Management of Hemodynamically Significant Pelvic Fractures

Original Date: 12/2013 | Supersedes: 11/2019, 06/2020 | Last Review Date: 04/2024
Purpose: To develop a protocol to ensure rapid identification and treatment of hemodynamically significant pelvic fractures.

Background: Patients in hemorrhagic shock due to pelvic fractures present complex clinical problems.

Common errors in the treatment of these patients include:

  • Failure to apply a pelvic binder to an open book pelvis
  • Failure to identify and correct coagulopathy
  • Misidentification of source of hemorrhage (or missing additional / contributing sources of hemorrhage – most commonly in blunt polytrauma patients)
  • Failure to rapidly triage patient to the hybrid operating room
  • Patients stay in the Emergency Department too long
  • Failure to rule out concomitant perineal, urologic or rectal injury

Indications for AP Pelvis Films during Trauma Resuscitation:

  • Hemodynamic instability
  • Pelvic pain or tenderness
  • Instability of pelvis on physical exam
  • Suspicion of femur fractures
  • Suspicion of hip dislocation
  • Perineal trauma
  • Intubated patients (s/p high mechanism trauma)

Applying a Pelvic Binder:

  • Indications:
    1. Any open book pelvic fracture (APC-I, APC-II, APC-III)1 despite hemodynamic status
    2. A patient with a suspected pelvic fracture and hemodynamic instability, where pelvic films are not available.
      apc
      Alton & Gee, 2014.
  • Steps:
    • Pelvic binder should be centered over greater trochanters.
      pelvic binder
    • If access to groins is necessary, move binder to mid-thigh or knees and tape feet together.
      pelvic binder
    • Before leaving trauma bay, ensure thorough evaluation for perineal/rectal/urologic injury
      • If concern for urethra / bladder injury is present, Retrograde Urethrogram (RUG) & Cystogram should be completed after CTA abdomen/pelvis with IV contrast 3,5

Contraindications to pelvic binder:  None*

  • Lateral compression fracture patterns (LC I, II, III) can be worsened by inappropriate application of pelvic binder.
    cpb

Identification and Treatment of Coagulopathy:

  • Obtain intravenous access above the diaphragm (upper extremity, chest, or neck)
  • Controlled resuscitation, permissive hypotension: don’t “pop the clot”
    • Systolic blood pressure goal >70 mmHg
    • MAP > 50 mmHg
  • Hemostatic resuscitation:
    • Minimize crystalloid and colloid administration
    • Resuscitate with 1:1:1 ratio of RBCs:FFP:platelets
      • Give FFP and platelets early
  • Rapidly identify source of bleeding and definitively control hemorrhage.
    • Early placement of ultrasound-guided Common Femoral arterial line, to facilitate possible REBOA placement in hemodynamically unstable pelvic fractures
  • Correct TEG and reverse anti-coagulant/anti-platelet medications as indicated

Identify Source of Bleeding:

  • Chest radiograph to evaluate for hemothorax/tension pneumothorax
  • Pelvic radiograph to evaluate for and identify type of pelvic fracture.
    • Place pelvic binder if patient is found to have an open book pelvis (APC I, II, III)
    • Contact orthopedic surgery resident immediately (4-BONE)
  • FAST exam:
    • FAST Negative and non-responder:
      • Consider diagnostic peritoneal aspiration (DPA) to rule out concurrent intra-abdominal hemorrhage
      • Consider Zone III REBOA placement prior to transport
        • Adequate placement at aortic bifurcation can be ensured by the loss of the contralateral femoral pulse.
      • Proceed to angiography / hybrid operating room +/- pre-peritoneal packing
    • FAST Positive and patient non-responder
      • Consider zone I REBOA placement prior to transport
      • Proceed to hybrid OR for laparotomy +/- angiography +/- pre-peritoneal packing
  • If patient has a sustained response to initial resuscitation:
    • Proceed to CT for further imaging, or to operating room if indicated by clinical picture (traumatic diaphragm injury, intra-abdominal bleeding, evisceration).

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA)

rebc

Once in the hybrid operating room, the two most common therapeutic interventions are:

  1. Pre-peritoneal pelvic packing (PPP)4,6
    • Infraumbilical vertical midline incision (~8cm) to just above pubic tubercle.
    • In a large pelvic hematoma, the pre-peritoneal space should already be developed for you. Additional blunt dissection may be necessary.
    • Divide subcutaneous tissue and fascia, but do not breach peritoneum.
    • Gently retract bladder out of the way
      • *Note: If Foley in place and bladder decompressed, may not immediately visualize bladder, particularly if large hematoma is present. Proceed carefully.
    • Pack the pelvis with three laparotomy pads on each side.
      • If the pre-peritoneal dissection is difficult, the patient likely does not have a large pelvic hematoma… and another source of hemorrhage should be sought.
        ppp
  2. Pelvic angioembolization:
    • Activate STAT IR and Post Case for OR 41
      • See STAT Interventional Radiology Consult Clinical Practice Policy.
      • Trauma faculty to IR faculty direct discussion
    • The IR team will meet you and the patient in the hybrid operating room for angiography.

Other operative Considerations  ~

  • Concomitant laparotomy is common when managing hemodynamically significant pelvic fractures.
    • To preserve the pre-peritoneal space for packing, a skin bridge should be left between the PPP incision and the laparotomy incision.
  • If performing a colostomy or suprapubic catheter, coordinate with orthopedic surgery as the location, as these can impact their pelvic fixation/reconstruction.
  • Careful evaluation of the perineum needs to be performed in the emergency department and/or operating room so that open wounds are not missed.

Indications to Consider Emergent External Fixation:

  • The pelvic binder provides adequate reduction of the pelvic ring in most cases.
  • If access to the groin, abdomen, genitalia, or perineum is necessary and closure of the pelvic ring by wrapping the feet and/or moving the pelvic binder lower is unsuccessful, then discuss with orthopedic surgery regarding emergent external fixation.

References:

  1. Alton, T. B., & Gee, A. O. (2014). Classifications in brief: young and burgess classification of pelvic ring injuries. Clinical Orthopaedics and Related Research®, 472, 2338-2342.
  2. Brenner ML, Moore LJ, DuBose JJ, Tyson GH, McNutt MK, Albarado RP, Holcomb JB, Scalea TM, Rasmussen TE. A Clinical Series of Resuscitative Endovascular Balloon Occlusion of the Aorta for Hemorrhage Control and Resuscitation. J Trauma Acute Care Surg. 2013 Sep;75(3):506-11.
  3. Coccolini, F., Stahel, P. F., Montori, G., Biffl, W., Horer, T. M., Catena, F., … & Ansaloni, L. (2017). Pelvic trauma: WSES classification and guidelines. World Journal of Emergency Surgery, 12, 1-18.
  4. Cothren CC, Osborn PM, Moore EE, Morgan SJ, Johnson JL, Smith WR. Pre-peritoneal Pelvic Packing for Hemodynamically Unstable Pelvic Fractures: a Paradigm Shift. J Trauma. Apr 2007;62(4):834-39.
  5. Cullinane, D. C., Schiller, H. J., Zielinski, M. D., Bilaniuk, J. W., Collier, B. R., Como, J., … & Wynne, J. L. (2011). Eastern Association for the Surgery of Trauma practice management guidelines for hemorrhage in pelvic fracture—update and systematic review. Journal of Trauma and Acute Care Surgery, 71(6), 1850-1868.
  6. Smith, W. R., Moore, E. E., Osborn, P., Agudelo, J. F., Morgan, S. J., Parekh, A. A., & Cothren, C. (2005). Retroperitoneal packing as a resuscitation technique for hemodynamically unstable patients with pelvic fractures: report of two representative cases and a description of technique. Journal of Trauma and Acute Care Surgery, 59(6), 1510-1514.