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Hemorrhage in Pelvic Fractures…Where To Go

Hemorrhage in Pelvic Fractures…Where To Go. Dr. Dora Tai. Introduction. Introduction. Bleeding from Pelvic Fractures. Three bleeding sources: Arteries (10-15%) Low-pressure venous plexus (80-90%) Fractured cancellous bone surfaces.

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Hemorrhage in Pelvic Fractures…Where To Go

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  1. Hemorrhage in Pelvic Fractures…Where To Go Dr. Dora Tai

  2. Introduction

  3. Introduction

  4. Bleeding from Pelvic Fractures • Three bleeding sources: • Arteries (10-15%) • Low-pressure venous plexus (80-90%) • Fractured cancellous bone surfaces Giannoudis PV, Pape HC. Damage control orthopaedics in unstable pelvic ring injuries. Injury, Int. J.Care Injured 2004;35:671-677. Geeraerts T, Chhor V, Cheisson G, Martin L, Bessoud B, Ozanne A, Duranteau J. Clinical review : Initial management of blunt pelvic trauma patients with haemodynamic instability. Critical Care 2007; 11:204-212. White CE, Hsu JR, Holcomb JB. Haemodynamically unstable pelvic fractures. Injury, Int. J.Care Injured 2009; 40: 1023-1030.

  5. 1 2 3 ↓ clot dislodgement ↓ elimination of thrombotic process ↓ consumption of clotting factors Reduce pelvic volume ↓ ↓ blood loss promotes tamponade effect Return bony pelvic components back into apposition ↓ Haemostatic pathways to control venous bleeding External Pelvic Stabilization Miller PR, Moore PS, Mansell E, Meredith W, Chang MC. External fixation or arteriogram in bleeding pelvic fracture : Initial therapy guided by markers of haemorrhage. J Trauma 2003; 54(3):437-443. DiGiacomo JC, Bonadies JA, Cole FJ, Diebel L, Hoff WS, Holevar M, Malcynski J, Scalea T. Practice management guidelines for haemorrhage in pelvic fracture. Eastern Association for the Surgery of Trauma 2001; 1-15.

  6. Pelvic Binder Non-invasive, inexpensive Easy to apply Access to abdomen White CE, Hsu JR, Holcomb JB. Haemodynamically unstable pelvic fractures. Injury, Int. J.Care Injured 2009; 40: 1023-1030.

  7. External Fixator Mohanty K, Musso D, Powell JM, Kortbeek JB, Kirpatrick AW. Emergent management of pelvic ring injuries: An update. Can J Surg 2005; 48(1):49-55. DiGiacomo JC, Bonadies JA, Cole FJ, Diebel L, Hoff WS, Holevar M, Malcynski J, Scalea T. Practice management guidelines for haemorrhage in pelvic fracture. Eastern Association for the Surgery of Trauma 2001; 1-15.

  8. Posterior C clamp Mohanty K, Musso D, Powell JM, Kortbeek JB, Kirpatrick AW. Emergent management of pelvic ring injuries: An update. Can J Surg 2005; 48(1):49-55. DiGiacomo JC, Bonadies JA, Cole FJ, Diebel L, Hoff WS, Holevar M, Malcynski J, Scalea T. Practice management guidelines for haemorrhage in pelvic fracture. Eastern Association for the Surgery of Trauma 2001; 1-15.

  9. External Fixator • Indications: • If laparotomy or packing is needed for unstable pelvic fracture Heetveld MJ, Harris I, Schlaphoff G, Sugrue M. Guidelines for the management of haemodynamically unstable pelvic fracture patients. ANZ J.Surg 2004; 74: 520-529. Suzuki T, Smith WR, Moore EE. Pelvic packing or angiography : Competitive or complementary? Injury, Int. J.Care Injured 2009; 40: 343-353.

  10. Arterial Bleeding White CE, Hsu JR, Holcomb JB. Haemodynamically unstable pelvic fractures. Injury, Int. J.Care Injured 2009; 40: 1023-1030.

  11. Arterial Bleeding • Indicators of significant arterial bleeding: • Lack of response to initial resuscitation • Contrast material extravasation (blush) on CT scan • Sensitivity 80-84% • Specificity 85-98% Yoon W, Kim JK, Jeong YY, Seo JJ, Park JG, Keun HK. Pelvic arterial hemorrhage in patients with pelvic fractures : Detection with contrast-enhanced CT. RadioGraphics 2004;24:1591-1606. Miller PR, Moore PS, Mansell E, Meredith W, Chang MC. External fixation or arteriogram in bleeding pelvic fracture : Initial therapy guided by markers of haemorrhage. J Trauma 2003; 54(3):437-443.

  12. CT Scan Axial CT scan shows pelvic haematoma (white arrows) with extravasation of contrast medium (arrowhead).

  13. Angiography and Embolization Digital angiography of the left internal iliac artery with extravasation of contrast Geeraerts T, Chhor V, Cheisson G, Martin L, Bessoud B, Ozanne A, Duranteau J. Clinical review : Initial management of blunt pelvic trauma patients with haemodynamic instability. Critical Care 2007; 11:204-212. Heetveld MJ, Harris I, Schlaphoff G, Sugrue M. Guidelines for the management of haemodynamically unstable pelvic fracture patients. ANZ J.Surg 2004; 74: 520-529.

  14. Angiography and Embolization • Indications: • 1.Persistent haemodynamic instability • 2.Ongoing bleed despite pelvic packing • 3.Arterial extravasation of contrast Heetveld MJ, Harris I, Schlaphoff G, Sugrue M. Guidelines for the management of haemodynamically unstable pelvic fracture patients. ANZ J.Surg 2004; 74: 520-529. Balogh Z, Caldwell E, Heetveld M, Amours SD, Schlaphoff G, Harris I, Sugrue M. Institutional practice guidelines on management of pelvic fracture-related haemodynamic instability : Do they make a difference ? J Trauma 2005; 58:778-782. Suzuki T, Smith WR, Moore EE. Pelvic packing or angiography : Competitive or complementary? Injury, Int. J.Care Injured 2009; 40: 343-353.

  15. Pelvic Packing Preperitoneal space White CE, Hsu JR, Holcomb JB. Haemodynamically unstable pelvic fractures. Injury, Int. J.Care Injured 2009; 40: 1023-1030. Giannoudis PV, Pape HC. Damage control orthopaedics in unstable pelvic ring injuries. Injury, Int. J.Care Injured 2004;35:671-677. Gansslen A, Giannoudis P, Pape HC. Haemorrhage in pelvic fracture: Who needs angiography ? Curr Opin Crit Care 2003; 9:515-523.

  16. Pelvic Packing White CE, Hsu JR, Holcomb JB. Haemodynamically unstable pelvic fractures. Injury, Int. J.Care Injured 2009; 40: 1023-1030. Giannoudis PV, Pape HC. Damage control orthopaedics in unstable pelvic ring injuries. Injury, Int. J.Care Injured 2004;35:671-677. Gansslen A, Giannoudis P, Pape HC. Haemorrhage in pelvic fracture: Who needs angiography ? Curr Opin Crit Care 2003; 9:515-523.

  17. Pelvic Packing • Indications: • Ruptured pelvic haematoma at laparotomy (transperitoneal) • Unresponsive to embolization/initial resuscitation • No angiography facilities available Heetveld MJ, Harris I, Schlaphoff G, Sugrue M. Guidelines for the management of haemodynamically unstable pelvic fracture patients. ANZ J.Surg 2004; 74: 520-529. White CE, Hsu JR, Holcomb JB. Haemodynamically unstable pelvic fractures. Injury, Int. J.Care Injured 2009; 40: 1023-1030.

  18. CROSS-ROAD SITUATION: ANGIO or PACKING

  19. Comparison of Interventions Suzuki T, Smith WR, Moore EE. Pelvic packing or angiography : Competitive or complementary? Injury, Int. J.Care Injured 2009; 40: 343-353. Papakostidis C, Giannoudis PV. Pelvic ring injuries with haemodynamic instability : Efficacy of pelvic packing, a systematic review. Injury, Int. J.Care Injured 2009; 40S4: S53-S61.

  20. Time to intervention: PACKING group vs ANGIO group(45mins vs 130mins)(p=0.01) • Blood transfusionin the first 24 hours: ,less in the PACKING group • (6.9 unit vs 10.1 units ; p=0.01) • Mortality: PACKING group 4/20 vs ANGIO group 6/20 (p = 0.48)

  21. Early mortality rate: 10% (95% CI: 3−18%) Late mortality rate: 13% (95% CI: 5−22%) Overall mortality: 28% (95% CI: 16.8−39.4%) Increase in SBP after EPP (p=0.002) Mortality : 28%

  22. QEH Data

  23. QEH Protocol 2004-2008 Pelvic Fracture Hypotension Wrap Pelvis with Sheet/Binder FAST Scan/ Diagnostic Peritoneal Lavage Grossly Positive Grossly Negative Laparotomy + External Fixation Sustained Response to Initial Resuscitation? No Yes Stable Angiography + Embolization Amenable to External Fixation Yes No Yes No ICU Angiography + Embolization External Fixation ICU+CT

  24. QEH Protocol 2008-2009 Pelvic Fracture Shock Wrap Pelvis with Sheet/Binder FAST Scan/ Diagnostic Peritoneal Lavage Grossly Positive Grossly Negative Sustained Response to Initial Resuscitation? Pelvic Fixation Pelvic Packing Laparotomy Yes No Stable External Fixation Pelvic Packing No Yes ICU +/- CT scan Angiography Unstable or Ongoing Bleeding ICU Yes No Angiography ICU

  25. Retrospective Review for Unstable Pelvic Fractures • Study period : June 2007- End of 2009 • Number of patients: 24 • Aim: To compare the mortality rate between the 2 protocols • Previous protocol : (Angiogram +/- Embolization) Feb 2004 – June 08 • Current protocol : (Packing +/- Angiogram +/- Embolization) Jun 08 onward

  26. Retrospective Review for Unstable Pelvic Fractures • Male : Female 15:9 • Age: mean 47.7yrs, median 45yrs, range:18-84yrs • Mechanism of injury: Blunt trauma • Road traffic accident: 13 • Fell from height: 11 • Trauma score (Median / Mean) : ISS 41.2/ 43 • Overall mortality : 58.3% (14/24)

  27. QEH Data

  28. The Golden Hour…every second counts!

  29. Acknowledgements • Dr. Li Wing Hong • Dr. Lee Kin Bong • Dr. Lee Kin Yan • Dr. Tang Lap Fai • Dr. Ho Hiu Fai • Ms Annice Chang

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