Trauma and Critical Care—Pelvic Fracture
Concept
High frequency of associated injuries given the force needed to fracture the pelvis. Often associated with falls and motor vehicle accidents. Usually classified by the vec- tors of force that produced the injury:
Anterior-posterior compression Lateral compression
Vertical shear
Combined vector injury
Way Question May be Asked?
“33 y/o male is brought into the emergency room after falling off of the second story of a building. He is tachy- cardic and has a systolic blood pressure of 90. What do you want to do?” May get the scenario with patient status post MVA, fall, or crushed in an industrial accident. Be systematic in the work-up and on guard for the associated ureteral/rectal injuries and the ongoing blood loss requir- ing angiography.
How to Answer?
In trauma setting, always the ABCs first:
Airway and C-spine control (intubate with C-spine control if necessary)
Breathing and Ventilation (does pt need chest tube—
place before CXR) Circulation and IV access Disability (Neuro status)
Don’t skip secondary survey either, or you will miss some key finding (high riding prostrate, blood at urethral meatus, blood on rectal exam)!
History Should be an “AMPLE” one
Allergies Meds
Past medical history Last meal
Events surrounding trauma
Physical Exam
Head to toe
Finger/scope in every hole/orifice Pelvic and rectal exam
Labs/Diagnostic Studies
Full panel including T+C Lateral C-spine
CXR Pelvis x-ray DPL if unstable
CT scan abdomen/pelvis if stable (include head if neuro sx’s)
Surgical Treatment:
(1) Resuscitate the pt and treat any associated life- threatening injuries:
(a) 2 large bore peripheral IVs
2 liters crystalloid (20 cc /kg), can repeat once if no response, followed by blood if hemody- namically unstable
(2) DPL if suspect intra-abominal injury in unstable pt (incision above the umbilicus to avoid entering pelvic hematoma!)
(a) take to OR only if grossly bloody, otherwise, unlikely to be enough hemorrhage to be source of pt’s hypotension
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(b) if grossly bloody, position in lithotomy to be able to perform rigid sig to evaluate rectum (3) Blood at urethral meatus
(a) urethrogram first→ suprapubic cystotomy if positive urethrogram
(b) cystogram if urethrogram negative (c) if cystogram positive, is injury intra or
extraperitoneal?
(d) intraperitoneal gets primary repair in layers (e) consider all bladder injuries get suprapubic
cystotomy (4) If rectal injury,
(a) diverting sigmoid loop colostomy (b) presacral drains
(c) rectal washout
(5) if retroperitoneal hematoma,
(a) don’t explore unless ruptured or expanding (b) if explore, ligate internal iliacs, pack, and go to
angiogram for embolization if necessary (6) Stabilize all unstable fractures early with external
fixator in ER (after DPL if hemodynamically unstable)
(7) Angiogram to embolize bleeders especially if pt is bleeding externally
(8) All open pelvic fractures get diverting sigmoid colostomy
Common Curveballs
Associated injuries and how to manage:
Ureteral Rectal
Spleen Liver Chest Small bowel Pancreas
Pelvic fracture will be unstable Pelvic fracture will be “open”
DPL will be grossly positive
DPL will only be positive by RBC count (don’t do laparotomy first)
Pelvic hematoma will be expanding/ruptured
Pt will have neurologic injury and be hypotensive with grossly positive DPL (testing your priorities→ explore abdomen first as this is most life-threatening)
Pt will develop DVT/PE during hospitalization (change scenario!)
Strikeouts
Not knowing how to proceed or proceeding expedi- tiously in unstable pt
Not performing DPL in unstable pt
Performing DPL with incision below umbilicus Not identifying associated injuries
Not knowing what to do with pelvic hematoma Exploring stable retroperitoneal hematoma
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