Download Extra-peritoneal Packing of Hemorrhagic Pelvic Fracture

Extra-peritoneal Packing of Hemorrhagic Pelvic Fracture
By: Thomas S. Kefalas & Colby DeCapua
Lock Haven University Physician Assistant Program
Figure 1. Fractured pelvis (5).
Abstract
Figure 4. Extraperitoneal pelvic
packing (1).
Studies
1. A protocol for angiographic embolization in
• Hemodynamically unstable pelvic fracture = 40% mortality
exsanguinating pelvic trauma: a report on 31
rate (3).
patients
• 85% of cases venous bleeding is the culprit (2).
- Significant pelvic arterial injuries are rare (2.5%).
• Extra-peritoneal pelvic packing is more time efficient (6).
2. Preperitonal pelvic packing for hemodynamically
• Continuous attempt to limit blood transfusions when
unstable pelvic fractures: a paradigm shift
physiologically appropriate (2).
- Blood transfusions pre-intervention vs
• Extra-peritoneal pelvic packing in the face of a
subsequent 24 hours were significantly different (12
hemodynamically unstable patient suffering from a pelvic
vs 6; p = 0.006).
fracture:
3. Direct retroperitoneal pelvic packing versus pelvic
• Decreases the need for pelvic embolization.
angiography: a comparison of two management
• Decreases post-procedural blood transfusions.
protocols for haemodynamically unstable pelvic
• Reduces early mortality associated with exsanguinations fractures
from pelvic hemorrhage (6).
- Operative packing ocurred a median of 45
minutes from admission (vs 130 min for
Background
angiography).
Pelvis consists of
4. Blood transfusion is an independent predictor of
Sacrum
mortality after blunt trauma
Coccyx
- Mortality rates between the transfused and
Ilium (2)
nontransfused groups = 15.12% and 1.84% (P <
Pubis (2)
0.000). Transfusing ≥ 2 units of blood increases
Ischium (2)
M&M.
Figure 2. Pelvic boney anatomy (7).
Blood Supply
1. Inferior mesenteric artery: Supplies transverse,
descending, and sigmoid colon, rectum.
2. Common iliac artery: →external and internal iliac arteries
3. Internal iliac artery: → Posterior = iliolumbar, lateral sacral, and
superior gluteal. Anterior = parietal (obturator, internal pudendal,
inferior gluteal) visceral branches (umbilical, middle vesical, inferior
vesical, middle hemorrhoidal, uterine, and vaginal). Superior vesical
artery arises from the umbilical artery.
4. Internal pudendal: Supplies branches to rectum, gentialia, + perineum.
5. Veins: Few valves allowing bidirectional flow. Begins in small sinusoids
draining into many venous plexuses within or adjacent to pelvic organs.
Multiple anastomoses between parietal and visceral branches. Veins
draining pelvic plexuses navigate alongside arterial supply. They are thus
named via the accompanying arteries. Multiple veins course alongside a
Figure 3. Algorithm for initial pelvic trauma
treatment (1).
single artery (3).
Discussion
• Pelvic veins = thin-walled + easily disrupted (4).
• ≈ 85 % of pelvic bleeding is venous in nature (2).
• Pelvic packing may serve to tamponade the venous
bleeding (3).
•Pelvic packing is as effective as pelvic angiography
for stabilizing hemodynamically unstable patients
with pelvic fractures (6)
• Speed is crucial for the survival of the bleeding
patient.
• 45 minutes versus 130 minutes (6).
• Packing is a rapid method for controlling pelvic
fracture-related hemorrhage that can supplant the
need for emergent angiography (6).
• Significant ↓in blood product transfusion post
pelvic packing.
• Transfusing ≥ 2 units of blood was strongly
associated with an ↑ M&M (2).
• Pelvic packing ↓the need for pelvic embolization,
↓post-procedural blood transfusions, and reduces
early mortality due to exsanguination (6).
• “Pelvic packing, as a part of a damage control
protocol, could potentially aid in early intrapelvic
bleeding control and provide crucial time for a
more selective management of hemorrhage” (8).
Literature Consulted
1. Brohi, K. (2008, May 20). Management of exsanguinating pelvis injuries. Retrieved from
http://www.trauma.org/index.php/main/article/668/
2. Charles, A. (2007). Blood transfusion is an independent predictor of mortality after blunt trauma. The American
Surgeon, 73(1), 1-5.
3. Cothren, CC. (2007). Preperitonal pelvic packing for hemodynamically unstable pelvic fractures: a paradigm
shift. Journal of Trauma, 62(4), 834-842.
3. Katz, VL., Lentz, GM., Lobo, RA., & Gershenson, DM. (2007). Katz: comprehensive gynecology, 5th ed..
Philadelphia, PA: Mosby Elsevier.
4. Marx, JA., Hockberger, RS., Walls, RM., Adams, JG., & Barsan, WG. (2009). Marx: rosen's emergency medicine,
7th ed.. Philadelphia, PA: Mosby Elsevier.
5. Matta, JM., & Klenck, RE. (n.d.). Orthopedic surgery, hip and pelvis reconstruction. Retrieved from
http://www.hipandpelvis.com/patient_education/ortho_surg/page2.html
6. Osborn, PM., Smith, WR., Moore, EE., Cothren, CC., Morgan, SJ., Williams, AE., Stahel, PF. (2009). Direct
retroperitoneal pelvic packing versus pelvic angiography: a comparison of two management protocols for
haemodynamically unstable pelvic fractures. Injury, 40(1), 54-60.
7. Pelvic anatomy. (n.d.). Retrieved from
http://radiology.usc.edu/presentations/saddleprosthesis/page2_anat_final2.htm
8. Popakostidis, C., & Giannoudis, PV. (2009). Pelvic ring injuries with haemodynamic instability: efficacy of pelvic
packing, a systematic review. Injury, 40(4), 53-61.
9. Totterman, A., Dormagen, JB., Madsen, JE., Klow, NE., & Skaga, NO. (2006). A protocol for angiographic
embolization in exsanguinating pelvic trauma: a report on 31 patients. Acta Orthopaedica, 77(3), 462-468.