Canberra Hospital and Health Services
ClinicalProcedure
Pelvic Injury – Management of the Unstable Trauma Patient (16 years and over)
Contents
Contents
Purpose
Alerts
Scope
Definition of terms
Section 1 – Treatment algorithm
Section 2 – Primary Survey
Section 3a – The responsive patient who is safe for diagnostic CT scan
Section 3b – Critically unwell patient with positive FAST or DPA
Section 3c – Critically unwell with negative FAST or DPA
Caveat
Implementation
Evaluation
Related Policies, Procedures, Guidelines and Legislation
References
Search Terms
Purpose
Blunt abdominal trauma resulting in life threatening haemorrhage is not an uncommon presentation to the emergency department. Pelvic fractures with major blood loss leading to haemodynamic instability require a multi-disciplinary management approach that is time critical. A well designed clinical practice guideline allows for a more efficient path to definitive haemorrhage control.
The purpose of this document is to guide treatment of critically unwell trauma patients with pelvic fractures, based on reliable scientific evidence. It is tailored to the skill base and facilities available at The Canberra hospital.The guideline is designed to support the trauma team in making decisions. It does not supersede clinical judgement and trauma clinician experience.
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This Standard Operating Procedure (SOP) describes for staff the process to
ScopeAlerts
This document pertains to patients 16 years and over that require emergent management and admission for suspected pelvic injuries, which includes single system injury and polytrauma. The management of paediatric pelvic fractures is an orthopaedic decision and will depend on the patient’s haemodynamic status, stability of the pelvic ring, type of fracture and the patient’s age. Patients aged less than 16 years are therefore excluded from this guideline.
The document relies upon senior clinician decision making and collaboration between subspecialty teams including Emergency Physicians, General/Trauma Surgeons, Orthopaedic Surgeons, Interventional Radiologists and Intensivists. This should be initiated early in the management of such a patient and consultant attendance at Trauma Code is strongly encouraged to facilitate optimal collaboration and time critical decision-making.
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Scope
The protocol is applied to the adultpatient who hasplain film imaging demonstrating a pelvic fracture. Thedegree of haemodynamic compromise and confirmation of a pelvic fracture will be established in the emergency department during the primary survey, when this guideline may be implemented.
The protocol and included algorithm refers to the haemodynamically unstable patient. 75%-90% of patients that are haemodynamically unstable from a pelvic fracture will have an arterial source of bleeding. The most effective means of haemorrhage control is angio embolisation in this sub-group of patients. As such, all patients that are haemodynamically unstable from a pelvic fracture are treated as being from an arterial source until proven otherwise through Medical Imaging.
Venous bleeding can be effectively managed in most cases by stabilisation of the pelvic ring. If the patient continues to remain unstable, then pelvic packing is an option but is rarely required for venous bleeding.
The Trauma Team will receive the patient in the Emergency Department following a Trauma Code (Trauma Team Activation Guideline). Members of the trauma team are allocated by the Trauma Team Leader.
Trauma Team Members:
- Trauma Team Leader (ED Registrar/Consultant) / Nursing Team Leader
- Airway Doctor (ED, ICU or Anaesthetics Registrar/Consultant) / Airway Nurse
- Circulation Doctor (ED or ICU Registrar/Consultant) / Circulation Nurse
- Procedure Doctor (ED or Surgical Registrar/Consultant) / Procedure Nurse
- Radiographer
- Wardsperson (blood bank runner and patient transport)
Other clinical teams directly involved in the treatment pathway are from the following areas:
- Interventional Radiology
- Orthopaedics
- Radiology nursing staff
- Theatre nursing staff
- Blood Bank and Pathology staff
The processes suggested in these guidelines will always be secondary to the direction of the trauma team leader (see Trauma Team Activation Guideline), who may deviate from these guidelines if clinical circumstances require it.
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Definition of terms
All interventions suggested in this guideline are performed under the direction of senior proceduralists. Both arterial embolisation and extra-peritoneal packing with pelvic external fixation arecomplementary, meaning if haemorrhage control is unable to be gained by the initial procedure, the patient should immediately undergo the alternate procedure.
1)The trauma team is the central element of trauma care and management and refers to a multidisciplinary group of health care professionals who aim to provide the multi-trauma patient with immediate, expert assessment, resuscitation and treatment. Trauma team activation occurs from the Emergency Department and is initiated by the triage nurse prior to, or on, patient arrival.
2)The haemodynamically compromised patient is defined as:
The adult trauma patient with a systolic blood pressure that is not responsive to the initial fluid and resuscitative measures taken prior to arrival to and in the emergency department. These measures may include the massive transfusion protocol (MTP).
3)Pelvic fracture is diagnosed by a senior medical staffmember. E.g. supervising emergency consultant and senior trauma surgical registrar
4)The presence or absence of blood loss in other compartments will be established during the primary survey upon patient arrival in the Emergency Department.
- External blood loss – Assessed by general inspection after adequate exposure
- Thoracic blood loss –Assessed by plain chest xray or volume output from intercostal catheter (ICC)
- Intra-abdominal blood loss – Assessed by focused assessment with sonography in trauma (FAST) scan and/or diagnostic peritoneal aspirate (DPA). The choice of which will be dependent on the level of experience of the trauma team members.
- Long bone fractures – Assessed by general inspection and confirmed on plain Xray.
5)Extravasation of contrast material in the pelvis at contrast-enhanced CT is an accurate indicator of ongoing arterial haemorrhage in patients with pelvic fractures and is referred to within the algorithm as intravascular contrast extravasation (ICE)
6)Definitive haemorrhage control in pelvic arterial bleeding is bycatheter angiography and arterial embolisation. This procedure is performed in the angiography suite in the Medical Imagingdepartment by an interventional radiologist
7) Definitive haemorrhage control from intra-abdominal sources is byexploratory laparotomy. This procedure is performed in the Operating Theatres by the Trauma/General surgeon. During this procedure the pelvic ring will be stabilised by external fixation performed by the orthopaedic surgeon.
8)Haemorrhage arising simultaneously from intra-abdominal and pelvic sources will be managed initially by exploratory laparotomy followed by extra-peritoneal pelvic packing. This procedure is performed in the Operating Theatre by the Trauma/General surgeonat the time of exploratory laparotomy.
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Section 1 –Treatment algorithm
The algorithm below describes the key steps to the management guideline:
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Section 2 – Primary Survey
The objectives of the primary survey are to synchronously evaluate and resuscitate the patient. The approach to the primary survey is in accordance with the internationally recognised and Royal Australasian College of Surgeons endorsed Emergency Management of Severe Trauma (EMST)principles.
The evaluation for circulatory compromiseaims to localise the site or sites of blood loss. This includes:
1.Adequate patient exposure and general inspection for external blood loss
2.Chest Xray for intra-thoracic blood loss
3.FAST scan and/or DPA for intra-abdominal blood loss
4.Pelvic Xray for pelvic/extra-peritoneal blood loss
Upon completion of the primary survey, the trauma leader should estimate the relative degree of haemodynamic compromise based upon clinical assessment and anticipate the potential location/s of major haemorrhage and the need for massive transfusion protocol activation (see CHHS12/138: Massive Transfusion Protocol).
This guideline can be used to support the decisions of the trauma team leader in patients with pelvic fractures who have potential major haemorrhage from an abdomino-pelvic source.
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Section 3a – The responsive patient who is safe for diagnostic CT scan
Patients who respond to initial resuscitation or are deemed by the trauma team leader as safe to undergo diagnostic CT scan can be transferred to the CT scanner. This arm of the algorithm provides the greatest diagnostic information. For this reason aggressive resuscitative measures will be implemented to allow patients access to this management pathway.
Approach
Following the primary survey and initial resuscitation, patients with a systolic blood pressure of greater than 90mmHg or patients deemed safe by the trauma team leader will be directed for transfer to the CT scanner. The patient will be escorted to and from the CT scannerby all members of the trauma team whilst the trauma code remains active.
If possible, the patient will be transferred on to the CT table feet first with attached relevant monitoring equipment. The images of the CT scan will be reviewed and relevant findings directed to the trauma team leader prior to the patient transferring off the CT table.
Staff involved in this procedure are:
1.Trauma team
2.Wardsmen
3.Emergency department nursing staff
4.CT radiographers
5.Radiology registrar/ Consultant
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Section 3b – Critically unwell patient with positive FAST or DPA
Transfer for Exploratory laparotomy
Severely compromisedpelvic trauma patients who are considered by the trauma team leader as unsafe to undergo diagnostic CT scan follow the second arm of the treatment pathway. The priority in these patients is urgentdefinitive haemorrhage control.
Patients with concurrent blood loss from pelvic and Intra-abdominal sources should be urgently transferred to the operating theatres for
1.Emergency exploratory laparotomy
2.Pelvic external fixation
3.Pelvic extra-peritoneal packing
Approach
Upon completion of the primary survey, a pelvic fracture proven on x-ray and positive findings on FAST or DPA suggest that the source of major blood loss could be both the pelvis and/or the abdominal cavity.Controlling intra-abdominal haemorrhage is the priority in this setting and exploratory laparotomy is indicated.The Critical Bleeding Massive Transfusion Procedure should also be activated immediately if not already active.
Pelvic external fixation is performed while in the operating theatres by senior orthopaedic surgeons. After pelvic external fixation, extra-peritoneal pelvic packing is performed by appropriately trained general/trauma or orthopaedic surgeon.
The patient will be escorted to the operating theatre by members of the trauma team whilst the trauma code remains active. The patient is then either handed over to the on call Trauma Consultant,anaesthetistand the operating surgeons as appropriate.
Staff involved in this procedure are:
1.Trauma team
2.Theatre nursing team
3.Wardsmen
4.Anaesthetist and team
5.Trauma surgeon and team
6.Orthopaedic surgeon
7.Pathology/ blood bank
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Section 3c – Critically unwell with negative FAST or DPA
Severely compromised pelvic trauma patients who are agreed by the trauma team leader and the interventional radiologist on call to be unsafe to undergo diagnostic CT scan follow the second arm of the treatment pathway. This will apply to only a very small proportion of patients who are too unstable to undergo CT. This must be done with close collaboration of Senior Consultant staff involved in procedural management of these patients. The priority is definitive haemorrhage control.
CT angiography should be performed if at all possible to confirm the site of bleeding so that the patient undergoes the most appropriate treatment to control haemorrhage and time is not wasted.
In collaboration with the interventional radiologist on call and given feasibility to proceed with the procedure in a timely manner, patients suspected of imminent exsanguination from a pelvic source without other significant sites of blood loss, should be emergently transferred to the angiography suite for:
1.Catheter angiography
2.Embolisation as appropriate
It should be recognised that there may be occasions when Interventional Radiology cannot respond within the specified timeframe i.e. when they are already engaged in a procedure. See caveat below.
Approach
Upon completion of the primary survey, a pelvic fracture proven on xray and negative findings on FAST or DPA in a haemodynamically unstable patient suggests that the source of major blood loss could be isolated to the pelvis/ extra-peritoneal space. In the case of patients agreed to be too unstable to undergo CT, controlling pelvic haemorrhage is the priority in this setting and urgent catheter angiography and embolisation is indicated.
The patient will be escorted to the angiography suite by all members of the trauma team whilst the trauma code remains active. The trauma team leader continues to oversee the care of the patient whilst the trauma code remains active. The patient may be handed over to Trauma Consultant/Surgeon and anaesthetic team whenthe trauma team leader deemsit to be appropriate.Under direction of Orthopaedic/Trauma Surgeon and Interventionalist, the external pelvic binder will be temporarily released (but not removed) at the beginning of the procedure, leaving the binder control at the level of the iliac creststo allow access for catheterisation.Catheter angiography and embolisation will be performed by senior Interventional Radiologist.
Staff involved in this procedure are:
1.Trauma team
2.Interventional Radiologist
3.Orthopaedic Surgeon
4.Angiography suite radiographer
5.Angiography suite nursing team
6.Wardsmen
7.Anaesthetist and team
8.Pathology/ blood bank
Following this intervention, if haemodynamic instability continues, or if pelvic bleeding remains uncontrolled, the patient should be transported to Operating Theatres urgently for pelvic external fixation +/- laparotomy, extra-peritoneal packing, or other damage control interventions.
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Caveat
In the event that Interventional Radiology is unable to provide interventional services within 45 mins e.g. when already engaged in a procedure or mechanical breakdown/maintenance, haemorrhage control should be gained through pelvic external fixation.
The patient will be escorted to the operating theatre by all members of the trauma team whilst the trauma code remains active. The patient is then either handed over to the on call Trauma Consultant or anaesthetist and the operating surgeons as appropriate.
Staff involved in this procedure are:
1.Trauma team
2.Theatre nursing team
3.Wards men
4.Anaesthetist and team
5.Trauma surgeon and team
6.Orthopaedic surgeon
7.Pathology/ blood bank
Note: Do not divert patient unless trauma team leader confirms, as redirection is likely to cost more time
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Implementation
Each senior member of the respective teams will be responsible for informing and distributing the information to their respective team members. The information will also be available on the hospital intranet and accessible at any time.
Each department will be responsible for educating their staff in accessing and executing therelevant tasks that contribute clinical information gathered to implement this algorithm.
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Evaluation
Outcome Measures
Appropriate documentation will be audited as a part of major trauma systems analysis.
Current Key Performance Indicators (Threshold 100%)
- Trauma team activation (According to activation criteria)
- Trauma team response - volume per minute of fluid resuscitation
- Emergency surgery in < 40 mins from arrival
- Emergency catheter angiography in < 60min from arrival
Method
The Trauma Service will be responsible for auditing compliance, storing all identified issues on the Major Trauma Database; reporting monthly to the ACT Trauma Committee.
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Related Policies, Procedures, Guidelines and Legislation
- CHHS Trauma Team Activation Guideline
- CHHS Critical Bleeding Massive Transfusion Procedure
- CHHS Fresh Blood Products Administration (Adults, Paediatrics and Neonates)Procedure
- CHHS Patient Identification and Procedure Matching Policy
- CHHS Patient Identification and Procedure Matching Procedure
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References
1.Abrassart S, Stern R, Peter R. Unstable pelvic ring injury with hemodynamic instability: what seems the best procedure choice and sequence in the initial management? Orthopaedics & traumatology, surgery & research : OTSR. 2013;99(2):175-82.
2.Ballard RB, Rozycki GS, Newman PG, Cubillos JE, Salomone JP, Ingram WL, et al. An algorithm to reduce the incidence of false-negative FAST examinations in patients at high risk for occult injury. Focused Assessment for the Sonographic Examination of the Trauma patient. Journal of the American College of Surgeons. 1999;189(2):145-50; discussion 50-1.
3.Baque P, Trojani C, Delotte J, Sejor E, Senni-Buratti M, de Baque F, et al. Anatomical consequences of "open-book" pelvic ring disruption: a cadaver experimental study. Surgical and radiologic anatomy : SRA. 2005;27(6):487-90.
4.Ben-Menachem Y, Coldwell DM, Young JW, Burgess AR. Hemorrhage associated with pelvic fractures: causes, diagnosis, and emergent management. AJR American journal of roentgenology. 1991;157(5):1005-14.
5.Blackmore CC, Cummings P, Jurkovich GJ, Linnau KF, Hoffer EK, Rivara FP. Predicting major hemorrhage in patients with pelvic fracture. The Journal of trauma. 2006;61(2):346-52.
6.Blackmore CC, Jurkovich GJ, Linnau KF, Cummings P, Hoffer EK, Rivara FP. Assessment of volume of hemorrhage and outcome from pelvic fracture. Archives of surgery. 2003;138(5):504-8; discussion 8-9.
7.Bottlang M, Krieg JC, Mohr M, Simpson TS, Madey SM. Emergent management of pelvic ring fractures with use of circumferential compression. The Journal of bone and joint surgery American volume. 2002;84-A Suppl 2:43-7.
8.Bottlang M, Simpson T, Sigg J, Krieg JC, Madey SM, Long WB. Noninvasive reduction of open-book pelvic fractures by circumferential compression. Journal of orthopaedic trauma. 2002;16(6):367-73.
9.Boulanger BR, McLellan BA, Brenneman FD, Wherrett L, Rizoli SB, Culhane J, et al. Emergent abdominal sonography as a screening test in a new diagnostic algorithm for blunt trauma. The Journal of trauma. 1996;40(6):867-74.