Trauma– Pelvic Fractures
Jay B. Baker, MD
Learning Objectives
• Understand pathology of pelvic fractures
• Assess and work up trauma patients for
pelvic fracture
• Treat the unstable pelvis
• Disposition pelvic fractures appropriately
Introduction
• Pelvic fractures are one of the few “talk
and die” cases that can totally ruin your
day
• Associated with other severe injuries
• Intraperitoneal– liver, spleen
• Retroperitoneal– bladder, urethral
• Vascular injuries including aortic rupture1
• Thus hypotension may be from a source
other than the pelvis in blunt trauma
Sources of Blood Loss
• Unstable pelvic fractures with
hemorrhagic shock have four potential
sources of blood loss–
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Fractured bone surfaces
Pelvic venous plexus
Pelvic arterial injury
Up to 30% extrapelvic sources—chest,
abdomen, multiple extremity, external1
Classification
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Originally designed to predict bleeding risk, but not
sensitive or specific enough3
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AP compression– “Open book”
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Lateral compression
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Usually from “side on” trauma
Pelvic volume is compressed so life-threatening hemorrhage
may be less likely
60-70%
Vertical shear  major pelvis instability
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Usually from “head on” trauma
Frequency is 15-20%
Jumpers or “head on” MVC
5-15% 1
Combinations may occur, associated with major bleeding.
AP compression– Open book
Lateral compression
Vertical Shear
Assessment
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Leg-length discrepancy or rotational deformity without
fracture suggests unstable pelvis fracture
Motion may be detected by grasping iliac crests and pushing
inward, then outward (aka compression-distraction
maneuver)
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Inspect flank, scrotum, and perianal area for bleeding
including urethral meatus
Inspect for lacerations in perineum, vagina, rectum, or
buttocks for open pelvic fractures
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Weingart recommends compression only4
Once pelvic instability is demonstrated, no further maneuvers
are necessary
May defer vaginal speculum exam to OR
Palpate for high-riding prostate gland in males
Initial Imaging
• AP xray of pelvis confirms clinical exam
• FAST is specific for intra-abdominal injury
but not for retroperitoneal bleeding
• If positive, patient goes to OR for laparotomy
• If negative, patient needs CT abd/pelvis
• Some surgeons might perform supraumbilical DPA to rule out intra-abdominal
bleeding
• Not infra- to avoid possible pelvic hematoma
CT Abdomen and Pelvis
• Obtain CTAP in hemodynamically stable
patient with clinical suspicion of intraabdominal injury
• Defer retrograde urethrogram (RUG) in
severe pelvic trauma
• Assessment for life-threatening injuries takes
precedence
• IV contrast for RUG may interfere with
interpretation of pelvic angiogram or CTAP5
Management
• Splint unstable pelvis fractures with
simple techniques
• Goal– Decrease pelvic volume prior to
transfer and during resuscitation
• Wrap a 12” sheet around the greater
trochanters and tighten down6
• Commercially available pelvic splints
• Other pelvis stabilizing devices e.g. ex-fix
are not preferred due to time-intensive
Applying the Pelvic Splint
Sample algorithm
• Surgical consult
• Pelvic splint
• Evaluate for intraperitoneal gross blood
• If (+), then dispo patient to the OR for
laparotomy
• If (-), then dispo to angiography1
• NB: Angioembolization may be performed
concurrently with laparotomy
Controversy
• Some centers perform pre-peritoneal
packing first7
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May be performed simultaneously with
laparotomy if necessary
A lot quicker when your surgeons are in house
and your IR is still driving into the hospital
• Some centers reserve angioembolization for
non-coagulopathic patients who continue to
bleed from a pelvic source despite preperitoneal packing
Summary
• Unstable pelvic fractures can bleed to
death as a solo injury or in association
with other severe injuries
• Unstable pelvic fractures must be splinted
immediately
• Unstable pelvic fractures require prompt
surgical management and may require
angioembolization by interventional
radiology
References
1.
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6.
7.
Fildes J et al. Advanced Trauma Life Support Student Course Manual (8th
edition), American College of Surgeons 2008.
Nickson, Chris, “Trauma! Pelvic Fractures I.” Weblog entry. Life in the
Fast Lane.com. April 23, 2012.
http://lifeinthefastlane.com/2012/04/trauma-tribulation-027/
Cullinane DC et al. Eastern Association for the Surgery of Trauma practice
management guidelines for hemorrhage in pelvic fracture- update and
systematic review. J Trauma 2011 Dec;71(6):1850-68.
Weingart, Scott, “Severe Pelvic Trauma.” Weblog entry. EMCrit blog: A
discussion of the practice of ED critical care. April 30, 2012.
http://emcrit.org/podcasts/severe-pelvic-trauma/
Runyon MS. Blunt genitourinary trauma. In: UpToDate, Walls RM,
Bachur RG (Ed), UpToDate, Waltham, MA, 2012.
McGonigal, Michael, “Compression Of The Fractured Pelvis With A
Sheet.” Weblog entry. The Trauma Professional’s Blog.
http://regionstraumapro.com/post/9038627564
Burlew CC, Moore EE. Definitive management of severe pelvic fractures
in adults. In: UpToDate, Frankel, HL (Ed), UpToDate, Waltham, MA, 2011.
Simulation Training Assessment
Tool– Unstable Pelvic Fracture
Jay B. Baker, MD
Simulation Training Assessment Tool (STAT)– Unstable Pelvic Fracture
SCENARIO ALGORITHM
SET UP
• In situ—ED resuscitation bay
• Sim Man 3G w/ C collar & backboard
• VS control by dedicated tech
PRE ARRIVAL
• 27 yo female w/ CC: back & pelvis pain s/p
thrown from horse
• HR 90, BP 115/70, RR 22, SPO2 98%, GCS
15
• Transient hypotension en route, resolved
with NS 500 cc
ARRIVAL
• Pt in full spinal precautions
• 18g x1 @ LUE
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PRIMARY SURVEY
A- Patent, speaking
B- BS = bilat, RR 22
C- HR 120, BP 90/40
D- GCS 15
E- Superficial abrasions
SECONDARY SURVEY
C spine- C collar, nontender C spine
Abdomen– TTP at LUQ
Pelvis—Unstable with lateral compression
(distraction contraindicated)
Rectal—+gross blood
GU—Perineal bruising, vaginal deferred
Date:
Instructor(s):
Learner(s):
Learning Objectives:
1. Recognize and treat pelvic fracture with hemodynamic instability
2. Recognize intraabdominal bleeding with EFAST and treat with PRBCs
3. Consult Trauma Surgery & Interventional Radiology for disposition
CRITICAL ACTIONS
ME
NI
SUSTAIN
1° survey– recognize & treat
potential hemodynamic instability
FAST—recognize peritoneal fluid
and begin IVF resuscitation
2° survey– recognize pelvic
fracture, rectal for gross blood
Apply pelvic binder– 12” wide
sheet at greater trochanters
Reassess VS frequently
BP falls to 80/50
Transfuse w/ O(-) PRBCs, T&C
4-8 units
Initial orders including portable
pelvis xray
Foley contraindicated, RUG
deferred until after CT
BP rises to 110/70 with PRBC transfusion
LABS & IMAGES
• FAST positive at Morrison’s pouch
• H/H 8/24
• Pelvic xray– Open book fx
DISPOSITION
• To OR with trauma team, IR called in for
angio (they will take at least 30 mins)
Dispo to OR for intraabdominal
injury, consult IR for angio
Effective team leadership,
communication and synergy
TOTAL
ME = Meets Expectations; NI = Needs Improvement
IMPROVE
Synopsis
• This case assesses the learner’s management of an unstable
pelvic fracture with hemoperitoneum from likely intraabdominal
injury.
• The setting is the ED resuscitation bay. The patient has a CC of
back and pelvis pain after she was thrown from a horse and
couldn’t walk due to pain. Her vitals are stable en route despite a
brief SBP 85 that improved after NS 500. When the learners
enter the room, they see Sim Man on a backboard and C collar
w/o a monitor. The team leader (TL) must begin the 1° survey
immediately and find patient is conscious, in pain, tachycardic,
and mildly hypotensive. The TL must order fluid resuscitation and
proceed to 2° survey while a team member performs the FASTwhich is positive in Morrison’s Pouch. Secondary survey reveals
TTP at LUQ, unstable pelvis, perineal ecchymosis, and positive
gross blood at rectum.
• The pelvic binder must be applied quickly after detection. The
instructor will decrease the SBP to 80– this must be detected with
repeat VS. If learner fails to reassess VS, instructor may cause
the patient to lose consciousness. Improvisation may be required
depending on learner’s decision making if this occurs.
Transfusion with emergency release PRBCs should be initiated
quickly with T&C for 4 units minimum regardless if H/H is
obtained. Foley is contraindicated. If PRBCs are not ordered,
patient may lose consciousness as above.
• Patient’s BP will stabilize with transfusion. Due to
hemoperitoneum, patient will dispo to the OR with general surgery
consult. Interventional radiology must be considered for possible
embolization.
• If pain control is attempted, it should begin with low doses of
short acting agents e.g. fentanyl 25 mcg.
• The entire case should not take longer than 15 minutes.
Personnel and roles
• Instructor assesses learners with STAT, jockeys VS through two
changes
• Confederate nurse (possibly a Sr. resident) is helpful, not
obstructive, doesn’t give away case
Essential props and supply checklist
• 3G Sim Man w/ C collar, back board, moulage: perineal brusing
and gross blood at rectum
• Monitor, monitor leads, O2 mask, IV x 2, IVF
• A pelvic binder that is stocked in your ED or a bed sheet
• Simulated PRBCs
Debriefing
• Take notes with STAT to record impressions of learners’
performance with special attention to observed performance
gaps. Use your notes to aid your debriefing.
• Begin with Reaction phase– Allow learners to blow off steam,
clarify facts of case, collect insight for Teaching Phase. 1-2
minutes.
• Proceed into Teaching phase– Discuss each of the Critical
Actions, mentioning each one in sequence. Proceed quickly
where the learner performed well. Focus debriefing on areas
where performance gaps were noted. 10-15 minutes.
• Take time to teach how to apply a pelvic splint correctly if this is
needed.
• Summary phase– Ask learners to summarize briefly the following:
• What did they do well that they will do with a real patient?
Briefly augment with any additional observations.
• What did they learn that they will do with a real patient?
Briefly augment with any additional observations.
Images
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Pelvic fx film
CXR
Lateral C spine
FAST x 4 windows w
+MP
Nl CXR
Nl lateral C spine
Labs
• iSTAT
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Na 140
K 4.2
Cl 100
CO2 23
BUN 18
Cr 0.8
Hct 24
Hb 8.1
AnGap 19