Update on the Early Management of the Fractured PelvisUpdate on the Early Management of Update on the Early Management of the Fractured Pelvisthe Fractured Pelvis

Robert C. Mackersie, M.D.,FACSDepartment of SurgerySan Francisco General Hospital

Robert C. Mackersie, M.D.,FACSRobert C. Mackersie, M.D.,FACSDepartment of SurgeryDepartment of SurgerySan Francisco General HospitalSan Francisco General Hospital

Critical Care Medicine & Trauma 2009Critical Care Medicine & Trauma 2009Critical Care Medicine & Trauma 2009

> 90% will have other injuriesindex for intraabdominal injury (9-

11%)index for bladder injury (4-6%)index for renal injury (1-2%)index for urethral injury (2-3%)other: TBI, chest, aorta

> 90% will have other injuries> 90% will have other injuriesindex for intraabdominal injury (9index for intraabdominal injury (9--

11%)11%)

index for bladder injury (4index for bladder injury (4--6%)6%)index for renal injury (1index for renal injury (1--2%)2%)

index for urethral injury (2index for urethral injury (2--3%)3%)

other: TBI, chest, aorta other: TBI, chest, aorta

Why this is such a problem:Why this is such a problem:Why this is such a problem:

ITIT’’S THE S THE BLEEDINGBLEEDING……. . STUPID!!STUPID!!

arterialarterialvenous venous bonebone

OPEN FX. OPEN FX. (recto(recto--vagvag. . injinj))COMPLEX COMPLEX FRACTURES FRACTURES ((orthoortho) )

Why this is such a problem II:Why this is such a problem II:Why this is such a problem II:

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single break unstable crush

complicationsARDSdeath

Will immediate external compression be necessary? Does patient require immediate assessment

of abdomen & possible laparotomy?Will patient require pelvic A/G for diagnosis &

control of hemorrhage?Will the patient need pelvic ex-fix & when?Routing: OR? CT? A/G? ICU? (particularly

tough w/ combined injuries)

Will immediate external compression be Will immediate external compression be necessary? necessary? Does patient require immediate assessment Does patient require immediate assessment

of abdomen & possible of abdomen & possible laparotomylaparotomy??Will patient require pelvic A/G for diagnosis & Will patient require pelvic A/G for diagnosis &

control of hemorrhage?control of hemorrhage?Will the patient need pelvic exWill the patient need pelvic ex--fix & when?fix & when?Routing: OR? CT? A/G? ICU? (particularly Routing: OR? CT? A/G? ICU? (particularly

tough w/ combined injuries)tough w/ combined injuries)

Critical Decisions:Critical Decisions:Critical Decisions:

Recognition of risk: Recognition of risk: Recognition of risk:

deformitysuprapubic, scrotal, perineal

hematomasopen fracture bleeding“pelvic rock” unreliable & potentially

dangerous !plain radiographs

shock, obtundation, (+) physical exam, hematuria

deformitydeformitysuprapubicsuprapubic, scrotal, , scrotal, perinealperineal

hematomashematomasopen fracture bleedingopen fracture bleeding““pelvic rockpelvic rock”” unreliable & potentially unreliable & potentially

dangerous !dangerous !plain radiographsplain radiographs

shock, shock, obtundationobtundation, (+) physical exam, , (+) physical exam, hematuriahematuria

Recognition of risk: Recognition of risk: Recognition of risk:

Hemodynamics (VS, base deficit)Transfusion requirementsED cystogramPelvic radiographs

Pelvic fracture typeNumber of fracture sitesPosterior element involvementDegree of displacement of hemipelvisOVERALL PREDICTIVE POWER IS POOR

HemodynamicsHemodynamics (VS, base deficit)(VS, base deficit)Transfusion requirementsTransfusion requirementsED ED cystogramcystogramPelvic radiographsPelvic radiographs

Pelvic fracture typePelvic fracture typeNumber of fracture sitesNumber of fracture sitesPosterior element involvementPosterior element involvementDegree of displacement of Degree of displacement of hemipelvishemipelvisOVERALL PREDICTIVE POWER IS POOROVERALL PREDICTIVE POWER IS POOR

Airway control (intubation)Airway control (intubation)Airway control (intubation)

Low threshold for intubationshock, transfusion requirementselderly

associated chest injuriesassociated CNS injurymost patients requiring external

compression (belts, MAST, etc.)

Low threshold for intubationLow threshold for intubationshock, transfusion requirementsshock, transfusion requirements

elderlyelderly

associated chest injuriesassociated chest injuries

associated CNS injuryassociated CNS injurymost patients requiring external most patients requiring external

compression (belts, MAST, etc.)compression (belts, MAST, etc.)

central venous pressure, arterial linesthermistor foley or core temperature monitorserial arterial base deficitIntraabdominal compartment syndr.ICP & coags where approp. Role of the anesthesiology service!!

central venous pressure, arterial linescentral venous pressure, arterial linesthermistorthermistor foleyfoley or core temperature or core temperature monitormonitorserial arterial base deficitserial arterial base deficitIntraabdominal compartment Intraabdominal compartment syndrsyndr..ICP & ICP & coagscoags where where appropapprop. . Role of the anesthesiology service!! Role of the anesthesiology service!!

Monitoring for major pelvic fx.Monitoring for major pelvic Monitoring for major pelvic fxfx..

ProtocolProtocol--drivendrivenAirway controlAirway controlAbdAbd evaluationevaluationGood monitoringGood monitoringUninterrupted supply Uninterrupted supply of blood/products of blood/products Hypothermia prevent.Hypothermia prevent.AnesthesiologistsAnesthesiologistsThe The angioangio suite = ORsuite = OR

‘Vortex’ Control: warm & out of shock‘‘VortexVortex’’ Control: warm & out of shockControl: warm & out of shock

MASSIVE TRANSFUSION PROTOCOLMASSIVE TRANSFUSION PROTOCOLActivated by surgeon / anesthesiologistActivated by surgeon / anesthesiologistMTP coordinatorMTP coordinator44--6FFP:46FFP:4--8u 8u PRBCsPRBCs available at all timesavailable at all timesPlatelets to stay > 50 x 109/ l.Platelets to stay > 50 x 109/ l.‘‘HemostaticHemostatic’’ resuscitation: (tailored to case)resuscitation: (tailored to case)

1:1:1 (FFP, PRBC, non1:1:1 (FFP, PRBC, non--apheresisapheresis platelets)platelets)cryocryo for fibrinogen < 100 mg% after FFPfor fibrinogen < 100 mg% after FFP

(LAPAROTOMY first - PRN for abd injPro-coagulants (MTP, PCC, rFVIIa…)External compression (MAST, belts)Pelvic packing – selected patientsARTERIOGRAPHY (dx. & rx.)PELVIC FIXATION

(LAPAROTOMY (LAPAROTOMY firstfirst -- PRN for PRN for abdabd injinj

ProPro--coagulants (MTP, PCC, coagulants (MTP, PCC, rFVIIarFVIIa……))

External compression (MAST, belts)External compression (MAST, belts)

Pelvic packing Pelvic packing –– selected patientsselected patients

ARTERIOGRAPHY (ARTERIOGRAPHY (dxdx. & rx.). & rx.)

PELVIC FIXATIONPELVIC FIXATION

Pelvic fracture hemorrhage control: Pelvic fracture hemorrhage control:

Pro-coagulantsProPro--coagulantscoagulants

blood components, MTPPro-thrombin complex concentrate

(PCC) rFVIIaother agents

DDAVP aprotoninanti-fibrinolytic agents

blood components, MTPblood components, MTPProPro--thrombin complex concentrate thrombin complex concentrate

(PCC) (PCC) rFVIIarFVIIaother agentsother agents

DDAVP DDAVP aprotoninaprotoninantianti--fibrinolyticfibrinolytic agentsagents

Pelvic compression (sheets, belts)

Pelvic compression Pelvic compression (sheets, belts)(sheets, belts)

Very simply & rapidly appliedRe-conforms displaced pelvisMay help tamponadehemorrhageMuch less respiratory or constrictive problemsAllows arterial accesslimited data available…

Very simply & rapidly Very simply & rapidly appliedappliedReRe--conforms displaced conforms displaced pelvispelvisMay help May help tamponadetamponadehemorrhagehemorrhageMuch less respiratory or Much less respiratory or constrictive problemsconstrictive problemsAllows arterial accessAllows arterial accesslimited data availablelimited data available……

External circumferential pelvic compression

External circumferential pelvic External circumferential pelvic compressioncompression

Will NOT definitively control major arterial hemorrhage! No good controlled reports of comparative efficacyTakes time – not good

with severe injuriesMay displace posterior

injuries & worsen bleedGiving way to formal pelvic ORIF

Will NOT definitively Will NOT definitively control major arterial control major arterial hemorrhage! hemorrhage! No good controlled No good controlled reports of comparative reports of comparative efficacyefficacyTakes time Takes time –– not good not good

with severe injurieswith severe injuriesMay displace posterior May displace posterior

injuries & worsen bleedinjuries & worsen bleedGiving way to formal Giving way to formal pelvic ORIFpelvic ORIF

Pelvic (anterior) external fixation: Pelvic (anterior) external fixation:

Clinical use of pelvic bindersKrieg et.al. al. J. Trauma 2005

Clinical use of pelvic bindersClinical use of pelvic bindersKrieg Krieg et.alet.al. al. J. Trauma 2005. al. J. Trauma 2005

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initial binder ORIF binder ORIF0

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external rotation

fx.

external external rotation rotation

fxfx..internal

rotation fx.

internal internal rotation rotation

fxfx..

Emergent Pelvic Fixation with Exsanguinating Pelvic FracturesCroce et. al. JACS 2007

Emergent Pelvic Fixation with Emergent Pelvic Fixation with ExsanguinatingExsanguinating Pelvic FracturesPelvic FracturesCroce et. al. JACS 2007Croce et. al. JACS 2007

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Resus tx 24 hr Tx 48 hr Tx mortality

Ex FixBinder

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Ex FixBinder

Pelvic A/G, embolizationPelvic A/G, Pelvic A/G, embolizationembolization

CT useful to ID patients likely to benefitdefinitive rx. for arterial

hemorrhageeffective in 87 - 99% of

casesmay fail w/ coag, PVD,

severe shockrepeat embolization may

be requiredcomplications = ischemia,

impotence, emboli, arterial injury

CT useful to ID patients CT useful to ID patients likely to benefitlikely to benefitdefinitive rx. for arterial definitive rx. for arterial

hemorrhagehemorrhageeffective in 87 effective in 87 -- 99% of 99% of

casescasesmay fail w/ may fail w/ coagcoag, PVD, , PVD,

severe shocksevere shockrepeat embolization may repeat embolization may

be requiredbe requiredcomplications = ischemia, complications = ischemia,

impotence, emboli, arterial impotence, emboli, arterial injuryinjury

Ertel et.al. J. Ortho. Trauma 2001: 14 patients in severe shock or in extremis underwent lap + pelvic packing. 5/14 developed IACS. 33.2 U transfusion / first 12 hrs. NO A/G, EMBOLIZATION. Mortality 25%

Lap + pelvic packing to control venous & arterial hemorrhage

For dx/rx of other intraabdominal injuries & large vessel injuries

ErtelErtel et.alet.al. J. Ortho. Trauma 2001: . J. Ortho. Trauma 2001: 14 patients in 14 patients in severe shock or in extremis underwent lap + pelvic severe shock or in extremis underwent lap + pelvic packing. 5/14 developed IACS. 33.2 U transfusion / first packing. 5/14 developed IACS. 33.2 U transfusion / first 12 hrs. NO A/G, EMBOLIZATION. Mortality 25% 12 hrs. NO A/G, EMBOLIZATION. Mortality 25%

Lap + pelvic packing to control venous & arterial hemorrhageLap + pelvic packing to control venous & arterial hemorrhage

For For dx/rxdx/rx of other of other intraabdominalintraabdominal injuries & large vessel injuriesinjuries & large vessel injuries

Reports of pelvic packing for hemorrhage controlReports of pelvic packing for hemorrhage controlReports of pelvic packing for hemorrhage control

Totterman et.al. J. Trauma 2007: 18 patients with retroperitoneal pelvic packing. Time from injury to ED arrival = 98 minutes! Mean total transfusion requirement = 59 U, with ave. of 12 U prior to packing & 17 U in 24 hrs following packing.

15 patients had A/G, embolization following packing with 80% positive for arterial injury.

Mortality overall = 28% 1 death from ongoing pelvic hemorrhage, contributory in 4/5 non-survivors

Used for patients “who would not otherwise survive transferal to the angio suite.”

TottermanTotterman et.alet.al. J. Trauma 2007: . J. Trauma 2007: 18 patients with 18 patients with retroperitoneal pelvic packing. Time from injury to ED retroperitoneal pelvic packing. Time from injury to ED arrival = 98 minutes! Mean total transfusion arrival = 98 minutes! Mean total transfusion requirement = 59 U, with requirement = 59 U, with aveave. of 12 U prior to packing & . of 12 U prior to packing & 17 U in 24 hrs following packing. 17 U in 24 hrs following packing.

15 patients had A/G, 15 patients had A/G, embolizationembolization following packing following packing with 80% positive for arterial injury.with 80% positive for arterial injury.

Mortality overall = 28% 1 death from ongoing pelvic Mortality overall = 28% 1 death from ongoing pelvic hemorrhage, contributory in 4/5 nonhemorrhage, contributory in 4/5 non--survivorssurvivors

Used for patients Used for patients ““who would not otherwise survive who would not otherwise survive transferal to the transferal to the angioangio suite.suite.””

Totterman et.al. J Trauma 2007TottermanTotterman et.alet.al. J Trauma 2007. J Trauma 2007

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techniquetechnique

Pelvic EP packingPelvic EP packing

Needed: Protocol driven approachNeeded: Protocol driven approachNeeded: Protocol driven approach

Immediate I.D. of ‘at-risk’ patientsAirway controlEarly reduction of pelvic displacement‘Vortex’ control & tight physiological

management blood & productsprevent hypothermiamonitoring for adequacy of resuscitation

Early management of abdominal injuryControl of pelvic fracture hemorrhage

Immediate I.D. of Immediate I.D. of ‘‘atat--riskrisk’’ patientspatientsAirway controlAirway controlEarly reduction of pelvic displacementEarly reduction of pelvic displacement‘‘VortexVortex’’ control & tight physiological control & tight physiological

management management blood & productsblood & productsprevent hypothermiaprevent hypothermiamonitoring for adequacy of resuscitationmonitoring for adequacy of resuscitation

Early management of abdominal injuryEarly management of abdominal injuryControl of pelvic fracture hemorrhageControl of pelvic fracture hemorrhage

Clinical pathway for unstable pelvic fracturesBiffl et. al. Ann. Surg 2001

Clinical pathway for unstable pelvic fracturesClinical pathway for unstable pelvic fracturesBifflBiffl et. al. Ann. et. al. Ann. SurgSurg 20012001

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Clinical pathway for unstable pelvic fracturesBalogh. al. J. Trauma 2005

Clinical pathway for unstable pelvic fracturesClinical pathway for unstable pelvic fracturesBaloghBalogh. al. J. Trauma 2005. al. J. Trauma 2005

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Stabilizes(C)

Abdominal /Pelvic CT

Pelvis fracture (A)

Resuscitate, AP XRay, FAST or DPA (B)

Pelvic binder (G)

OR for exploration(+/- external fixator)

(L)Preperitoneal Packing (M )

Angiography / Embolization

(H)Unstable

CT +OR for viscous injuryOperate for ongoing bleeding

Pelvic blush (E) ICUFinish evaluation, Resuscitation(D)

OR/ExplorationPreperitoneal Packing (K)

ConsiderRepeat Angiography (J)

ICU, finish evaluation (I)

CT -

Angiography / Embolization

(F)

WTA protocol

(JW Davis MD)

WTA WTA protocol protocol

(JW Davis MD)(JW Davis MD)

SFGH algorithmOn-line.

SFGH algorithmSFGH algorithmOnOn--line. line.

Protocolized Management ProtocolizedProtocolized Management Management

Protocols (PMGs) reduce undesirable practice variabilityProtocols also have the potential for limiting better-

than-average practice variabilityOne size does not fit all – careful analysis of

stratifying factors is essentialPMGs must be tailored to institutional expertise &

resourcesPMG must involve careful assessment of stratification

factors (physiological, demographic, resources, etc.) in order to promote “good” decisionsInstitutional PMGs should be constantly re-analyzed

& modified based on ongoing case experience

Protocols (Protocols (PMGsPMGs) reduce undesirable practice ) reduce undesirable practice variabilityvariabilityProtocols also have the potential for limiting betterProtocols also have the potential for limiting better--

thanthan--average practice variabilityaverage practice variabilityOne size does not fit all One size does not fit all –– careful analysis of careful analysis of

stratifying factors is essentialstratifying factors is essentialPMGsPMGs mustmust be tailored to institutional expertise & be tailored to institutional expertise &

resourcesresourcesPMG must involve careful assessment of stratificationPMG must involve careful assessment of stratification

factors (physiological, demographic, resources, etc.) factors (physiological, demographic, resources, etc.) in order to promote in order to promote ““goodgood”” decisionsdecisionsInstitutional Institutional PMGsPMGs should be constantly reshould be constantly re--analyzed analyzed

& modified based on ongoing case experience & modified based on ongoing case experience

Pelvic fx: Top ten points…Pelvic Pelvic fxfx: Top ten points: Top ten points……

1) It's the bleeding, stupid!! (and don’t forget abd injury)2) Avoid the vortex: warming, monitoring & massive transfusion protocols3) Old boy scout (girl scout) trick: pressure stop bleeding (binder, packing)4) Watch out for the elderly (physiologic fragility, pelvic space compliance)5) The CT scanner is (mostly) your friend (screening for angio)6) Anesthesia is definitely your friend (cooperative management)7) Embolization - more is not always better 8) The benefits of skeletal alignment (ex-fix)9) Beware of occult problems: (rectal, vaginal, GU complications )

10) Know where you're going: Protocol-driven approach

1) It's the bleeding, stupid!! (and don1) It's the bleeding, stupid!! (and don’’t forget t forget abdabd injury)injury)

2) Avoid the vortex: warming, monitoring & massive transfusion p2) Avoid the vortex: warming, monitoring & massive transfusion protocolsrotocols

3) Old boy scout (girl scout) trick: pressure stop bleeding (bin3) Old boy scout (girl scout) trick: pressure stop bleeding (binder, packing)der, packing)

4) Watch out for the elderly (physiologic fragility, pelvic spac4) Watch out for the elderly (physiologic fragility, pelvic space compliance)e compliance)

5) The CT scanner is (mostly) your friend (screening for 5) The CT scanner is (mostly) your friend (screening for angioangio))

6) Anesthesia is definitely your friend (cooperative management)6) Anesthesia is definitely your friend (cooperative management)

7) 7) EmbolizationEmbolization -- more is not always better more is not always better 8) The benefits of skeletal alignment (ex8) The benefits of skeletal alignment (ex--fix)fix)

9) Beware of occult problems: (rectal, vaginal, GU complications9) Beware of occult problems: (rectal, vaginal, GU complications ))

10) Know where you're going: Protocol10) Know where you're going: Protocol--driven approach driven approach

Current Management of Pelvic FracturesCurrent Management of Current Management of Pelvic FracturesPelvic Fractures

Robert C. Mackersie, M.D.,FACSDepartment of SurgerySan Francisco General Hospital

Robert C. Mackersie, M.D.,FACSRobert C. Mackersie, M.D.,FACSDepartment of SurgeryDepartment of SurgerySan Francisco General HospitalSan Francisco General Hospital

Critical Care Medicine & Trauma 2009Critical Care Medicine & Trauma 2009Critical Care Medicine & Trauma 2009