Field management of Pelvic Fracture CME.pptx

EMS CME lecture on pelvic fracture management

1. Pelvic Fractures

2. Case: Accident with injury - Major 50-year-old male restrained driver in a head on high speed MVC BP 87/45 and HR 130 Exam: airway intact, BS equal bilaterally, no obvious external hemorrhage. GCS 15. Pain on palpation of the lower abdomen and bruising in the groin. L LE internally rotated.  C/o pain in the left groin and buttock. Thoughts??

3. Bottom Line Up Front (BLUF) Mechanism of injury is best indication!! Pelvic fractures can be stable or unstable. Unstable should be treated with binder. Ask the alert patient about the presence of pain in the pelvic, back or groin regions. Standard trauma assessment and interventions but do not fully log roll the patient and do not ‘rock’ the pelvis.

4. Bottom Line Up Front (BLUF) Look for key physical signs. If there is any suspicion of fracture +/- hypotension, immobilize the pelvis. Use a scoop stretcher to facilitate the patient's movement on to a spinal board. Damage control resuscitation unless there is head injury as well Adequate pain management with ketamine

5. Pelvic Fractures 3% of all skeletal injuries annually in the United States  9% of trauma patients admitted to the hospital Most frequently occur in patients 15—28 years old Benign to rapidly life-threatening, with an overall mortality of 10—16%   Up to 50% mortality for pelvic fractures in the unstable hypotensive patient

6. stable Pelvic Fractures Ground level falls are a fairly small but significant portion of the total number of pelvic trauma injuries Almost exclusively an infirmity of the elderly

7. Unstable Pelvic Fractures Implies a high mechanism of energy transfer and can lead to high morbidity and mortality Different mechanisms of injury are more or less likely to cause pelvic fractures Typical high-energy, side-impact mechanisms of injury Motor vehicle and motorcycle accidents represent up to 58% of all causes Up to 83% of acetabular fractures Pedestrians struck by vehicles account for another 22%

8. Unstable Pelvic Fractures Hemorrhage is by far the biggest concern 38.5% of pelvis injury patients in hospital required blood transfusions Intra-abdominal injuries occur in ~15% of high-energy pelvic trauma Typically organs like the spleen, liver, and bowel bladder and urethra are not injured as frequently (3.5% of cases) Neurological impairment complications occur in 10-15% of patients, and up to 50% in severe sacral fractures

9. Anatomy of the Pelvis Ring-shaped bony structure consisting of the sacrum, coccyx, and three innominate bones: the ilium, ischium and pubis. Innominate bones join to form the acetabulum

10. Anatomy of the Pelvis Strength/stability results from ligaments connecting sacrum to the other pelvic bones Instability results when ligaments are disrupted The sacroiliac joint between the sacrum and ilium is the strongest joint in the body The pubic symphysis is the weakest link in the pelvic ring

11. Anatomy of the Pelvis Organs lying within the pelvis: Ureters and Bladder Rectum Sigmoid colon and anal canal Urethra Prostate in males Uterus and vagina in females

12. Anatomy of the Pelvis Vast array of large and small blood vessels and nerves lie anterior to the sacrum Pelvic bleeding typically unabated until hematoma develops and tamponades

13. Anatomy of the Pelvis Substantial and complex network of nerves run through the pelvis Damage unlikely to result in death but is almost always permanent Loss of sensation, motor control, or function to the lower limbs, reproductive organs, bladder, or bowel Risk of broken pelvic bones injuring nearby nerves if the patient is moved improperly

14. Stable: Pelvic Single Bone Fractures Stable single bone fractures of the pelvis are most common pelvic fracture Can involve any part of the boney pelvis including the sacrum, coccyx, pubis, ischium, or ilium Pubic Rami Fracture Account for greater than 50% of pelvis fractures. Usually simple breaks in the pelvic rim or avulsion fractures from falls from standing

15. Stable: Pelvic Single Bone Fractures Sacral fractures Typically from higher energy falls or MVC Can be falls from standing if osteoporosis Significant nerve injury can occur given the nerve roots’ exit through the sacral foramina Coccygeal fractures Fall from standing Typically transverse fractures with the inferior segment pushed inward

16. Stable: Pelvic Single Bone Fractures Iliac bone fractures Avulsion fracture Fracture where muscles attach on the crest from forceful contractions Fracture of the iliac wing Overall stable fracture given the stability from the surrounding musculature. Can have related vasculature injury given the force necessary to fracture Age dependent mechanism - high energy blunt trauma in the young, low energy falls in the elderly

17. UNSTABle : Pelvic ring fractures Most severe unstable fracture type - causes two breaks in the circular pelvic ring Often leading to an unstable pelvis High rate of related major hemorrhage  Complete trauma assessment!! Force required to disrupt strong ligaments and cause pelvic fractures is usually indicative of other serious pathology Commonly associated with chest trauma > head trauma > intraperitoneal trauma > long bone fx

18. Unstable: Lateral compression fracture Occurs when a lateral force vector causes an anterior ring disruption and sacral fracture Most common of the pelvic ring fractures Mostly occurring after a “ t-bone ” MVC

19. Unstable: Anterior-Posterior compression Fracture Midline force causes disruption at the pubic symphysis anteriorly and disruption of the sacral ligaments posteriorly Often associated with sacral venous plexus injur ies

20. Unstable: Anterior-Posterior compression FRacture Referred to as an “open book pelvic fracture” Increasing the pelvic volumes can lead to a greater area for blood to accumulate. In one study, pelvic diastasis of 5cm resulted in a 20% increase in pelvic volume

21. Unstable: Vertical shear fracture Vertical force causes an anterior ring fracture and disruption of the posterior sacral ligaments Commonly occurs in a fall from height or an MVC where force vector runs through the gas pedal through the femur up to through the pelvis

22. Unstable: Vertical shear fracture Lower extremity amputation due to blast or high energy trauma often associated with unstable pelvic fracture

23. Unstable: Straddle Fractures Fracture occurs at the bilateral inferior and superior pubic rami May also involve the posterior ligaments Often associated with bladder or urethra injury 33% of patients require laparotomy for intraperitoneal injuries

24. Pelvic Trauma: Neurologic Injury Depending on the fracture, neurologic abnormalities may be present Assess the conscious, alert patient for: Numbness and tingling in the pelvis or lower extremities Impaired movement/strength or LE paralysis Bladder and bowel incontinence

25. Pelvic Trauma: Hemorrhage Injury to the arteries/veins in the pelvis is a common and serious complication Most mortality from pelvic fractures arises from uncontrolled hemorrhage (specifically venous) Hemodynamic instability is an important sign Increasing pulse and respiratory rates, diminishing mental status, as well as increasing anxiety, disorientation, or confusion Elevated shock index: pulse > systolic

26. Pelvic Trauma Evaluation SIGNS & SYMPTOMS History, Mechanism of Injury, and Pain are the biggest clues Consider the force vectors into the pelvis based on details of the scene and physical signs found on exam Ask the alert, orientated patient about the presence of pain in the pelvic area, lower back (sacroiliac joint), groin and/or hips Any positive reply should be assumed to be a pelvic fracture Overall, maintain a high degree of suspicion for pelvic instability whenever history or symptoms suggest

27. Pelvic Trauma Physical Exam Bruising or swelling over the bony prominences Deformities or malrotation (without obvious extremity fracture) Impaired or painful LE movements Lack of distal lower extremity pulses Leg length discrepancies Open wounds in the pelvis Bleeding from rectum, vagina or urethra Testicular or perineal bruising/hematoma

28. Pelvic Trauma Evaluation

29. Pelvis Trauma Evaluation: Rocking Traditional teaching: “Rocking” or “springing” of the pelvis Use your palms to gently compress the pelvis inwards or downwards to assess for instability Landmark study by Grant published in 1990 Poor predictor of pelvic fractures with a specificity of 71% and a sensitivity of 59% May dislodge blood clots or further damage internal tissues by moving the broken boney fragments May be indicated in some cases but use with caution!! Rely on other physical findings as well as mechanism of injury instead

30. Pelvis Trauma Evaluation: Log Roll Anecdotal evidence of patients with pelvic fractures becoming hemodynamically unstable after log roll for back examination Avoid log rolling the patient! Has the potential to dislodge blood clots or exacerbate internal injuries by moving unstable fracture pieces

31. Pelvis Trauma Evaluation: Log Roll Partial log rolls of 10-15 degrees or scoop stretchers may provide better options for first responders

32. Pelvic Fracture: Treatment If mechanism of injury and hypotension (or increased SI) Damage control resuscitation Permissive hypotension to limit crystalloid use (systolic 80mmHg if no head injury) Resuscitate with whole blood Add TXA and calcium for coagulation support Keep warm AND Bind the pelvis!!

33. Procedure: Pelvic Binding Decreases the available space in the pelvis for hemorrhage to accumulate and may help create faster tamponade effect to stop any active vascular bleeds. Has been proven to increase MAP pressures in the short term May help keep all the sharp boney fragments from moving and causing more damage in and out of transport

34. Procedure: Pelvic Binding Special consideration: vertical shear pelvic ring fractures causes the effected side of the pelvis to be anterior/superior displaced so the lower extremity should be reduced inferiorly before closure of the pelvic with binder

35. Procedure: Pelvic Binding Binding can be performed with commercial products or simply with a bed sheet as shown below Common pitfall is placing the binder too high with no true closure of the pelvic ring Make device lays over the bilateral greater trochanters with proper amount of pressure to close the pelvic ring

36. SAM Pelvic Binder The SAM Pelvic Sling II has strong evidence supporting its use while reducing the risk of over-compression Uses controlled and consistent 180N required for stabilization with an autostop buckle to reduce the risk of over-compression in case of internal rotation injuries of the pelvic ring

37. Pelvic Binder rules to live by A pelvic binder is a treatment intervention rather than a packaging intervention and should be applied early Hypotension + high energy trauma (fall, mvc ) = binder Adequate training must be provided to ensure proper placement of device Associated femoral fractures should also be reduced/stabilized

38. Pelvic Binder rules to live by Patients with unstable pelvic fractures should not be fully log rolled on or off of a spinal board Place the pelvic binder next to the skin not over clothes Pelvic binder should be applied prior to extrication when possible

39. Bottom Line Again… Mechanism of injury!! Ask the alert patient about the presence of pain in the pelvic, back or groin regions. Standard trauma assessment and interventions but do not fully log roll the patient and do not ‘rock’ the pelvis.

40. Bottom Line AGAIN… Look for key physical signs. If there is any suspicion of fracture +/- hypotension, immobilize the pelvis. Use a scoop stretcher to facilitate the patient's movement on to a spinal board. Damage control resuscitation Adequate pain management with ketamine

41. Questions??