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Pelvic Fracture managemnt- Case based discussion .pptx
The document outlines the assessment and management of pelvic fractures in emergency medicine, detailing essential aspects like epidemiology, classifications, and treatment protocols. It includes a case study of a 39-year-old male with a pelvic fracture from a motorcycle accident, emphasizing the importance of initial assessment and potential complications. The document also discusses surgical approaches and considerations for managing associated injuries and complications.
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Pelvic Fracture managemnt- Case based discussion .pptx
- 1. Pelvic fractures Dr KTDPriyadarshani Registrar in Emergency Medicine National Hospital-Kandy 2024/01/17
- 2. Objectives • Initial assessmentand management • Epidemiology • Anatomy • Classifications • Management • Complications
- 3. Case • Age -39 Years old male • Timing - at 5 pm • Mechanism – MB rider collided with a lorry • Injury • Perineal laceration, unstable pelvis, externally rotated LL • Blood at the meatus • Signs – SPO2 100% on oxygen 10L/min, BP 80/50 mmHg, HR 130/min, GCS 15/15, Agitated • Treatment received – Fluid resuscitation up-to 6L of NS at LH
- 4. Epidemiology • Men in40s • Diversity in associated visceral and soft-tissue injuries • Mortality – • All type of pelvic fractures – 5-30% • Closed pelvic fracture and hypotension - 10-42% • Open pelvic fracture – 50%
- 5. Important considerations • Highenergy mechanisms, such as: • Motor vehicle crashes • Collisions with pedestrians • Falls from height • Major hemorrhage, which can be difficult to control • Other associated injuries • Intra-abdominal organs (28%), including aortic injury • Hollow viscus injury (13%) • Genitourinary injury • Rectal injury (up to 5%)
- 6. Initial assessment • ATLSapproach • Receive the patient • AT MIST • Triage • Activate trauma call • Trauma surgeons, • Orthopedic surgeons, • interventional radiologists or vascular surgeons, • anesthetist, • Blood bank, • theatre staff.
- 7. Primary survey • Airwaywith C-spine immobilization • Jaw thrust • Manual in-line stabilization • Breathing • Assess RR, auscultate, SPO2 • NRBM oxygen with 10-15 l/min • Circulation • PR, BP, CRFT • Supra diaphragmatic intravenous (IV) access. • Blood for FBC, Gr & DT – 4-8 Units, PT/INR, APTT, VBG, S.Ca, fibrinogen and ROTEM • Activate massive transfusion protocol+ IV tranexemic • Hemostatic resuscitation • Permissive hypotension – Target SBP 90mmHg, MAP 50 mmHg • Analgesia
- 9. Rapid hemorrhage control •Look for obvious bleeding • The floor (external hemorrhage), and four more, chest, abdomen, pelvis, and long bones. • Mechanical stabilization of the pelvic ring and external counter pressure. • Internal rotation of the lower limbs • Pelvic binder • REBOA with real-time fluoroscopy or under USS guidance • HD unstable - zone III of the aorta, or just above the aortic bifurcation
- 10. Major site ofhemorrhage •Surfaces of fractured bones •Pelvic venous plexus – 90% •Pelvic arterial injury – 10% •Extra-pelvic sources (present in 30% of pelvic fractures) •Bleeding into the retroperitonal space upto 5L.
- 11. Pelvic binder •Apply atthe level of the greater trochanters of the femur. •Tie the patient’s ankles together. • Pelvic splints • Improvise - Bed sheet, Kocher clamps, towel clips • Sam splint • T-pod •Caution • Should be applied before intubation • Exclude lateral compression pattern • Skin breakdown and ulceration in 24 hour
- 12. Following resuscitation • A-talking, rational • B- RR 36, SPO2 100% on RA • C- PR 127, BP 124/80 • D – GCS 15/15
- 13. • Primary surveyadjuncts • AP pelvis XR • EFAST • Disability • GCS / AVPU • Pupils • Exposure • Skin and soft tissue injury - open injury, Ecchymosis • Palpate on bony fragments, echchymisis, tenderness • Urethral injury- ecchymosis or hematoma of the scrotum or perineum, blood at urethral meatus, gross hematuria • Log roll – DRE, spine tenderness • DRE- sphincter tone, prostrate, palpable fracture, blood • VE- fractures, mucosal integrity, blood
- 14. Secondary Survey • Headto toe secondary survey & adjuncts • Head injury – NCCT brain with C-spine • Abdomen – Distention, tenderness • LL – length discrepancy, Malrotation • Distal neuro vascular status
- 15.
- 16. Injuries • Open bookpelvic fracture • APC III - Anterior symphyseal widening ≥ 25 mm, disruption of anterior and posterior SI, sacrospinous, and sacrotuberous ligaments & vertical fracture of pubic rami • R/ Neck of the femur fracture • R/ Acetabular fracture • Open wound - Perineal laceration
- 17. Anatomy • Pelvic ring– No inherent stability • Anterior stability - Symphysis pubis • Posterior stability - anterior and posterior sacroiliac ligaments • Pelvic Floor - sacrospinous and sacrotuberous ligaments The pelvis is a ring structure; thus, the identification of a single fracture should raise suspicions for a second fracture.
- 18. Classification • Young-Burgess classification •More useful in the ED as it is based on mechanism of injury. • Mechanisms • Lateral compression • Anterior-posterior compression • Vertical shear • Combined mechanical injury
- 20. Classification • Tile classification •Based on pelvic stability and useful for guiding pelvic reconstruction. • Type A, Rotationally and vertically stable • Type B, rotationally unstable, vertically stable • Type C, rotationally and vertically unstable
- 22. eFAST • Free fluid •Hepato renal pouch • Perisplenic space • Pelvis • Liver and kidney normal
- 23. Rule of DPA •Rule out a false negative FAST scan in a hemodynamically unstable patient • Performed above the umbilicus in patients with suspected pelvic fractures to avoid aspirating a pelvic hematoma • A positive result is the aspiration of 10 mL of frank blood or GI contents
- 24. Further management • Damagecontrol surgery • External fixation • Anterior EF approach – APC & LC • C-Clamp - VS • Extra-peritoneal packing - Adjunct • Direct pre-peritoneal approach to pelvis – Allows access to the retroperitoneal space • Angiographic embolization – adjunct • Transcatheter arterial embolization
- 25. • If patienthemodynamically stable • Arrange CT abdomen and pelvis with IV contrast • 30% of posterior injuries can be missed on plain radiographs. • Soft tissue may be evaluated to detect hematoma formation, active arterial bleeding • Rule out intra-abdominal and retroperitoneal injury • Characterize the type and severity of pelvic injury • Angiography • Identify arterial injury and to guide embolization
- 26.
- 27. Findings • Evidence ofbowel perforation • Retroperitoneal hematoma • Linear splenic laceration • Extra-peritoneal bladder rupture • Unstable pelvic fracture • No evidence of pelvic vessel injury with active bleeding
- 28. Supportive care • Analgesia •Broad spectrum antibiotics • IV Cefuroxime • IV Metronidazole • Tetanus prophylaxis • Skin traction – 3Kg
- 29. Associated Injuries &management • Should evaluated under anaesthesia in OR • Rectal injury – 5% • Intestinal injury - up to 5% • Require faecal Diversion colostomy • Pre-sacral drainage and perineal debridement • Bladder and urethral injury (5-20%) • Bladder: intra- and/or extraperitoneal • Cystoscopy • Extra – Catheter drainage • Urethral injury – Posterior urethra • Retrograde urethrogram
- 30. Neurologic injury 10-15% •Lumbosacralplexus L1-S4 • lateral femoral cutaneous nerve (L2-3) •Obturator nerve (L2-4) •Femoral nerve (L2-4) •Sciaticnerve(L4-S3) – decompression of nerve roots
- 31. Complications Acute Late • Majorhemorrhage and shock • Visceral and soft tissue injury • Nerve injury • Fat embolization • Acute respiratory distress syndrome • Venous thromboembolism • Abdominal compartment syndrome • Fracture complications • Incontinence • sexual dysfunction
- 32. Disposition • Operating theatre •Interventional radiology suite • Intensive care unit
- 33. Definitive Management • Surgicalfixation • Stabilise disrupted ring • Early mobilisation • Prevent deformity • Minimize long term disability • Gold standard- open method • Percutaneous methods are evolving
- 34. Anaesthetic considerations • Preop assessment- multidisciplinary team • IV access, positioning is affected by other injuries • Urological injuries- catheterisation, chest drains, EVD • Blood- 4-6U DT, intraoperative cell salvage • Metabolic derangements- coagulopathy, electrolyte imbalance • Critical care after surgery • Multimodal analgsia • Thromboprophylaxis- mechanical- ASAP, Chemical- HD stable and clotting parameters stabilised
- 35. References 1. AAOS3.pdf 2. ATLS10th Edition Student Manual.pdf 3. RCEM-Trauma-ibook.pdf 4. https://litfl.com/pelvic-trauma/ 5. https://www.bjaed.org/article/S2058-5349(18)30050- 7/fulltext
- 36.
Editor's Notes
- #10 Resuscitative endovascular balloon occlusion of aorta