Pelvic Fractures

Pelvis Fractures

Anatomy

The pelvis is a ring-like structure of bones at the lower end of the trunk. The two sides of the pelvis are actually three bones (ilium, ischium, and pubis) that grow together as people age. Strong connective tissues (ligaments) join the pelvis to the large triangular bone (sacrum) at the base of the spine. This creates a bowl-like cavity below the rib cage. On each side, there is a hollow cup (acetabulum) that serves as the socket for the hip joint.

Many digestive and reproductive organs are located within the pelvic ring. Large nerves and blood vessels that go to the legs pass through it. The pelvis serves as an attachment point for muscles that reach down into the legs and up into the trunk of the body. With all of these vital structures running through the pelvis, a pelvic fracture can be associated with substantial bleeding, nerve injury, and internal organ damage.

Management of Exsangunating Pelvis Injuries

Introduction

Trauma patients who present with unstable pelvic fractures have sustained a high energy injury that is commonly associated with disruption of arteries and veins resulting in major hemorrhage. Patients with pelvic fractures who present in shock have a mortality of 30-50%. When combined with injuries in other body regions such as the abdomen, the mortality rises even higher, approaching 100% in some series. However a systematic multidisciplinary approach to these injuries, directed initially only at hemorrhage control, can lead to significant improvements in survival.

Key Points

Pelvic Injury

• An unstable pelvic injury with signs of shock should be treated as a vascular injury.
• Hemorrhage may be from fractured bone and disrupted veins and arteries.
• High energy trauma is associated with multi-cavity injury, and there may be hemorrhage in the chest or abdomen as well as the pelvis and long bones.

Management

• A multidisciplinary approach is essential. All team members must know their roles and key decisions.
• Appropriate resuscitation maneuvers are as important as hemorrhage control interventions.
• Management of massive transfusion, coagulopathy and hypothermia are vital for success.
• A damage control approach should be adopted for all these patients: do the minimum necessary to save life.

Thoracic Trauma - Traumatic Cardiac Tamponade

Cardiac tamponade is a clinical syndrome caused by the accumulation of fluid in the pericardial space /sac (Sac surrounding the heart), resulting in reduced ventricular filling and subsequent hemodynamic compromise. It can occur from both a medical and traumatic etiology.  In this post we will discuss Traumatic Cardiac Tamponade. The condition is a traumatic emergency, the complications of which include pulmonary edema, shock, and death.

The speed in which the fluid builds up in the pericardial sac is the largest factor in survival.  The faster the fluid accumulates the higher the mortality.  This is why traumatic cardiac tamponade are often more dangerous than those of a medical cause. Rapid accumulation of as little as 150mL of fluid can result in a marked increase in pericardial pressure and can severely impede cardiac output,^[2] whereas 1000 mL of fluid may accumulate over a longer period without any significant effect on diastolic filling of the heart. This is due to adaptive stretching of the pericardium over time. A more compliant pericardium can allow considerable fluid accumulation over a longer period without hemodynamic insult.

Heart with pericardial sac opened.
 


X-ray showing the heart surrounded by a fluid filled pericardia sac.

Signs and symptoms

Symptoms vary with the acuteness and underlying cause of the tamponade. Patients with acute tamponade may present with dyspnea, tachycardia, and tachypnea. Cold and clammy extremities from hypoperfusion are also observed in some patients. Other symptoms may include the following:

• Elevated jugular venous pressure (JVD)
• Pulsus paradoxus

 

Beck triad

Described in 1935 by Claude Beck, this complex of physical findings, also called the acute compression triad, refers to increased jugular venous pressure, hypotension, and diminished heart sounds. These findings result from a rapid accumulation of pericardial fluid. This classic triad is usually observed in patients with acute cardiac tamponade.

 

The concept was developed by Claude Beck, a resident and later Professor of Cardiovascular Surgery at Case Western Reserve University.^[

 

 

Management

Prehospital treatment.

The prehospital treatment of pericardial tamponade is mainly supportive.  Position of comfort if
thermodynamically stable, semifowlers in in respiratory distress, supine if in hypoperfusion,.  High concentration O2, temperature maintenance, rapid transport to the appropriate facility (trauma center).

In Hospital treatment

Removal of pericardial fluid is the definitive therapy for tamponade and can be done using the following three methods:

• Emergency subxiphoid percutaneous drainage
• Echocardiographically guided pericardiocentesis
• Percutaneous balloon pericardiotomy

The role of medication therapy in cardiac tamponade is limited.


Pericardiocentesis

Survival Rates Similar for Gunshot, Stabbing Victims Whether Brought to the Hospital by Police or EMS

 

Interesting Study:

This study just reinforces that staying on the scene with an accessible trauma patient is inappropriate. Excessive time spent immobilizing, splinting, and otherwise "stabilizing" trauma patients is detrimental to their survival. With the concept of "permissive hypotension" (future post) and fluid resuscitation caused hypothermia there is no reason to stay on the scene.  IV's should be started en-route and depending on your protocol; fluid may be kept to "keep vein open" (KVO) rate (slow). Excessive fluid administration prior to internal bleeding being controlled has been shown to cool the trauma patient.  This cooling leads to worse coagulation.  There are numerous other issues surrounding fluid resuscitation that we will get into in other posts.

A couple of points we should consider about this study.  The patients were for the most part being transported to Level 1 and Level 2 trauma centers that actually handle trauma on a regular basis. The second point is that transport times were relatively short.

Survival Rates Similar for Gunshot, Stabbing Victims Whether Brought to the Hospital by Police or EMS

Philadelphia “Scoop and Run” Penetrating Trauma Victims Studied over Five-Year Period

Released: 1/2/2014 9:00 AM EST
Source Newsroom: Perelman School of Medicine at the University of Pennsylvania

more news from this source

Newswise — PHILADELPHIA - A new study from the Perelman School of Medicine at the University of Pennsylvania has found no significant difference in adjusted overall survival rates between gunshot and stabbing (so-called penetrating trauma injuries) victims in Philadelphia whether they were transported to the emergency department by the police department or the emergency medical services (EMS) division of the fire department.

“This study is an examination of current prehospital practices with an eye toward improving patient care and is by no means intended as a criticism of the highly trained and dedicated professionals of the Philadelphia Fire Department who provide outstanding care under difficult circumstances,” said lead author Roger Band, MD, assistant professor of Emergency Medicine at the Hospital of the University of Pennsylvania. “The Fire Department, the Police Department, and health care professionals all share the same goal: learn all we can in order to continually improve the care and services we provide to patients and the community.”

The study, published online ahead of print in the Annals of Emergency Medicine, examined 4,122 patients taken to eight Level I and Level II adult trauma centers in Philadelphia between January 1, 2003 and December 31, 2007. Of these, 2,961 were transported by EMS and 1,161 by the police. The overall mortality rate was 27.4 percent. Just over three quarters (77.9 percent) of the victims suffered gunshot wounds, and just under a quarter (22.1 percent) suffered stab wounds. The majority of patients in both groups (84.1 percent) had signs of life on delivery to the hospital. A third of patients with gunshot wounds (33.0 percent) died compared with 7.7 percent of patients with stab wounds.
Although patients transported by the police department were more likely to die compared with those transported by EMS (29.8 percent versus 26.5 percent), these findings appear to be explained by the more severely injured population that the police typically transport to the hospital and not the mode of transport itself.

The Penn study also found that severely injured gunshot victims transported by the police were more likely to survive. “There could be many factors contributing to this finding, such as the fact that police may have shorter response times to an event simply by virtue of how they patrol,” said Band.
While previous studies suggest that trauma victims have similar mortality rates whether brought to the hospital by emergency medical services or police, the current Penn study is the largest investigation to date examining the relationship between method of transport and mortality in penetrating trauma.

More than 25 years ago, the Philadelphia Police Department began allowing police department transport of individuals with penetrating trauma to the hospital, commonly referred to as a “scoop and run.” A current department directive states: “Police personal will transport: Persons suffering from a serious penetrating wound, e.g., gunshot, stab wound … to the nearest accredited trauma center. Transportation will not be delayed to await the arrival of the Fire Department paramedics.” While EMS follows citywide protocols, no formal policy outlines how care should be provided to injured patients transported by police. Typically, individuals transported by police have not been rendered care, including direct pressure on bleeding extremity wounds. However, the Philadelphia Police Department has recently issued tourniquets to every police officer in the city.
For decades, there has been heavy debate among medical professionals on how to best balance the potentially competing priorities of fast transport to the emergency department (possibly in first-arriving, traditional police vehicles) with the benefits of transport by specially trained emergency medical personnel in expressly equipped vehicles. Previous studies have shown survival benefit for EMS-type transport in such cases as myocardial infarction (heart attack), respiratory arrest, cardiac arrest, and perhaps trauma.

“It is critically important to remember that our study focuses on a very specific type of patient with a specific disease process, in a densely populated urban environment and we in no way are suggesting that patients with serious medical symptoms, such as chest pain or difficulty breathing, do anything but call 911 and await the highly trained EMS personnel who have the skill and equipment to deal with the situation and any potential problems,” said senior study author, Brendan Carr, MD, MS, assistant professor Emergency Medicine and Biostatistics and Epidemiology at Penn.
The research team notes that additional prospective studies in different large cities in the U.S. could help to validate the safety and efficacy of the “scoop and run” approach used in Philadelphia