Pelvic Trauma

1. Pelvic Trauma College of Emergency Medicine Southampton 29th March 2011 Dr Gareth Davies Consultant in EM & PHC Medical Director London’s Air Ambulance

2. Aims • Review epidemiology • Review types / classification of pelvic fracture & its importance • Review various treatment modalities • Which are most pertinent to the ED clinician • Importance of patient handling • Review an example algorithm for ED management • Review a diagnostic dilemma

3. Epidemiology • Rare in context of all trauma • < 5% of ED fractures • Causes • Car RTA’s 50% • Pedestrian 20% • Motorcycle 10% • Falls 10% • Crush 5% • Misc 5%

4. Epidemiology • Disease associated with other injuries • 50% have head 50 % long bone • May have conflicting management strategies • Significant mortality rate 15 - 50% • Hypotension assd with higher mortality

5. Classifications • Tile, Toronto • Complex • Based on stability of post segment • ? benefit to ED clinician • Young and Burgess, Baltimore • Mechanism-based classification: Antero-posterior (AP) compression Lateral compression Vertical shear

6. AP Compression Fractures

9. Lateral Compression Fractures

12. Vertical shear fractures

14. In anyone patient multiple types Windswept pelvis

15. Importance of classification ? For ED physician debatable All can be unstable All can produce catastrophic bleeding Focus for ED - controlling bleeding

17. Pelvic Haemorrhage • Hyper acute • Road side • Acute • ED • Theatre • Angio • Subacute • ITU

18. Where does blood go? Retroperitoneal Intraperitoneal External

19. Retroperitoneal haematoma • Large volume - litres • Not picked up by FAST

20. Intraperitoneal bleeding • It’s a dilemma • Remember surgery is trauma • Positive FAST =/= theatre • Depending on clinical picture go to CT to assess intra-abdominal injuries • Move to angio • Caution mesenteric vessel bleed

21. Bleeding from the pelvis • Venous bleeding – around 90% • Sacral venous plexus • Arterial bleeding – around 10% • Branches of internal iliac artery • Bleeding from disrupted bones • Vertical shear > open book > lateral compression

22. Treatment Strategies External / Internal Fixation Pelvic packaging Angiography Patient handling Binders Blood pressure control Coagulation control Temperature control

23. Relationship between patient movement , handling and bleeding

24. Moving patient like this associated with a fall in BP

25. ATLS “springing” of the pelvis Produced falls in BP

26. In resus characteristic times when BP fell Log rolling packaging for scanner spinal examination

27. ? “Not an issue just top them up with some gelo”!!??

28. Moving patients was not good

33. Case study

34. 150 degrees of motion

35. Dislodgement of clot Loss of tamponade Movement at Sacro iliac joint Fall in blood pressure Net effect

36. 150o 90o 90o At hospital On Spinal Board 90o 90o RSI On Spinal Board Total = 330o Grand Total = 510o

37. Could things be better?

38. Roll onto half a scoop blade when ready to RSI

39. 150o 10o 10o On scoop Counter traction Left blade out Right blade out RSI Left blade in Right blade in At hospital Total = 170o 0o Total = 170o

40. Board and early roll 510 degrees 70% reduction in movement Scoop and delayed roll 170 degrees

41. Handling of pelvic fractures Should be based on patient need Recognises the whole of the patient pathway Not what suits individual practitioners Remember first clots are the best

42. Clinical Strategy Promote clots Promote clot stability

43. What do most trauma patients arrive on in your department? 50% RTA

44. Preferred Handling Device For Poly Trauma Patients? JRCALC - Scoop

45. Other treatment modalities…..

46. Binders

47. 1970’s

50. Geneva Belt