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