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Multiple Trauma
ICU Fellowship Training
Radboudumc
Injury Severity Score
Severe trauma = ISS > 15
Region
Injury description
AIS
Square top 3
Head & Neck
Cerebral contusion
3
9
Face
No injury
0
-
Chest
Flail chest
4
16
Abdomen
Minor liver contusion
Complex rupture spleen
2
5
25
Extremity
Fractured femur
3
External
No injury
0
-
ISS total
Score 50
Abbreviated Injury Scale
AIS: 1 minor, 2 moderate, 3 serious, 4 severe, 5 critical, 6 maximal/untreatable
Only highest AIS score in each body region
Endotracheal intubation with
C-spine control
Failure at first attempt
Suphan L. BJA 2016;116:27-36
Failure at first attempt
Cormack Grade I
Stomp trauma van de
thoracale aorta
•
< 1% in high impact trauma but 16% of
mortality
•
2d cause of death after severe TBI in car
accidents
•
Approximately 80% die before reaching
hospital
•
If untreated 30% of survivors dead within 24 hrs
Initial tear in intima and media - later on adventitia
10 - 40% normaal!
Minimal aortic damage
•
10% of aortic lesions detected with CT
•
Example isolated intimal tear < 1 cm
•
Low chance of rupture
Treatment
•
TEVAR
•
Immediate control of BP with β-blocker and iv
anti-hypertensive medication
•
In rare cases open repair with interposition graft
30% ✝
10% spinal cord lesion
Endovascular treatment
Mortality ↓↓
Spinal cord lesion ↓↓
Traumatische tamponade
•
Suspicion usually high with penetrating trauma
•
Rare and difficult diagnosis with blunt trauma
•
Often no CVP ↑, heart sounds often difficult to
detect, tachycardia multifactorial, pulsus
paradoxus also with hypovolemia
Low pressure tamponade
Classic tamponade
Sagrista-Sauleda J. Circulation 2006;114:945-952
Case (1)
•
Female, 79
•
Blunt chest trauma
•
Previous medical history -
Case (2)
•
A-B-C-D stabiel
•
Multiple fracturen
•
Bilaterale long contusie
Differential diagnosis
•
Congestive heart failure
•
Non-cardiogenic pulmonary edema
‣ FES
‣ Due to pulmonary contusion
•
Bilateral alveolar bleeding
•
Bilateral pneumonia
TEE
TEE
PHT << 200 ms
Blunt chest trauma and
acute AOI
•
Loss valve suspension
•
Avulsion coronary cusp
•
Perforated leaflet
•
Dissecting aneurysm
NCC avulsion
Behandeling
•
Chirurgische interventie met AVR - zelden
valvuloplastiek wegens grote recidief kans
Literature
•
First description 1830
•
Extremely rare - less than 100 cases
•
Mechanism: sudden ↑ in intrathoracic pressure
during diastole (highest pressure gradient when
valve is closed)
Pelvic Fractures
Classification
Young-Burgess system
•
Three main patterns of injury
AP compression
Lateral compression
Vertical shear
AP compression
•
External rotation of one or both hemipelves
•
Iliac wings move outward - pubic diastasis
•
Associated injuries - sacroiliac joint diastasis and
less commonly sacral fractures
•
Increased pelvic volume - spontaneous tamponade
of hemorrhage unlikely
AP compression
•
AC1 - pubic diastasis < 2.5 cm = stable
•
AC2 - pubic diastasis > 2.5 cm + anterior SIJ
disruption = vertical stable but rotational
unstable (classic open book)
•
AC3 - pubic diastasis > 2.5 cm + anterior and
posterior SIJ disruption = vertical + rotational
unstable
S.J. Slater, D.A. Barron / European Journal of R
AC2 fracture
Fig. 4. AC type 2 fracture. Note pubic diastasis but intact posterior ligaments. This
is an ‘open book’ fracture.
Lateral compression
•
Most common type of pelvic fracture
•
Internal rotation of hemipelvis with coronal ramal
fractures, contralateral SIJ disruption and central
acetabular fractures
•
High incidence of sacral fractures (80 - 90%)
•
Reduction in pelvic volume
Lateral compression
•
LC 1 - Ipsilateral „buckle” sacral and coronal pubic
rami fractures = stable
•
LC2 - LC1 + ipsilateral iliac wing # or posterior SIJ
disruption = rotational unstable but vertical
stable
•
LC3 - LC2 + external rotation of contralateral
hemipelvis ± contralateral sagital ramal fractures =
rotational unstable but vertical stable
s
.
-
l
-
LC2 Fracture
Right sided pubic rami #
Ipsilateral sacral buckle #
Vertical shear fractures
•
Vertically and rotationally unstable due to disruption
of posterior ligaments
•
Vertical force is often the femur with ramal fractures
anteriorly and ligamentous jury posteriorly
•
Hemipelvis shifted cranially
•
High rate of associated injuries to torso and spine
and often hemodynamic instability
re
as
in
ly
drs
sk
an
6%
Vertical
shear
fracture
Fig. 6. Vertical shear fracture.
Vertically
orientated
pubic rami fractures and cranial
Sacral fractures
Is high rate of neurologic injury
•
Zone 1 - sacral ala lateral to sacral foramina (L5
nerve root impingement with 6% sustained injury)
•
Zone 2 - neuroforamina with unilateral sacral
anesthesia (no involvement of central sacral canal)
•
Zone 3 - body of sacrum (up to 50% neurological
compromise including cauda equina syndrome)
high intensity
22
S.J. Slater, D.A. Barron / European Journal of Radiology 74 (2010) 16–23
of associate
is low. The
nerve root c
Rarely, t
this involve
and a trans
ation. As a
injury.
In the pr
picion for a
identify mo
tified on MR
15. Conclu
Pelvic fr
associated
early detec
mistake in
pelvic fract
vides a relia
unstable pa
fracture. CT
edge of pel
and remind
tions.
Fig. 8. Coronal STIR sequence MRI. ‘Honda sign’ (arrows) demonstrating sa
insufficiency fractures in an elderly female. Note the typical vertical
and horizo
References
high intensity in the sacral ala bilaterally.
Sacral fracture
[1] American
manual. 8
2008.
[2] Hilty
of associated neurological injury, whereas the risk below
thisMP,
le
adiminish
is low. These fractures can cause intraspinal and intraforami
[3] Guillamo
trauma re
nerve root compromise (Fig. 7a and b).
[4] Eastridge
Rarely, there may be a U-shaped sacral fracture. Highlytherapeu
unsta
ring
disru
this involves longitudinal fractures through the foramina bilater
[6] Huber-W
Fig. 7. (a and
Sacral
fracture in anfracture
alcoholic man
who sat
down too hard!
This
andb) a
transverse
with
subsequent
spino-pelvic
disso
trauma
r
low energy mechanism of injury raises concern for underlying osteopenia. These
2009;373
ation.
As
a
result,
there
is
a
high
rate
of
associated
neurolog
fractures can be difficult to detect on AP views, but this particular injury was more
[7] Cerva Jr
General management
•
Recognition of life-threatening injuries (ATLS)
•
Recognition of acute injuries
•
Fracture classification (suspicion for undetected
injuries)
Severe pelvic # in 80% associated with at least 2 other injuries
CT-scan versus pelvic radiograph
Multiple # pubic rami, sacrum
and right femur
Left epidural hematoma with
intracranial air
Complicated liver injury with
active contrast extravasation
90% [7].
Three sources of bleeding are recognised in pelvic fractures,
arterial, venous and bleeding from cancellous bone. Management
of these different sources varies greatly. It is generally accepted that
venous and cancellous bleeding is managed by initial stabilisation
of the fracture to facilitate tamponade. In such cases, close monitoring is advised as young patients in particular can appear stable
or metastable despite ongoing arterial haemorrhage.
Arterial bleeds are commonly from the superior gluteal and the
internal pudendal arteries. The greater sciatic foramen is a common
exit pathway for many pelvic vessels and any fracture involving this
area incurs a higher risk of bleeding. The superior gluteal artery is
at risk of laceration from the sharp fascia of the piriformis muscle as
it enters the greater sciatic foramen. The internal pudendal artery
also exits the pelvis here but re-enters through the lesser sciatic
foramen. It is injured in anterior–posterior compression fractures
where there are inferior pubic rami fractures or fractures involving
the lesser sciatic foramen. Therefore the fracture location can be
used to predict which artery has been injured.
Major risk - bleeding
•
Mortality up to 60% in case of haemodynamic
instability
•
Bleeding: arterial, venous or from cancellous bone
•
Injured artery related to fracture site
Most common
Artery injured
Fracture site
Superior gluteal
Greater sciatic foramen, ischial spine
or tuberosity
AP compression fracture involving
lesser sciatic foramen, inferior pubic
ramus
Superior obturator foramen, superior
pubic ramus, pubic acetabulum
Acetabulum, injured posterior to
inguinal canal
Sacral foramina or posterior
trans-sacral fracture
Posterior fracture involving ilium or
anterior SIJ’s
Internal pudendal
Obturator
Femoral
Lateral sacral
Iliolumbar
-
a
a
Identifying other organ injuries earlyit
Reducing the number of unnecessarya
fo
w
th
u
5. Vascular injuries
Fig. 2.
In pelvic fractures, the most comm
cation is bleeding. Where there is haem
fractures are reported to have a high m
(Fig. 2a–c). CT can quickly and accura
absence of haemorrhage with an accur
90% [7].
Three sources of bleeding are reco
arterial, venous and bleeding from can
of these different sources varies greatly.fo
venous and cancellous bleeding is man
in
of the fracture to facilitate tamponadeo
[8
toring is advised as young patients in pp
or metastable despite ongoing arterialv
a
Arterial bleeds are commonly fromct
internal pudendal arteries. The greaterin
s
exit pathway for many pelvic vessels ana
q
area incurs a higher risk of bleeding. Th
at risk of laceration from the sharp fascir
D
it enters the greater sciatic foramen. Th
r
also exits the pelvis here but re-entero
(a–c) Unstable pelvic fracture (a, arrows) with contrast extravasation on CT
Arterial bleeding - therapy
•
Depends on several factors including associated
injuries - hemodynamic instability - reaction to
external fixation/pelvic packing
•
Angiography very effective (85 - 100%) in isolated
injury when performed early
•
Proposed management algorithm should
incorporate early CT scanning if possible
e228
C. Arvieux et al.
Anatomical and physiological fundamental
and management principles
Anatomy of pelvic and perineal injuries
Vascular injuries
The pelvis is characterized by its abundant and complex
vascularization. Three potential bleeding sources (arterial,
venous and cancellous bone) can co-exist to various degrees,
which explain the magnitude and initial severity of bleeding
in pelvic and perineal trauma (PPT). The quantity of blood
loss depends equally on the mechanism of fracture according
to Tile’s classification [2]: type C fractures (vertical shear)
and type A (anteroposterior compression) injuries have the
highest risk of severe bleeding.
Other local and locoregional injuries
Urinary tract and digestive tract lie in close proximity to
bony structures [3], explaining the frequent association of
bony and visceral injuries. The pelvic organs are contained
within the rigid bowl of the bony pelvis: a pelvic fracture
attests to high energy transfer and is frequently associated
with distant injuries: severe pelvic fractures are associated
with at least two other traumatic injuries in 80% of cases [4].
Moreover, neurologic structures that control the bladder and
anal sphincters and sexual functions must be considered in
management to minimize postoperative urinary and fecal
incontinence and sexual disorders.
Surgical access to the pelvis
The pelvic cavity forms a truncated cone with potential
access from above (abdominal) or below (perineal), but the
narrowness of both accesses explains why hemostasis can
be difficult and complex, and accounts for the surging popularity of containment strategies, pelvic packing and the
predominant role of arterial embolization [5].
Physiological consequences of bleeding
Figure 1.
Technique of pelvic compression with a sheet wrap.
e230
Figure 3.
Ganz® pelvic clamp. Suicide attempt in an 18-year-old
Figu
Arthrodesis at day 30 via the ilioinguinal route. At 1 year, the patient
walks without crutches but with a limp.
urethrograph
urgent attent
Digestive tr
In the event o
early infectio
agate along t
tissues. Such a
tion which sh
drainage and
mary rectal in
surgical mana
(bony splinte
fairly simply
Here again, t
tates the init
Patient w
admission
Figure
4. for
Preperitoneal
packing technique:
presacral and
Risk
rectal ischemia
and the
necrosis
paravesical spaces are tightly packed by inserting four to eight pads
Definition
Urological injury
•
Especially with separation of pubic symphysis or
fractured pubic ramus
•
Usually extraperitoneal
•
Intraperitoneal with blunt trauma to a distended
bladder
•
CT cystography
Neurological injury
•
10% following pelvic fractures
•
Bladder, bowel and erectile dysfunction
•
Transverse sacral # - intraspinal and intraforaminal
nerve root injury
•
Greater sciatic notch # or posterior acetabulum # sciatic nerve injury
C. Arvieux et al.
Urethra injury
20
. Ganz® pelvic clamp. Suicide attempt in an 18-year-old
who threw herself under a truck. Initial management confemoral traction, insertion of a Ganz® clamp, debridement
nage of the perineal injury. Colostomy and transfer to Uniospital on day 5. Removal of the clamp on day 10, insertion
nal fixation (Slatis) with maintenance of femoral traction.
sis at day 30 via the ilioinguinal route. At 1 year, the patient
thout crutches but with a limp.
S.J. Slater, D.A. Barron / European Journal of Radiology 74 (2010) 16–23
ciated injuries. Many studies have attempted to predict the r
of haemorrhage according to fracture pattern [4,20]. Howev
whilst unstable pelvic fractures are more frequently associa
Transurethral catheterization is formally
with contraindicated.
haemorrhage, fracture pattern cannot be used to absolut
Placement of a suprapubic catheter and performance of
predict haemorrhage [10].
urethrography are critically important but should not delay
Figure 5.
Perineal hematoma.
urgent attention to hemostasis [30].
Digestive tract involvement
9. Pelvic ring fractures
In the event of traumatic rectal injury, there
major risk
The ispelvis
is of
considered to be a ring structure comprised
early infection because fecal contamination and sepsis propthree
bones, the
agate along the anatomic planes into
the surrounding
softsacrum and two innominate bones. The pos
rior ring
includes
tissues. Such an injury requires immediate
surgical
interven-the sacrum, SI joints and iliac bones, whilst
tion which should combine hemostasis,
local
debridement,
anterior ring is comprised of the pubic bones and symphysis. T
drainage and diverting colostomy [31]. In the setting of priSI joints can be divided into anterior and posterior and are h
mary rectal injury (firearm and knife wounds, impalement),
by the
anterior and posterior sacroiliac ligaments. T
surgical management is complex. A together
secondary rectal
injury
(bony splinter from pelvic fractures)posterior
is most often
treated ligaments are the strongest in the body and
sacroiliac
fairly simply by local wound care, drainage
and
colostomy.
most important in maintaining pelvic stability. The sacrotubero
Here again, the hemodynamic stability of the patient dicand sacrospinous ligaments provide additional support posterio
tates the initial management.
Conversely, the pubic symphysis anteriorly is weaker and m
easily
ruptured.
Fig. 3. (a and b)
Window
cleaner who fell from a ladder. Unstable pelvic frac-
Perineal wounds
•
Rectal examination with blood - recognition
essential - otherwise mortality up to 50%
•
Exploration in OR < 6 hours with complete
assessment and debridement
•
Diverting colostomy
•
Drainage and secondary healing (vacuum
dressings)