How to Handle Early Pelvic Fractures

European guide lines have been published and since it is the first of its kind, I have presented them here:

Anaesth Crit Care Pain Med. 2018 Dec 20. pii: S2352-5568(18)30567-8.
doi: 10.1016/j.accpm.2018.12.003. [Epub ahead of print]
EARLY MANAGEMENT OF SEVERE PELVIC INJURY (FIRST 24 HOURS).
Incagnoli P et al.
https://www.ncbi.nlm.nih.gov/pubmed/30579941

1) A spontaneous pelvic pain must be assessed  in conscious trauma patients  in order to diagnose a  pelvic fracture. We recommend all trauma patients with shock or altered consciousness be  systematically considered as having pelvic trauma ,

2) We suggest the open pelvic injury , associated major injury or major bleeding , be considered at risk  of  severe  pelvic trauma .

3)  We recommend external pelvic compression  be  applied as  soon  as possible in all patients with  suspected severe pelvic trauma We suggest that pelvic binders , regardless of type (except sheet wrapping) , be  used  to apply  external pelvic compression. In order to be efficient  (compared to surgical C – clamp compression), pelvic  binders must be placed around the great trochanters.

4) Al l patients with severe pelvic trauma  could  be initially transported to a referral centre fully staffed  and equipped to treat any aspect of trauma (“trauma centre”) .

5) We suggest getting a pelvic X – ray upon arrival to the trauma centre  for patients who are  haemodynamically unstable patients and/or require urgent intervention(s) to stabilise vital signs . We do not suggest a pelvic X – ray upon arrival to the trauma centre  for haemodynamically stable  patients . A  body (including pelvic) CT – scan with intravenous contrast should be performed .

6) We suggest a n  E – FAST (Extended Focus Assessment with Sonography for Trauma)  be  performed  in all  patients with suspected severe trauma including patients  with suspected severe pelvic trauma.

7) We recommend performing a thoraco – abdomino – pelvic CT – scan with contrast before angiographic  embolization in patients with severe pelvic trauma when allowed by the patient ’s haemodynamic  status . [ie finding other trauma sites]

8)  We do not suggest  systematically  performing specific imaging workup for lower urinary tract injury  (urethral and/or bladder opacification) in severe pelvic trauma patients. We suggest performing a retrograde urethral and bladder  opacification , ideally with  a  CT – scan in  severe pelvic trauma patients with clinical symptoms of lower urinary tract injury (inability to urinate,  gross  haematuria , blood at the meatus, suprapubic tenderness and suprapubic penetrating wounds),  particularly before attempting urinary catheterization in men .

9) According to the  Young – Burgess or  Tile  classifications , unstable pelvic fracture,  particularly « open  book  » fractures and pelvic ring disruptions with posterior fractures or  active extravasation of contrast agent during the arterial phase of the CT – scan or angiography , should  probably  be considered at radio – anatomical criteria of severe pelvic trauma .

10)   We recommend bleeding control procedures  be performed  as soon as possible in actively  bleeding severe pelvic trauma. In the setting of severe pelvic trauma, bleeding control procedures may  be angiographic embolization or surgical pelvic pre – peritoneal packing by a  trained proficient team .  We recommend that the time between admission to the hospital and  bleeding control  procedures, regardless of type , should  not  exceed 60 minutes.

11)   We  recommend that a non – selective embolization through the common femoral artery  be  performed  in unstable  patients, stable patients who present multiple active bleeding targets on CT – scan  and/or when attempted selective embolization fails .

12)  We suggest not performing a secondary systematic angiographic verification in severe pelvic  trauma patients having undergone initial angiographic  embolization .

13) We suggest performing a surgical pre – peritoneal pelvic packing in association with an external  fixation in the case of haemodynamic instability when impossible to:

– Transfer the patient to the CT – scan or/and for embolization

– Perform an embolization in less than 60minutes once the diagnosis has been made.

14)  We recommend performing a n early external fixation of the pelvis in patients with a severe pelvic  trauma with haemodynamic instability to limit the expansion of the pelvic haematoma. External  fixation can be  performed by a Ganz clamp or an anterior pelvic external fixator.
We  recommend using the Ganz clamp for Tile C fractures essentially, after a heavy traction of the  ascended lower limb (15% of the patient’s weight). Trained operators can set it up in the emergency  room .
We recommend using an external fixator for pelvic stabilisation of Tile C  fractures and to reduce  the ring disruption in Tile B1 and B3 fractures. It must be placed anteriorly and inferiorly in order to be  able to  perform a  laparotomy

15)   We suggest taking care of severe open pelvic trauma in referral centres because open pelvic  lesions are rare, their management is complex and demands a multidisciplinary approach . We recommend considering t he bleeding control and the perineal contamination  as primary  objectives in the management of severe open pelvic trauma.

 

Comment – some is highly technical but give a good overview of what should be done…

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