT' as described by
> k?
> 
> Intra-op findings (antibiotics administered );
> 
> Gen Surg - low midline laparotomy - pristine
> abdominal cavity, some bruising
> at peritoneal reflection, paused.
> 
> Orthopaedic: complete diastasis as soon as the
> support was released, the
> pelvis 'sprung' open, instantly held together by
> orthopaedic 'tongs'. Brisk
> venous ooze, welling up, retro-peritoneum either
> side of bladder - tightly
> packed - haemsotatic plugs and gauze, exactly as
> described by Olav and
> yes, 'surprisingly easy' and very effective, even
> for a novice. Site of
> subcutaneous emphysema identified - copious lavage.
> 
> Gen Surg-  Sigmoid loop mobilised and brought to the
> surface, Abdomen
> closed. lithotomy position, stoma matured, distal
> sigmoid copious washout
> with bladder catheter (balloon inflated). Rigid
> sigmoidoscopy repeated -
> small 'rent' in anterior rectum, haemostatic plugs
> just about visible! No
> further attempt at repair.
> 
> Day 2, patient awake, stable, plan to revisit /
> review and remove pack
> tomorrow.
> 
> Criticism: Would an end stoma, mucous fistula be a
> better option  (complete
> defunctioning)?
> 
> Finally, impressed with the practicality and ease of
> packing, a worthy
> damage limitation technique.
> 
> Best Wishes,
> Saboor Khan
> Coventry
> UK
> 
> > From: "Lorick Fox, MPAS, PA-C" <lorick at lorick.org>
> Subject: RE: Pelvic fracture - operative findings
> Date: Sun, 28 Oct 2007 18:07:36 +0200
> To: "'Trauma &amp; Critical Care mailing list'"
> <trauma-list at trauma.org>
> 
> Victim Of Modern Imaging Technology
> 
> Lorick Fox, MPAS, PA-C
> Gianaclis Support Complex
> 03-448-2335
> Fax 03-448-2339
> Mobile 018-230-4448
> 
> 
> > -----Original Message-----
> > From: trauma-list-bounces at trauma.org
> [mailto:trauma-list-
> > bounces at trauma.org] On Behalf Of Saboor Khan
> > Sent: Sunday, October 28, 2007 5:52 PM
> > To: Trauma &amp, Critical Care mailing list
> > Subject: Pelvic fracture - operative findings
> > 
> > Thanks to those who replied: Just to mention a few
> points:
> > 
> > 
> > 5. Just curious, what is a 'VOMIT' as described by
> k?
> > 
> > 
> 
> 
> > From: Olav Røise <olav.roise at medisin.uio.no>
> Subject: RE: Pelvic fracture - operative findings
> Date: Sun, 28 Oct 2007 17:41:45 +0100
> To: "'Trauma &amp; Critical Care mailing list'"
> <trauma-list at trauma.org>
> 
> What Saaboor experienced in this case is just what
> we have seen repeatedly
> over these 13 years we have used the technique. We
> have been around the
> world to spread this very efficient and lifesaving
> procedure and I can tell
> you it's astonishing to see how difficult it is to
> change practise among us
> surgeons.
> 
> Even more important, this is a technique for rural
> hospitals or hospital
> taking part in a  chain of care that doesn't have
> the angio services. We in
> Norway have therefore trained people in these
> hospitals by several trauma
> programs (BEST, war surgery courses, courses for
> lifesaving procedures). We
> also have been travelling around specifically for
> training this procedure
> among smaller hospitals. This practise improves the
> care and save lives. 
> 
> 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 Saboor Khan
> Sent: 28. oktober 2007 16:52
> To: Trauma &amp, Critical Care mailing list
> Subject: Pelvic fracture - operative findings
> 
> Thanks to those who replied: Just to mention a few
> points:
> 
> 1. I agree, with such an injury a urethrogram should
> have been performed.
> 2. Cannot comment on whether the crystalloid
> resuscitation was excessive.
> 3. The CT scan did not show a blush, however my
> (experienced) orthopaedic
> colleague, who has an interest in pelvic trauma, was
> concerned because of
> his hypotension - and wondered about packing - I
> hadn't performed one
> before!). I did not think that there was substantive
> evidence of a bleed.
> 4. A rigid sigmoidoscopy was performed, pre-op and
> he had blood in the
> rectum.
> 5. Just curious, what is a 'VOMIT' as described by
> k?
> 
> Intra-op findings (antibiotics administered );
> 
> Gen Surg - low midline laparotomy - pristine
> abdominal cavity, some bruising
> at peritoneal reflection, paused.
> 
> Orthopaedic: complete diastasis as soon as the
> support was released, the
> pelvis 'sprung' open, instantly held together by
> orthopaedic 'tongs'. Brisk
> venous ooze, welling up, retro-peritoneum either
> side of bladder - tightly
> packed - haemsotatic plugs and gauze, exactly as
> described by Olav and
> yes, 'surprisingly easy' and very effective, even
> for a novice. Site of
> subcutaneous emphysema identified - copious lavage.
> 
> Gen Surg-  Sigmoid loop mobilised and brought to the
> surface, Abdomen
> closed. lithotomy position, stoma matured, distal
> sigmoid copious washout
> with bladder catheter (balloon inflated). Rigid
> sigmoidoscopy repeated -
> small 'rent' in anterior rectum, haemostatic plugs
> just about visible! No
> further attempt at repair.
> 
> Day 2, patient awake, stable, plan to revisit /
> review and remove pack
> tomorrow.
> 
> Criticism: Would an end stoma, mucous fistula be a
> better option  (complete
> defunctioning)?
> 
> Finally, impressed with the practicality and ease of
> packing, a worthy
> damage limitation technique.
> 
> Best Wishes,
> Saboor Khan
> Coventry
> UK
> --
> trauma-list : TRAUMA.ORG
> To change your settings or unsubscribe visit:
> http://www.trauma.org/index.php?/community/
> 
> 
> > From: "Hardcastle, Tim, Dr <tch at sun.ac.za>"
> <tch at sun.ac.za>
> Subject: RE: Pelvic fracture
> Date: Mon, 29 Oct 2007 07:21:01 +0200
> To: "Trauma &amp; Critical Care mailing list"
> <trauma-list at trauma.org>
> 
> Olav et al
> 
> We have included it in the DSTC course as of 2007
> too! (Certainly in Scandinavia and RSA)
> 
> Tim
> Dr T C Hardcastle
> M.B.,Ch.B.(Stell); M.Med(Chir); FCS(SA)
> Senior Surgeon / Senior Lecturer: Surgery (Trauma
> and ICU)
> ATLS  instructor and DSTC Cape Town Course Director
> Intern program Coordinator: Surgery
> M.Med (Emergency Medicine) Executive Committee
> member
> Clinical Head (Director): Diana Princess of Wales
> Trauma Unit
> Division of Surgery (General) Room 4064
> Department of Surgical Sciences
> Tygerberg Hospital / University of Stellenbosch
> PO Box 19063
> Tygerberg 7505
> Western Cape
> South Africa
> e-mail: tch at sun.ac.za
> Cell: +27824681615
> Office: +27219389281 or 4911 pager 0302
> 
> 
> 
> -----Original Message-----
> From: trauma-list-bounces at trauma.org
> [mailto:trauma-list-bounces at trauma.org]On Behalf Of
> Olav Røise
> Sent: Sunday, October 28, 2007 4:13 PM
> To: 'Trauma &amp; Critical Care mailing list'
> Subject: RE: Pelvic fracture
> 
> 
> 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
> 
=== message truncated ===> From: "Hardcastle, Tim, Dr
<tch at sun.ac.za>"
> <tch at sun.ac.za>
> Subject: RE: Pelvic fracture - operative findings
> Date: Mon, 29 Oct 2007 07:24:22 +0200
> To: "Trauma &amp; Critical Care mailing list"
> <trauma-list at trauma.org>
> 
> Saboor
> 
> If done properly with a mature stoma above skin
> opened longitudinally then the loop-stome IS full
> defunctional. We have not used devided stoma for
> rectal injury for many years - no major problems.
> See the report in June 2007 WJS from the other Cape
> Medical School (UCT).
> 
> Tim
> Dr T C Hardcastle
> M.B.,Ch.B.(Stell); M.Med(Chir); FCS(SA)
> Senior Surgeon / Senior Lecturer: Surgery (Trauma
> and ICU)
> ATLS  instructor and DSTC Cape Town Course Director
> Intern program Coordinator: Surgery
> M.Med (Emergency Medicine) Executive Committee
> member
> Clinical Head (Director): Diana Princess of Wales
> Trauma Unit
> Division of Surgery (General) Room 4064
> Department of Surgical Sciences
> Tygerberg Hospital / University of Stellenbosch
> PO Box 19063
> Tygerberg 7505
> Western Cape
> South Africa
> e-mail: tch at sun.ac.za
> Cell: +27824681615
> Office: +27219389281 or 4911 pager 0302
> 
> 
> 
> -----Original Message-----
> From: trauma-list-bounces at trauma.org
> [mailto:trauma-list-bounces at trauma.org]On Behalf Of
> Saboor Khan
> Sent: Sunday, October 28, 2007 5:52 PM
> To: Trauma &amp, Critical Care mailing list
> Subject: Pelvic fracture - operative findings
> 
> 
> Thanks to those who replied: Just to mention a few
> points:
> 
> 1. I agree, with such an injury a urethrogram should
> have been performed.
> 2. Cannot comment on whether the crystalloid
> resuscitation was excessive.
> 3. The CT scan did not show a blush, however my
> (experienced) orthopaedic
> colleague, who has an interest in pelvic trauma, was
> concerned because of
> his hypotension - and wondered about packing - I
> hadn't performed one
> before!). I did not think that there was substantive
> evidence of a bleed.
> 4. A rigid sigmoidoscopy was performed, pre-op and
> he had blood in the
> rectum.
> 5. Just curious, what is a 'VOMIT' as described by
> k?
> 
> Intra-op findings (antibiotics administered );
> 
> Gen Surg - low midline laparotomy - pristine
> abdominal cavity, some bruising
> at peritoneal reflection, paused.
> 
> Orthopaedic: complete diastasis as soon as the
> support was released, the
> pelvis 'sprung' open, instantly held together by
> orthopaedic 'tongs'. Brisk
> venous ooze, welling up, retro-peritoneum either
> side of bladder - tightly
> packed - haemsotatic plugs and gauze, exactly as
> described by Olav and
> yes, 'surprisingly easy' and very effective, even
> for a novice. Site of
> subcutaneous emphysema identified - copious lavage.
> 
> Gen Surg-  Sigmoid loop mobilised and brought to the
> surface, Abdomen
> closed. lithotomy position, stoma matured, distal
> sigmoid copious washout
> with bladder catheter (balloon inflated). Rigid
> sigmoidoscopy repeated -
> small 'rent' in anterior rectum, haemostatic plugs
> just about visible! No
> further attempt at repair.
> 
> Day 2, patient awake, stable, plan to revisit /
> review and remove pack
> tomorrow.
> 
> Criticism: Would an end stoma, mucous fistula be a
> better option  (complete
> defunctioning)?
> 
> Finally, impressed with the practicality and ease of
> packing, a worthy
> damage limitation technique.
> 
> Best Wishes,
> Saboor Khan
> Coventry
> UK
> --
> trauma-list : TRAUMA.ORG
> To change your settings or unsubscribe visit:
> http://www.trauma.org/index.php?/community/
> 
> > From: Sanjay Gupta MD <sanjaygupta99_91 at yahoo.com>
> Subject: RE: Pelvic fracture - operative findings
> Date: Mon, 29 Oct 2007 04:01:19 -0700 (PDT)
> To: "Trauma &amp, Critical Care mailing list"
> <trauma-list at trauma.org>
> 
> I would agree that a loop stoma can be a fully
> defunctionalized stoma.  I used to repair
> imperforate
> anus in infants and we used a diverting loop stoma
> proximally.  Almost never had a fecal spillage in
> the
> distal loop.  One trick that we used to do was to
> take
> a couple of stitches on each side of the common wall
> of the intestine to ensure that the posterior wall
> of
> the colostomy does not sag down into the abdomen
> over
> a period of several months. 
> 
> 
> Sanjay 
> 
> 
> 
> 
> --- "Hardcastle, Tim, Dr <tch at sun.ac.za>"
> <tch at sun.ac.za> wrote:
> 
> > Saboor
> > 
> > If done properly with a mature stoma above skin
> > opened longitudinally then the loop-stome IS full
> > defunctional. We have not used devided stoma for
> > rectal injury for many years - no major problems.
> > See the report in June 2007 WJS from the other
> Cape
> > Medical School (UCT).
> > 
> > Tim
> > Dr T C Hardcastle
> > M.B.,Ch.B.(Stell); M.Med(Chir); FCS(SA)
> > Senior Surgeon / Senior Lecturer: Surgery (Trauma
> > and ICU)
> > ATLS  instructor and DSTC Cape Town Course
> Director
> > Intern program Coordinator: Surgery
> > M.Med (Emergency Medicine) Executive Committee
> > member
> > Clinical Head (Director): Diana Princess of Wales
> > Trauma Unit
> > Division of Surgery (General) Room 4064
> > Department of Surgical Sciences
> > Tygerberg Hospital / University of Stellenbosch
> > PO Box 19063
> > Tygerberg 7505
> > Western Cape
> > South Africa
> > e-mail: tch at sun.ac.za
> > Cell: +27824681615
> > Office: +27219389281 or 4911 pager 0302
> > 
> > 
> > 
> > -----Original Message-----
> > From: trauma-list-bounces at trauma.org
> > [mailto:trauma-list-bounces at trauma.org]On Behalf
> Of
> > Saboor Khan
> > Sent: Sunday, October 28, 2007 5:52 PM
> > To: Trauma &amp, Critical Care mailing list
> > Subject: Pelvic fracture - operative findings
> > 
> > 
> > Thanks to those who replied: Just to mention a few
> > points:
> > 
> > 1. I agree, with such an injury a urethrogram
> should
> > have been performed.
> > 2. Cannot comment on whether the crystalloid
> > resuscitation was excessive.
> > 3. The CT scan did not show a blush, however my
> > (experienced) orthopaedic
> > colleague, who has an interest in pelvic trauma,
> was
> > concerned because of
> > his hypotension - and wondered about packing - I
> > hadn't performed one
> > before!). I did not think that there was
> substantive
> > evidence of a bleed.
> > 4. A rigid sigmoidoscopy was performed, pre-op and
> > he had blood in the
> > rectum.
> > 5. Just curious, what is a 'VOMIT' as described by
> > k?
> > 
> > Intra-op findings (antibiotics administered );
> > 
> > Gen Surg - low midline laparotomy - pristine
> > abdominal cavity, some bruising
> > at peritoneal reflection, paused.
> > 
> > Orthopaedic: complete diastasis as soon as the
> > support was released, the
> > pelvis 'sprung' open, instantly held together by
> > orthopaedic 'tongs'. Brisk
> > venous ooze, welling up, retro-peritoneum either
> > side of bladder - tightly
> > packed - haemsotatic plugs and gauze, exactly as
> > described by Olav and
> > yes, 'surprisingly easy' and very effective, even
> > for a novice. Site of
> > subcutaneous emphysema identified - copious
> lavage.
> > 
> > Gen Surg-  Sigmoid loop mobilised and brought to
> the
> > surface, Abdomen
> > closed. lithotomy position, stoma matured, distal
> > sigmoid copious washout
> > with bladder catheter (balloon inflated). Rigid
> > sigmoidoscopy repeated -
> > small 'rent' in anterior rectum, haemostatic plugs
> > just about visible! No
> > further attempt at repair.
> > 
> > Day 2, patient awake, stable, plan to revisit /
> > review and remove pack
> > tomorrow.
> > 
> > Criticism: Would an end stoma, mucous fistula be a
> > better option  (complete
> > defunctioning)?
> > 
> > Finally, impressed with the practicality and ease
> of
> > packing, a worthy
> > damage limitation technique.
> > 
> > Best Wishes,
> > Saboor Khan
> > Coventry
> > UK
> > --
> > trauma-list : TRAUMA.ORG
> > To change your settings or unsubscribe visit:
> > http://www.trauma.org/index.php?/community/
> > --
> > trauma-list : TRAUMA.ORG
> > To change your settings or unsubscribe visit:
> > http://www.trauma.org/index.php?/community/
> > 
> 
> 
> Sanjay Gupta MD
> Tel: 412 335 6304
> 
> __________________________________________________
> Do You Yahoo!?
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> 
> > --
> trauma-list : TRAUMA.ORG
> To change your settings or unsubscribe visit:
> http://www.trauma.org/index.php?/community/



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