Anesthesia

1. Literature review for
Anaesthetic management in
Pelvic fracture
Dr Htet Aung Htun
PG3(Anaesthesia)
UM(1)
PACU of Modular OT

2. Contents
• Trauma guideline for associated pelvic fracture
• Guideline for management of massive blood loss due to trauma

3. Trauma guideline for associated pelvic
fracture

4. Trauma guideline for pelvic fracture
The pelvic cavity is the area surrounded by
• pelvic bones
• containing the lower part of the retroperitoneal and intraperitoneal
spaces
• contains the rectum, bladder, iliac vessels, and female internal
reproductive organs
• Significant blood loss can occur from injuries to organs within the
pelvis and/or directly from the bony pelvis.

5. Trauma guideline for pelvic fracture
Pelvic Fractures and Associated Injuries-
• hypotension and pelvic fractures have high mortality
• Pelvic fractures asso; with hemorrhage
• disruption of the posterior osseous ligamentous complex (i.e.,
sacroiliac, sacrospinous, sacrotuberous, and fibromuscular pelvic
floor)

6. Trauma guideline for pelvic fracture
Mechanism of Injury
• motor vehicle crash, motorcycle crash, pedestrian–vehicle collision,
direct crushing injury, or fall
Classification (Young and Burgess classification of pelvic #)
• Pelvic fractures are classified into four types, based on injury force
patterns: AP compression, lateral compression, vertical shear, and
combined mechanism

7. Trauma guideline for pelvic fracture
Associated with
• motorcycle or a head-on motor vehicle crash
• external rotation of the hemipelvis with separation
of the symphysis pubis and tearing of the posterior
ligamentous complex.
• pelvic ring widens
• tearing the posterior venous plexus and branches of
the internal iliac arterial system.
• Hemorrhage can be severe and life threatening.
AP compression (Type A)

8. Trauma guideline for pelvic fracture
Associated with
• Force directed laterally into the pelvis
• most common mechanism of pelvic fracture in a motor
vehicle collision.
• Hemipelvis rotates internally (reducing pelvic volume and
tension on the pelvic vascular structures)
• This internal rotation may drive the pubis into the lower
genitourinary system, potentially causing injury to the
bladder and/or urethra.
• Hemorrhage rarely result
• Frail and elderly patients may bleed significantly following
minor trauma from lateral compression fractures.
Lateral compression (Type B)

9. Trauma guideline for pelvic fracture
Associated with
• Vertical displacement of the sacroiliac joint
• disrupt the iliac vasculature and cause severe
hemorrhage
• In this mechanism, a high-energy shear force occurs
along a vertical plane across the anterior and
posterior aspects of the ring.
• disrupts the sacrospinous and sacrotuberous
ligaments and leads to major pelvic instability
Vertical displacement (Type C)

10. Trauma guideline for pelvic fracture
Immediate management
• Log rolling the patient should be avoided ( haemodynamically unstable due
to compression and distraction of fracture pelvic)
• Placement of pelvic binder, which reduces the potential space within the
pelvic
• An injury is identified, a pelvic binder is removed & repeat a pelvic X-ray.
• Haemorrhage control can be achieved by:
• Pelvic external fixation—will clamp both sides of the pelvis together,
reducing pelvic volume and tamponading bleeding. This will take precedence
over laparotomy in an open book or vertical shear fracture.

11. Trauma guideline for pelvic fracture
• Pelvic packing to manage venous bleeding
• Selective angiography and embolisation to manage arterial bleeding.
• A single gentle attempt at catheterisation by an experienced doctor is
permissible, even if the CT findings suggest urethral injury.
• Multiple surgical teams may be operating at once in pelvic injuries

12. Trauma guideline for pelvic fracture
Rapid hemorrhage control (mechanical stabilization of the pelvic ring
and external counter pressure)
Pelvic Stabilization.
A. Pelvic binder. B. Pelvic stabilization using a sheet.

13. Trauma guideline for pelvic fracture
Pelvic Fractures and Hemorrhagic Shock Management Algorithm (ATLS
student manual 10th Edition,2021)

14. Guideline for management of massive blood
loss due to trauma

15. Guideline for management of massive
blood loss due to trauma
Hemorrhagic shock is a condition of
reduced tissue perfusion, resulting in
the adequate delivery of oxygen and
nutrients that are necessary for cellular
function
• Hemorrhage is an acute loss of
circulating blood volume.
• normal adult blood volume is
approximately 7% of body weight,
approximately 5 L
Massive blood loss is defined as the
• loss of one blood volume within 24
hrs
• Loss of 50% of blood volume within
3 hrs
• Rate of loss of blood > 150 ml/mins

16. Guideline for management of massive
blood loss due to trauma
Classification of hemorrhage

17. Guideline for management of massive
blood loss due to trauma
Interpretation of response to initial fluid resuscitation. Reproduced by kind permission of the
American College of Surgeons Committee on Trauma. Modified from Advanced Trauma Life
Support for Doctors, Student Manual, 10th Edition,2021.

18. Guideline for management of massive
blood loss due to trauma

19. Guideline for management of massive
blood loss due to trauma

20. Guideline for management of massive
blood loss due to trauma

21. Guideline for management of massive
blood loss due to trauma

22. Guideline for management of massive
blood loss due to trauma