Presacral venous plexus bleeding in patients with pelvic fractures
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1. The document discusses presacral venous plexus bleeding in patients with pelvic fractures and various methods to stop the bleeding. 2. Techniques used to stop bleeding include pelvic packing, use of sterile metallic thumbtacks, cauterization, suturing, and ligating bleeding vessels. 3. Damage control resuscitation principles are also described, including permissive hypotension, blood product transfusion in a 1:1:1 ratio, and rewarming.
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Presacral venous plexus bleeding in patients with pelvic fractures
- 1. 1 Presacral venous plexus bleeding in patients with pelvic fractures. Bleeding stoppage methods. Darja Ivanova Faculty of Medicine, IV November 22, 2016
- 2. 2 The sacrum and innominate bones along with many ligamentous complexes, comprise the pelvis. Fractures and ligamentous disruptions of the pelvis suggest that major forces were applied to the patient. (1) auto-pedestrian crashes motor vehicle crashes motorcycle crashes a fall from a height greater than 3.6 meters (1)
- 3. 3 Disruption of the pelvic ring tears the pelvic venous plexus and occasionally disrupts the internal iliac arterial system. (2)
- 4. 4 1. AP compression, 2. lateral compression, 3. vertical shear, 4. complex (combination) pattern (2) Patterns of force leading to pelvic fractures
- 5. 5 Patients with hemorrhagic shock and unstable pelvic fractures have four potential sources of blood loss: 1.fractured bone surfaces, 2.pelvic venous plexus, 3.pelvic arterial injury, 4.extrapelvic sources. (1)
- 7. 7 Damage control management in the polytrauma patient
- 8. 8 Damage Control Part 0: Rapid Transport to Definitive Care Damage Control Part 1: Rapid Control of Hemorrhage and Contamination Damage Control Part 2: Resuscitation Damage Control Part 3: Return for Completion of Operative Repairs Damage Control Part 4: Definitive Abdominal Closure (4) Damage control
- 9. 9 1. Early decision making » hypotension » elevated lactate and/or base deficit 1. Triad of death 2. Associated injuries 3. Predicted or present abdominal compartment syndrome 4. Planned reoperation (4) Indications
- 10. 10 1. Hypothermia T < 34°C, (4) 100% mortality T <32.8°C (3) Duchesne JC, McSwain NE Jr, Cotton BA, et al. Damage control resuscitation: the new face of damage control. J Trauma- Inj Infect Crit Care. 2010;69(4):976–90 2. Coagulopathy »decreased circulating concentration »dysfunction of various components of the clotting mechanism – activation of protein C, – depletion of I, II, V, VII, VIII, IX and X clotting factors 3. Acidosis pH < 7.2 (or base excess greater than 8 in a patient with a corrected pH due to hyperventilation) (4) Triad of death
- 11. 11 1. Early decision making 2. Triad of death 3. Associated injuries 4. Predicted or present abdominal compartment syndrome (ACS) 5. Planned reoperation (4) Indications
- 12. 12 The main components include: Permissive hypotension and restrictive fluid administration Haemostatic resuscitation Rewarming Correction of acidosis Arrest of haemorrhage by surgical and non- surgical techniques (3) Damage control resuscitation (DCR)
- 13. 13 pelvic binders application of compressive dressings to actively bleeding wounds the use of tourniquets in more severe injuries temporary aortic balloon catheter tamponade tranexamic acid (TXA) surgical haemorrhage control »selective embolisation of bleeding vessels and organs »stent grafting »temporary intravascular shunts (3) Early haemorrhage control
- 14. 14
- 15. 15
- 16. 16 Data published in the period between 1 January 1960 and 31 July 2013 (7)
- 17. 17
- 18. 18 The common international protocol ATLS (Advanced Trauma Life Support) » ABCDE - A - airway maintanence, - B - breathing and ventilation, - C - circulation and hemorrhage control, - D - disability-Neuro, - E - exposure/environment control (8)
- 19. 19 2L of crystalloid packed red blood cells (PRBC) and fresh frozen plasma (FFP) 1:1 and platelets 1:1:1 haemoglobin and/or haematocrit base deficits and lactate levels trauma-induced coagulopathy may be present in 25% of patients crystalloid use is limited »transfusion of platelets to keep count above 100,000/ mL (8)
- 20. 20 internal rotation of the legs stabilisation of pelvic ring injuries the pelvic C-clamp (8) http://khourychiropractic.com.au/uncategorized/hips-dont-lie/ https://www.researchgate.net/figure/7386583_fig2_FIG-2-A-Circumferential-pelvic- antishock-sheeting-is-applied-in-this-example-patient https://www.depuysynthes.com/hcp/trauma/products/qs/pelvic-c-clamp-1
- 21. 21 pneumatic pressure using Military antishock trousers (MAST) http://www.fire-city.kurume.fukuoka.jp/fire/dousuru/kyukyutai1.html vacuum mattress http://unikon.lv/lv/produkti/vakuuma_matracis_res_q_matt(8)
- 22. 22 Bleeding stoppage techniques during operation Electric cautery Suture ligation Selective embolization Sterile metallic or titanium thumbtacks, occluder pin Pelvic packing (roller gauze) http://www.scielo.mec.pt/scielo.php? script=sci_arttext&pid=S1646-69182013000300004 http://hemoccluderpin.com/hemorrhage-occluder-pin/ http://img.diytrade.com/smimg/2177743/4030941 6-4021433-0/Electrocautery_Pen/8a25.jpg
- 23. 23
- 24. 24 Male, 57 years old Adenocarcinoma of the rectum the bleeding site was identified on the anterior surface of the sacrum pressed with finger Electric cautery, suture ligation Hemostatic agents Left three large laparotomy laps packed in pelvis
- 25. 25 4h »2000ml Er concentrate »500ml plasma »6000ml crystalloids and colloids Transferred to ICU 48h removed the packs ICU discharged 7 days after the second operation
- 26. 26
- 27. 27 Female, 46 years old the presacral venous plexus was bleeding profusely diathermy and compression packing ligated the right internal iliac artery, the left internal iliac artery, the left internal iliac vein 5 sterilized thumbtacks at the bleeding point around the sacral plexus region along with compression packing with gauges packed the pelvic cavity with roller gauges bounded together in knots and brought out to the skin was discharged successfully
- 28. 28 Conventional hemostatic procedures, such as tamponing, suturing, and cauterization, sometimes do not resolve but just perpetuate the hemorrhage. Traditional methods for stopping bleeding include pelvic packing and the use of sterile metallic or titanium thumbtacks. Packing has the disadvantage of reoperation for removing the packs and risk of re- bleeding. Situation in Latvia? Discussion
- 29. 29 Thank you!
- 30. 30 1. Advanced Trauma Life Support Student Course Manual 8th edition, 2008 2. Advanced Trauma Life Support Student Course Manual 9th edition, 2012 3. Damage control resuscitation: lessons learned M. Giannoudi, P. Harwood, 2016 4. Damage Control Management in the Polytrauma Patient. Hans-Christoph Pape, Andrew B. Peitzman, C. William Schwab, Peter V. Giannoudis 5. Атлас анатомии человека. В 4 томах. Том 3. ст. 149-150. Р.Д. Синельников, Я.Р. Синельников, А.Я. Синельников. Москва, Новая волна, издатель Умеренков, 2012 6. Anatomy of the Sacral Venous Plexus, Robert M. Zeitt and Constantin Cop, 1982 7. Surgical management of presacral bleeding. V Celentano, JR Ausobsky, P Vowden Bradford Teaching Hospitals NHS Foundation Trust, UK, 2014 8. Emergency Treatment for Clinically Unstable Patients with Pelvic Fracture and Haemorrhage, Roman Pavi and Petra Margeti, 2012 References
Editor's Notes
- There are four patterns of force leading to pelvic fractures: AP compression, lateral compression, vertical shear, and complex (combination) pattern. An AP compression injury can be caused by an auto-pedestrian collision or motorcycle crash, a direct crushing injury to the pelvis, or a fall from a height greater than 3.6 meters. With disruption of the symphysis pubis, there often is tearing of the posterior osseous ligamentous complex, represented by a sacroiliac fracture and/or dislocation or sacral fracture. With opening of the pelvic ring, there can be hemorrhage from the posterior pelvic venous complex and, occasionally, branches of the internal iliac artery. Lateral compression injuries often result from motor vehicle crashes and lead to internal rotation of the involved hemipelvis. The pelvic volume is actually compressed in such an injury, so life-threatening hemorrhage is not common. A high-energy shear force applied in a vertical plane across the anterior and posterior aspects of the ring disrupts the sacrospinous and sacrotuberous ligaments and leads to major pelvic instability. This commonly results from a fall. (2) And there also can be hemorrhage from the posterior pelvic venous complex.
- Indications for damage control. 1. Early decision making: hypotension in transport or in the trauma resuscitation area, elevated lactate and/or base deficit.
- Hypothermia is common among polytrauma patients, especially those with haemorrhagic shock. The causes are multiple but include physical exposure to the environment both at the scene and in hospital, intoxication, circulatory changes and administration of cold fluids. Severe hypothermia is associated with a high mortality. Prognosis is directly related to the degree of hypothermia, with 100 % mortality having been observed in patients who present with core body temperatures under 32.8° . Hypothermia causes and exacerbates bleeding abnormalities through multiple mechanisms. Moderate hypothermia (32–34 °C), directly reduces coagulation factor activity by approximately 10 % for each degree fall in temperature, whilst also inhibiting platelet aggregation. Acute traumatic coagulopathy is a process recognised to occur early following the tissue trauma and shock resulting from severe injury. In polytrauma patients it has been associated with increased bleeding morbidity, higher transfusion requirements, increased risk of organ dysfunction, longer critical care stays and increased overall mortality. Coagulopathy of trauma arises from decreased circulating concentration, and dysfunction of, various components of the clotting mechanism. Hypovolaemic shock, reduced protein C levels and protein C activation have been observed in acute trauma. The coagulaopathy seen in acute trauma is driven by the activation of protein C and is associated with the depletion of many clotting factors including: I, II, V, VII, VIII, IX and X. Inadequate or inappropriate circulation in trauma patients results from blood loss, tissue damage and vascular injury. This results in the generation of toxic metabolites, anaerobic metabolism and lactic acidosis. Homeostatic mechanisms carefully maintain a narrow pH range and as the patient deteriorates may become impaired themselves, exacerbating such problems. The degree of acidosis and lactate levels on admission have been shown to predict mortality in the trauma patient.
- The World Society of Abdominal Compartment Syndrome (WSACS) definition of ACS: the presence of IAH (Intra-abdominal hypertension) accompanied by organ dysfunction(s) such as cardiac, respiratory, and renal dysfunction. ACS is referred to as “secondary” when there are no conditions originating from the abdomino-pelvic region
- Damage control resuscitation (DCR) forms part of an overall approach to patient care rather than a specific intervention and has evolved from damage control surgery. It is characterised by early blood product administration and haemorrhage control with restoration of blood volume and physiologic stability. This approach should be initiated at first contact with the patient in the prehospital environment and continue through their initial reception and treatment until haemorrhage is arrested and physiology corrected. The main components of DCR include:
- Simple interventions that reduce bleeding before definitive care is available should form part of trauma care resuscitative protocols. Examples of this include the use of pelvic binders, application of compressive dressings to actively bleeding wounds and the use of tourniquets in more severe injuries where this is not effective. These measures should be taken as soon as possible, increasingly in the pre-hospital setting. Temporary aortic balloon catheter tamponade is seeing a resurgence in use. This can be used as a temporising measure in patients with catastrophic abdominal, pelvic and lower limb haemorrhage. Whilst there are significant potential complications and consequences, when simple interventions fail or are not possible, this provides a valid alternative. tranexamic acid (TXA) Surgical haemorrhage control is still regarded as the gold standard for the majority of patients. Endovascular management by interventional radiology allows selective embolisation of bleeding vessels and organs and stent grafting of major and peripheral vessel injuries without many of the specific risks of open procedures. Temporary intravascular shunts can be life and limb saving by bridging damaged vessels and maintaining blood flow, hence reducing acute haemorrhage and critical warm ischaemia times of distal organs and limbs.
- Tranexamic acid is an antifibrinolytic and inhibits fibrinolysis by blocking the lysine-binding sites on plasminogen. Tranexamic acid works to stabilize and inhibit the degradation of existing clots. Tranexamic acid has been prospectively proven to reduce mortality in trauma-related hemorrhage. Its use will likely expand into such areas as resuscitation and massive transfusion protocols and the prehospital setting.
- Anticoagulation. Normally, a fibrin clot will form at the site of endothelial damage after activation of the extrinsic pathway. In trauma-related coagulopathy, hypoperfusion prompts the endothelium to express thrombomodulin (TM). This complexes with thrombin, changing its function from procoagulant to anticoagulant as it is no longer available to form a fibrin clot. In addition, activated protein C (aPC) inhibits the extrinsic pathway through Factor V and Factor VIII. TXA functions by blocking the lysine-binding sites on plasminogen and hence inhibiting fibrinolysis, resulting in inhibition of clot degradation. The CRASH-2 trial, showed that the use of TXA could reduce mortality rates associated with exsanguinating haemorrhage by 15 % with few complications. To have such an effect it must be given within 3 h of injury as an immediate intravenous dose of one gram followed by a further 1 g infusion over 8 h. It therefore should form part of early resuscitative protocols.
- The common international protocol ATLS (Advanced Trauma Life Support) is standard in most emergency settings. It teaches the acronym ABCDE concept for polytrauma patient care.
- Patients with haemodinamic instability due to haemorrhage should be initially resuscitated with 2 L of crystalloid followed by packed red blood cells (PRBC) and fresh frozen plasma (FFP) in a 1:1 ratio and platelets ideally in a 1:1:1 (pack) ratio. If the patients’ systolic blood pressure remains less than 90 mmHg despite PRBC transfusion, the patient is considered as a »non-responder«, and requires more advanced treatment. Haemoglobin and/or haematocrit levels measured within minutes of patient arrival in the trauma bay may be a reliable marker of ongoing haemorrhage and need for massive transfusion. High base deficits and lactate levels have correlated with mortality in pelvic trauma and those with base deficits of 5 mmol/L on arrival were more likely to die. Improvement in base deficit and blood lactate signals amelioration of oxygen debt and reversal of the shock state. Trauma-induced coagulopathy may be present in 25% of patients. Crystalloid use is then significantly limited and should serve mainly as a carrier to keep lines open between blood products. Early transfusion of platelets as six packs to keep platelet counts above 100,000/ mL during massive transfusion appears to provide a survival advantage
- The simplest method to reduce the volume of an unstable pelvis is internal rotation of the legs. However, medical caregivers must also avoid the external rotation of the legs which increases the pelvic volume. Reduction of venous bleeding by stabilisation of pelvic ring injuries is most expeditiously accomplished with a longitudinally folded bed sheet wrapped circumferentially around the pelvis, placed between the iliac crests and greater trochanters, and secured anteriorly by clamping or with simple commercially available devices. Rapid reduction and posterior stabilisation can be performed with the pelvic C-clamp, which consists of two pins applied to the ilium in the region of the sacroiliac joints. It may be applied in the emergency department, but it is preferable to place the device in the operating room under fluoroscopic control. They can provide prompt stabilisation of the posterior pelvic ring and can be effective in case of complete disruption of the posterior ring, and because the clamp can be rotated cephalad and caudad, access to the abdomen and perineum is not limited. The C-clamp can be applied for a haemodinamically unstable patient status based on an AP pelvic X–ray. However, it is not applicable in iliac fractures and transiliac fracture dislocations.
- Pelvic packing was developed as a direct haemostasis to control haemorrhage due to pelvic fractures during the 1960s. It is important to remember that stabilisation of the pelvis must precede pelvic packing. This technique facilitates control of retroperitoneal bleeding through a small incision which does not violate the intraperitoneal space and leaves the peritoneum intact. First a simple external fixator or C-clamp is placed to stabilize the ring of packing then using an 8-cm midline incision of the lower abdomen, direct access to the bleeding retroperitoneal space is possible and then presacral area and paravesicle space is packed with surgical lap packs usually 3 per side. The key is packing of the true pelvis, below the pelvic brim and not the false pelvis, above pelvic brim. Packing above the pelvic brim has minimal tamponade effect since the major venous bleeding occurs in the plexi of vessels located in the true pelvis. Direct compression and immobilisation of the pelvic ring and lower extremity can be achieved via pneumatic pressure using Military antishock trousers (MAST). The use of MAST was advocated in 1970s and 1980s to induce pelvic tamponade and increase venous return. But the device is also associated with inherent complications, such as lower extremity ischemia/reperfusion, development of compartment syndrome, and skin necrosis. For most prehospital care systems it is a history, but nowadays we have vacuum mattress. Consisting of a sealed air-tight (typically polymer bag) enclosing small beads and fitted with one or more valves while at ambient air pressure the beads free to move, but when moulded and air evacuated external atmospheric pressure locks the beads in place the mattress becomes rigid.
- Pelvic packing was developed as a direct haemostasis to control haemorrhage due to pelvic fractures during the 1960s. It is important to remember that stabilisation of the pelvis must precede pelvic packing. This technique facilitates control of retroperitoneal bleeding through a small incision which does not violate the intraperitoneal space and leaves the peritoneum intact. First a simple external fixator or C-clamp is placed to stabilize the ring of packing then using an 8-cm midline incision of the lower abdomen, direct access to the bleeding retroperitoneal space is possible and then presacral area and paravesicle space is packed with surgical lap packs usually 3 per side. The key is packing of the true pelvis, below the pelvic brim and not the false pelvis, above pelvic brim. Packing above the pelvic brim has minimal tamponade effect since the major venous bleeding occurs in the plexi of vessels located in the true pelvis.
- A male patient 57 years old, was admitted to the hospital with an adenocarcinoma of the rectum located 7cm within the anal verge. The abdominal cavity was entered through a midline incision. After the ligation of the inferior mesenteric vessels and the division of the proximal colon, a severe hemorrhage occurred during posterior rectal mobilization. By maintaining continuous suction, the bleeding site was identified on the anterior surface of the sacrum and pressed with finger. Electric cautery and suture ligation failed to control bleeding. The bleeding was temporarily arrested by finger compression, and in order to gain better view, the surgeon quickly completed the resection of the rectum. Application of topical hemostatic agents also failed to stop bleeding.Because of the continuing bleeding and the poor general state of the patient three large laparotomy laps were left packed in the pelvis, covering the sacral vessels under pressure.
- During the 4h operation, the patient received 2000ml of erythrocyte concentrate, 500ml of plasma and 6000ml of crystalloids and colloids. After the operation the patient was transferred to the intensive care unit, where controlled breathing was continued and his circulation was aided by infusion of catecholamines. After 48 hours, relaparotomy was performed to remove the packs. There was no evidence of re-bleeding and the surgeon completed operation. After the end of the operation the patient was again returned to the intensive care unit and the patient was discharged 7 days after the second operation.
- A 46-year-old Malay lady with Recurrent Ovarian Cancer. During the mobilization of the tumour, the presacral venous plexus was bleeding profusely. Haemostasis was difficult despite the diathermy and compression packing. The decision was made to ligate the right internal iliac artery and the left internal iliac artery. The left internal iliac vein was ligated as well due to iatrogenic injury during mobilization. Haemostasis was still not achieved. They applied 5x sterilized thumbtacks at the bleeding point around the sacral plexus region along with compression packing with gauges and bleeding slowed down significantly. Before closure, the pelvic cavity was packed with roller gauges bounded together in knots and brought out to the skin. They were removed slowly from postoperative day 6 onwards with the removal of one to two gauges per day depending of the patient tolerant to the removal. The removal was facilitated by intravenous fentanyl administration and also topical anaesthetic at the site of the incision. All the gauges were removed on day 8.