Broward General Medical CenterLevel I Trauma Center

Michael W. Parra, MDDirector of Trauma Critical Care Research

Director of the International Trauma Critical Care Improvement Project

Clinical Assistant Professor/NOVA Southeastern UniversityBroward General Level I Trauma Center

Fort Lauderdale, FL

H & P

• 80 yo F s/p MVC• Restrained driver• T-boned on driver side• No LOC• Complaining of left sided hip pain• PmedHx:

– Hypothyroidism– HTN– CAD– Hypercholesterolemia

H & P

• Meds:– Levothyroxine– Imdur– Atenolol– Protonix– Zocor– HCTZ– Diovan

• Psurg Hx:– Cardiac Stents x 2 in 2001

Prehospital

• Vital Signs at Scene:– P: 102– RR: 16– BP: 122/77– GCS: 15 AAOx3

• Inmobilized with C-collar and Back Board• Total IVF given 200 cc NS• Tranported via ground to Level I Trauma Center• Total transport time less than 15 minutes

Level I Trauma Bay

• Primary and Secondary Survey only reveal pubic tenderness

• Vital Signs:– P: 96– RR: 21– BP: 110/82– O2 Sat: 94% on 2 Lt NC – GCS: 15

Level I Trauma Bay

• Initial Work Up:– Trauma Labs including cardiac enzymes

» H/H: 10/30» Plts: 136» PT/PTT: 12/21

– PCXR– AP Pelvic XR: Bilateral Superior and Inferior

Rami Fractures– 12 Lead EKG = NSR with RBBB

Level I Trauma Bay

• Patient becomes hemodinamically unstable• Vital Signs:

– P: 110– RR: 24– BP: 66/32

• FAST performed by trauma surgeon: Negative

Level I Trauma Bay

• “Damage Control Resuscitation” initiated:– 2 U PRBC’s transfused

• Hemodinamically Unstable Pelvic Fracture Protocol initiated:

– TPOD placed

• Patient Responds hemodinamically to initial resuscitation efforts

• STAT CT Abd/Pelvis: Active extravasation of contrast

Level I Trauma Bay

• Patient taken immediately to Angio Suite• Pelvic Angiogram performed via Rt femoral artery

access• “Damage Control Resuscitation” continued in

Angio Suite:– 2 more Units PRBC’s– 2 units of FFP

Level I Trauma Bay

• Pelvic Embolization (PE)Left Hypogastric Branch - 5 coils

• Patient remains hemodinamically unstable

• Patient taken immediately from angio suite to the OR for Preperitoneal Pelvic Packing for control of presumptive ongoing venous pelvic bleeding

OR

• Supraumbilical Exploratory Laparotomy• Infraumbilical Preperitoneal Pelvic Packing• On Table Retrograde Cystogram with

Methillin Blue

OR

• Elap Negative• On Table Cystogram with no intra o

extraperitoneal extravasation of dye• “Damage Control Resuscitation” totals:

– 6 Units PRBC’s– 3 Units FFP– 1 Pack of Platelets– 1 Unit of Cryoprecipitates – 400 cc NS

PPP & PE

Post-Op

• Transferred to the ICU

• Patient rewarmed to a temp of 37C

• Extubated later that same day

• H/H remained stable at 10/30

• Pelvic Packing removed 36 hours later in the OR

Post-Op

• Patient taken on POD#5 for ORIF of pelvic fractures by Ortho Service

• Patient recovers well and is eventually discharged to Rehab

Abstract Being Presented At The 2010 Panamerican Trauma Symposium

Montevideo/Uruguay • Title:

Institutional Review and the Implementation of a New Algorithm for the Treatment of Hemodynamically Unstable Pelvic Fractures

2010 Panamerican Trauma Symposium Abstract

• Purpose: Evaluation of the current treatment modalities at our local trauma centers of hemodynamically unstable pelvic fractures, and the proposal of an algorithm for their management that consists of initial immobilization with a pelvic orthotic device

(T-POD) and preperitoneal pelvic packing (PPP) in conjunction with angio-embolization

2010 Panamerican Trauma Symposium Abstract

• Method: Retrospective review from 2007-2009 of hemodynamically unstable pelvic fractures at two regional trauma centers: Delray Level II Trauma Center and Broward General Level I Trauma Center

2010 Panamerican Trauma Symposium Abstract

• Results: – A total of 50 patients sustained pelvic fractures and

underwent pelvic angiography for ongoing hemodynamic instability and presumptive active arterial or venous pelvic bleeding

– Ten patients were excluded due to the discovery of an alternate source of bleeding that required operative repair

– The most common alternate sources of bleeding were liver and splenic lacerations

– Of the remaining 40 patients, the male to female ratio was 1.7:1

2010 Panamerican Trauma Symposium Abstract

• Results: – Mean age was 49, ranging from 17-91 – The mean ISS score was 24, ranging from 4-75 – The mean lowest systolic blood pressure was 78.5

ranging from 43-128 – The most common mechanism of injury was:

• motor vehicle crash (48%) • pedestrian hit by car (24%) • falls (12%) • motorcycle crashes (7%)

2010 Panamerican Trauma Symposium Abstract

• Results:– Fifteen (37%) patients had positive angiograms and

underwent selective pelvic embolization– The remaining 25(63%) patients had presumptive

pelvic venous bleeding – Only 6 (15%) patients underwent pelvic

immobilization with a T-POD in the trauma bay and 4 (67%) of them survived

– Six (15%) patients had PPP, and 4 (67%) of them survived

– Only two patients had both T-POD and PPP, and both survived to discharge

2010 Panamerican Trauma Symposium Abstract

• Conclusion: – The therapeutic combination of a pelvic orthotic

device and preperitoneal pelvic packing added to a multi-interventional resuscitation algorithm might be life saving in patients with life-threatening pelvic injury

– Our retrospective institutional review has revealed an under utilization of both pelvic immobilization and damage control pelvic bleeding techniques

– We propose the following algorithm for the management of such patients and the evaluation of its effectiveness prospectively at our regional trauma centers

Initial Trauma EvaluationIncluding

AP Pelvis in Trauma Bay

Pelvis FX

Pelvic Fx Stability R/O Any Other Associated Traumatic Injury

Hemodinamic Stability Hemodinamic Stability

Orthopaedic Surgeon EvaluationTPOD/Pelvic Sheet TPOD/Pelvic Sheet

Orthopaedic Surgeon Evaluation

R/O Any Other Associated Traumatic Injury

Transfuse 2 Units PRBC’s in Trauma Bay

FAST/DPL

OR OR OR

Supraumbilical LaparotomyInfraumbilical PPP

Infraumbilical PPP

Intra-Operative External Pelvic FixationIf Pelvic Fx Unstable

Post Op Angiography

TICU/Complete Evaluation and Resuscitation

Yes No

Unstable Stable

Stable Unstable

Stable

Unstable

Positive Equivocal Negative