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Hemorrhage in Pelvic Fractures…Where To Go

Dr. Dora Tai

Introduction

Introduction

Bleeding from Pelvic Fractures

Three bleeding sources:

1. Arteries (10-15%)

2. Low-pressure venous plexus (80-90%)

3. Fractured cancellous bone surfaces

Giannoudis PV, Pape HC. Damage control orthopaedics in unstable pelvic ring injuries. Injury, Int. J.Care Injured 2004;35:671-677.Geeraerts T, Chhor V, Cheisson G, Martin L, Bessoud B, Ozanne A, Duranteau J. Clinical review : Initial management of blunt pelvic trauma patients with haemodynamic instability. Critical Care 2007; 11:204-212.White CE, Hsu JR, Holcomb JB. Haemodynamically unstable pelvic fractures. Injury, Int. J.Care Injured 2009; 40: 1023-1030.

External Pelvic Stabilization

1

Reduce pelvic volume

↓↓ blood loss

promotes tamponade effect

2

Return bony pelvic components back into

apposition ↓

Haemostatic pathways to control venous

bleeding

3

↓ clot dislodgement

↓ elimination of thrombotic process

↓ consumption of clotting factors

Miller PR, Moore PS, Mansell E, Meredith W, Chang MC. External fixation or arteriogram in bleeding pelvic fracture : Initial therapy guided by markers of haemorrhage. J Trauma 2003; 54(3):437-443.DiGiacomo JC, Bonadies JA, Cole FJ, Diebel L, Hoff WS, Holevar M, Malcynski J, Scalea T. Practice management guidelines for haemorrhage in pelvic fracture. Eastern Association for the Surgery of Trauma 2001; 1-15.

Pelvic Binder

Non-invasive, inexpensive

Easy to apply

Access to abdomen

White CE, Hsu JR, Holcomb JB. Haemodynamically unstable pelvic fractures. Injury, Int. J.Care Injured 2009; 40: 1023-1030 .

External Fixator

Mohanty K, Musso D, Powell JM, Kortbeek JB, Kirpatrick AW. Emergent management of pelvic ring injuries: An update. Can J Surg 2005; 48(1):49-55.

DiGiacomo JC, Bonadies JA, Cole FJ, Diebel L, Hoff WS, Holevar M, Malcynski J, Scalea T. Practice management guidelines for haemorrhage in pelvic fracture. Eastern Association for the Surgery of Trauma 2001; 1-15.

Posterior C clamp

Mohanty K, Musso D, Powell JM, Kortbeek JB, Kirpatrick AW. Emergent management of pelvic ring injuries: An update. Can J Surg 2005; 48(1):49-55.

DiGiacomo JC, Bonadies JA, Cole FJ, Diebel L, Hoff WS, Holevar M, Malcynski J, Scalea T. Practice management guidelines for haemorrhage in pelvic fracture. Eastern Association for the Surgery of Trauma 2001; 1-15.

External Fixator

Indications:

If laparotomy or packing is needed for unstable pelvic fracture

Heetveld MJ, Harris I, Schlaphoff G, Sugrue M. Guidelines for the management of haemodynamically unstable pelvic fracture patients. ANZ J.Surg 2004; 74: 520-529.

Suzuki T, Smith WR, Moore EE. Pelvic packing or angiography : Competitive or complementary? Injury, Int. J.Care Injured 2009; 40: 343-353.

Arterial Bleeding

White CE, Hsu JR, Holcomb JB. Haemodynamically unstable pelvic fractures. Injury, Int. J.Care Injured 2009; 40: 1023-1030.

Arterial Bleeding

Indicators of significant arterial bleeding:1. Lack of response to initial resuscitation

2. Contrast material extravasation (blush) on CT scan Sensitivity 80-84% Specificity 85-98%

Yoon W, Kim JK, Jeong YY, Seo JJ, Park JG, Keun HK. Pelvic arterial hemorrhage in patients with pelvic fractures : Detection with contrast-enhanced CT. RadioGraphics 2004;24:1591-1606.

Miller PR, Moore PS, Mansell E, Meredith W, Chang MC. External fixation or arteriogram in bleeding pelvic fracture : Initial therapy guided by markers of haemorrhage. J Trauma 2003; 54(3):437-443.

CT Scan

Axial CT scan shows pelvic haematoma (white arrows) with extravasation of contrast medium (arrowhead).

Angiography and Embolization

Digital angiography of the left internal iliac artery with extravasation of contrast

Geeraerts T, Chhor V, Cheisson G, Martin L, Bessoud B, Ozanne A, Duranteau J. Clinical review : Initial management of blunt pelvic trauma patients with haemodynamic instability. Critical Care 2007; 11:204-212.Heetveld MJ, Harris I, Schlaphoff G, Sugrue M. Guidelines for the management of haemodynamically unstable pelvic fracture patients. ANZ J.Surg 2004; 74: 520-529.

Angiography and Embolization

Indications:

1.Persistent haemodynamic instability

2.Ongoing bleed despite pelvic packing

3.Arterial extravasation of contrastHeetveld MJ, Harris I, Schlaphoff G, Sugrue M. Guidelines for the management of haemodynamically unstable pelvic fracture patients. ANZ J.Surg 2004; 74: 520-529.

Balogh Z, Caldwell E, Heetveld M, Amours SD, Schlaphoff G, Harris I, Sugrue M. Institutional practice guidelines on management of pelvic fracture-related haemodynamic instability : Do they make a difference ? J Trauma 2005; 58:778-782.

Suzuki T, Smith WR, Moore EE. Pelvic packing or angiography : Competitive or complementary? Injury, Int. J.Care Injured 2009; 40: 343-353.

Pelvic Packing

Preperitoneal space

White CE, Hsu JR, Holcomb JB. Haemodynamically unstable pelvic fractures. Injury, Int. J.Care Injured 2009; 40: 1023-1030.Giannoudis PV, Pape HC. Damage control orthopaedics in unstable pelvic ring injuries. Injury, Int. J.Care Injured 2004;35:671-677.Gansslen A, Giannoudis P, Pape HC. Haemorrhage in pelvic fracture: Who needs angiography ? Curr Opin Crit Care 2003; 9:515-523.

Pelvic Packing

White CE, Hsu JR, Holcomb JB. Haemodynamically unstable pelvic fractures. Injury, Int. J.Care Injured 2009; 40: 1023-1030.

Giannoudis PV, Pape HC. Damage control orthopaedics in unstable pelvic ring injuries. Injury, Int. J.Care Injured 2004;35:671-677.Gansslen A, Giannoudis P, Pape HC. Haemorrhage in pelvic fracture: Who needs angiography ? Curr Opin Crit Care 2003; 9:515-523.

Pelvic Packing

Indications: Ruptured pelvic haematoma at

laparotomy (transperitoneal)

Unresponsive to embolization/initial resuscitation

No angiography facilities available

Heetveld MJ, Harris I, Schlaphoff G, Sugrue M. Guidelines for the management of haemodynamically unstable pelvic fracture patients. ANZ J.Surg 2004; 74: 520-529.

White CE, Hsu JR, Holcomb JB. Haemodynamically unstable pelvic fractures. Injury, Int. J.Care Injured 2009; 40: 1023-1030.

CROSS-ROAD SITUATION: ANGIO or PACKING

Angiography +/- embolisation

External fixation Pelvic Packing

Advantages • Less invasive

• High success rate

• Can stop arterial bleeding

• Quick to perform

• Does not limit access to abdomen

• Can be placed in the AED

• Quick to perform

• Does not require special technology

• Stabilize patient for angiography

Disadvantages/Complications

• Time consuming

• Requires interventional radiologist

• Haematoma

• Pin site infection

• Nerve and vascular injuries (C-clamp)

• Invasive

• Intrapelvic infection

• May not be effective for treatment of arterial bleeding

• Removal requiredSuzuki T, Smith WR, Moore EE. Pelvic packing or angiography : Competitive or complementary? Injury, Int. J.Care Injured 2009; 40: 343-353.Papakostidis C, Giannoudis PV. Pelvic ring injuries with haemodynamic instability : Efficacy of pelvic packing, a systematic review. Injury, Int. J.Care Injured 2009; 40S4: S53-S61.

Comparison of Interventions

Time to interventionTime to intervention: PACKING group vs ANGIO group (45mins vs 130mins)(p=0.01)

Blood transfusionBlood transfusion in the first 24 hoursin the first 24 hours: ,less in the PACKING group (6.9 unit vs 10.1 units ; p=0.01)

MortalityMortality: PACKING group 4/20 vs ANGIO group 6/20 (p = 0.48)

Early mortality rate: 10% (95% CI: 3−18%)

Late mortality rate: 13% (95% CI: 5−22%)

Overall mortality: Overall mortality: 28% 28% (95% CI: 16.8−39.4%)(95% CI: 16.8−39.4%)

Increase in SBP after EPP (p=0.002)

Mortality : Mortality : 28% 28%

QEH Data

2005 2006 2007 20082009 (8 mth)

Total no. of trauma cases 401 351 371 447 402

No of pelvic injury cases (%)

27 (7%)

38 (11%)

36 (10%

)

45 (10%

)

27 (7%)

Grossly NegativeGrossly Positive

QEH Protocol 2004-2008

No Yes

No

Yes No

Pelvic FracturePelvic Fracture

HypotensionHypotension

FAST Scan/ Diagnostic Peritoneal LavageFAST Scan/ Diagnostic Peritoneal Lavage

Wrap Pelvis with Sheet/Binder

Wrap Pelvis with Sheet/Binder

Laparotomy+ External Fixation

Laparotomy+ External Fixation

StableStable

Angiography+ EmbolizationAngiography

+ Embolization

Amenable to External Fixation

Amenable to External Fixation

Yes

External FixationExternal Fixation

ICUICU

ICU+CTICU+CT

Sustained Response to Sustained Response to Initial Resuscitation?Initial Resuscitation?

Sustained Response to Sustained Response to Initial Resuscitation?Initial Resuscitation?

AngiographyAngiography++ Embolization EmbolizationAngiographyAngiography

++ Embolization Embolization

QEH Protocol 2008-2009

YesYes

Pelvic FracturePelvic Fracture

ShockShock

FAST Scan/ Diagnostic Peritoneal LavageFAST Scan/ Diagnostic Peritoneal Lavage

Wrap Pelvis with Sheet/BinderWrap Pelvis with Sheet/Binder

Pelvic FixationPelvic Packing

Laparotomy

Pelvic FixationPelvic Packing

Laparotomy

Sustained Response to Sustained Response to Initial Resuscitation?Initial Resuscitation?

Sustained Response to Sustained Response to Initial Resuscitation?Initial Resuscitation?

StableStable

ICU +/- CT scanICU +/- CT scanNoNo

YesYes NoNo

Unstable or Ongoing Bleeding

Unstable or Ongoing Bleeding

External FixationExternal FixationPelvic PackingPelvic Packing

External FixationExternal FixationPelvic PackingPelvic Packing

NoNoYesYes

Grossly PositiveGrossly Positive Grossly NegativeGrossly Negative

ICUICU

AngiographyAngiography

AngiographyAngiography ICUICU

Study period : June 2007- End of 2009

Number of patients: 24

Aim: To compare the mortality rate between the 2 protocols

Previous protocol : (Angiogram +/- Embolization) Feb 2004 – June 08

Current protocol : (Packing +/- Angiogram +/- Embolization) Jun 08

onward

Retrospective Review for Unstable Pelvic Fractures

Male : Female 15:9

Age: mean 47.7yrs, median 45yrs, range:18-84yrs

Mechanism of injury: Blunt trauma

Road traffic accident: 13

Fell from height: 11

Trauma score (Median / Mean) : ISS 41.2/ 43

Overall mortality : 58.3% (14/24)

Retrospective Review for Unstable Pelvic Fractures

QEH Data

N= 24 ANGIO

N= 13

PACKING

N=11

P value

Age 44.8 (+/- 23.7) 51.2 (+/- 19.6) 0.464

Blood transfusion in AED (units)

3.3 (+/-4.4) 2.7 (3.37) 0.338

Combination of Combination of treatmenttreatment

0/130/13 5/115/11 0.0020.002

Time spent in AED (mins)

61.9 (+/- 33.5) 69.7 (+/- 15.6) 0.711

Systolic pressure on arrival (mmHg)

61.2 (+/- 15.5) 99.0 (+/- 32.6) 0.060

ISS 40.0 (+/- 12.7) 42.3 (+/- 18.1) 0.724

RTS 5.52 (+/- 2.4) 6.92 (+/- 2.0) 0.139

TRISS 0.45 ( +/- 0.3) 0.73 (+/- 0.2) 0.050

Mortality Mortality 10/13 (77% )10/13 (77% ) 4/11 (36%)4/11 (36%) 0.0950.095

The Golden Hour…every second counts!

Acknowledgements

Dr. Li Wing Hong Dr. Lee Kin Bong Dr. Lee Kin Yan Dr. Tang Lap Fai Dr. Ho Hiu Fai Ms Annice Chang