Unstable Pelvic Fracture: Clinical Approach
C. William Schwab, MD, FACS
Professor of Surgery Department of Surgery, University of Pennsylvania School of Medicine, Chief, Division of Traumatology & Surgical Critical Care, University of Pennsylvania Medical Center, Philadelphia, PA, USA
Introduction:
Pelvic fracture that presents with a life‐threatening hemorrhage is rare. In 1997, of the 2043 pelvic fractures reported to the Pennsylvania Trauma Systems Foundation, there were a total of 728 (36%) complex pelvic fractures (AIS 3, 4, 5) and only 81 (11%) of these patients presented with a systolic BP less than 90 mmHg. Despite advances, mortality for these patients with the most severe injuries has remained high at 40–50%. Therefore, preplanned protocols and established clinical pathways must afford rapid mobilization of resources and provide a structure for complex interdisciplinary decision‐making for these highly complex and stressful cases.
We have adapted several techniques and treatment strategies to our current management scheme (). This is not meant to be a comprehensive approach to the management of all pelvic fractures, but rather to focus on the group of patients with a biomechanically unstable pelvic fracture (UFP) presenting with significant and persistent blood loss. This can be determined on physical examination and by plain film radiographs. A UFP is defined simply as any fracture that makes the pelvic ring unstable. Classically they are the higher energy type fractures classified as anterior/posterior compression, lateral compression and vertical shear fractures. The use of a Noninvasive Pelvic Stabilization (NIPS) device and TPODTM (trauma pelvic orthotic device, BioCybernetic International) is gaining widespread acceptance anytime a UFP is identified. This two‐part “pelvic corset” is easy to apply, and has “closed” most unstable pelvic rings. The degree of closure can be checked by repeat plain film of the pelvis.
This clinical pathway may not be applicable to every hospital and in rural, or smaller hospitals with little experience, early transfer to a regional center should be strongly considered. Transfer should occur only after extrapelvic bleeding has been ruled out or treated, a noninvasive pelvic stabilizing (NIPS) device applied, and blood component resuscitation begun. This requires considerable judgement and no general statement can be made as to the exact or best “cut point for transfer”, as each case must be decided based on resources, speed of accessing those resources and experience. In general, most pelvic fractures presenting in shock do NOT have a UFP pattern (i.e. an open or crushed pelvic ring); rather, the majority have intraabdominal bleeding and require laporatomy and control of bleeding from abdominal viscera or vessels.This is especially true in children and in adults with simple or stable pelvic fracture. Conducting a laporatomy with a pelvic fracture requires modification and will be discussed below.
Figure 1 General algorithm for UFP in shock.
Conducting a Laparotomy with an Unstable Pelvic Fracture:
When an exploratory laparotomy must be done to control hemorrhage and treat visceral injury, this is best done with a NIPS device in place. Fascial release of the lower abdomen with an unstable pelvic ring has been shown to increase pelvic volume and may release any pelvic tamponade. Midline laporatomy, therefore, is best kept “high” and if possible the inferior midline fascia not opened; however, the surgical team should not limit access to the lower abdomen and pelvis, if necessary to gain control of injuries. The laparotomy is undertaken and rapid control of abdominal bleeding sites are sought and treated. Damage control techniques are best utilized as most patients have received multiple units of blood, and are cold and coagulopathic. If no abdominal source is found, the identification of a pelvic retroperitoneal hematoma is next sought. IF present this is left intact and therapeutically packed. Angiography is alerted that a study and embolization are needed. Therapeutic packing of the pelvis requires several wet sponges be placed deep into the pelvis followed with a series of sponges that tightly fill the pelvis. Subsequently, closure of the fascia and the abdominal skin to create a better tamponade effect has been our practice. This is followed by immediate angiography for embolization. These patients with pelvic packs and abdominal closure may develop abdominal compartment syndrome. They require continual bladder pressure monitoring, chemical paralysis and return to the OR within 24–36 hours. On rare occasion, bleeding into the pelvic hematoma is severe and some have recommended bilateral internal iliac artery ligation to decrease arterial flow into the central pelvis. This is a heroic maneuver requiring opening of the hematoma superiorly. It should be done rapidly and followed with tight pelvic packing and angiography. The mortality is very high even in centers with considerable pelvic fracture experience.
Figure 2 UFP: Abdominal bleeding requires LAP.
Conclusion:
The exsanguinating pelvic fracture patient is uncommon (1–2% of all pelvic fractures). Interdisciplinary clinical pathways are necessary to optimize resource mobilization, decision‐making and care. Non‐invasive pelvic stabilization devices should be rapidly applied to all UFP as a part of early resuscitation. Only life‐threatening intraabdominal bleeding should prompt laparotomy. Pelvic angiography and embolization should be used on all patients with a pelvic blush on CT scan, any pelvic fracture with hemodynamic instability and no other bleeding source identified, or those seen to have a large pelvic hematoma found at laparotomy. If laparotomy is necessary, a (pelvic corset) device should be applied prior to opening the abdomen. Closure of the abdomen and creation of temporary abdominal compartment syndrome may be necessary for tamponade of pelvic bleeding, while angiography and embolization is completed.
Management of Musculoskeletal Injuries From Missiles and Fragments Primary or Delayed Primary Closure – Time to Readjust Traditional Indications? Delay is Best!, still the BEST!
C. William Schwab, MD, FACS
Professor of Surgery, Department of Surgery, University of Pennsylvania School of Medicine, Chief, Division of Traumatology & Surgical Critical Care, University of Pennsylvania Medical Center, Philadelphia, PA, USA
High‐energy wounds of the extremities are often the result of high velocity missiles or blast injury. These complex wounds display a distinct pattern of injury including tissue cavitation, compression, crushing, and avulsion with associated fracturing of arterioles. While an increasing body of literature has supported the immediate skin closure of low velocity wounds, it remains unproven that such immediate definitive treatment is safe and efficacious for high‐energy wounds.
Unlike low velocity wounds or standard open extremity fractures, high energy wounds are often contaminated by foreign bodies, shrapnel, soil, stones, and shoe/clothing material, potentially placing them at higher risk of infection, skin graft failure and delayed amputation. A large body of evidence favors aggressive debridement of necrotic and infected tissue followed by second‐look re‐debridement and early secondary closure of the soft tissue defect following definitive fracture stabilization, preferably early, up to 72 hours following injury. Closure of the soft tissue defect will often require pedicle or free tissue flaps.
While immediate primary closure of these wounds may offer the advantage of reduced hospital stay, they do not improve healing time, and long‐term functional status. Furthermore, immediate closure often requires more extensive debridement resulting in larger defects to ensure pristine tissue upon which flaps are sure to take. Additionally, soft tissue defect coverage without allowing better demarcation of viable and non‐viable tissue can lead to septic complications leading to disastrous flap failures often resulting in unnecessary limb amputation. There is no conclusive evidence that septic complications are significantly different whether the wounds are closed immediately or in delayed primary fashion before 72 hours. The round‐the‐clock presence requirement of advanced microsurgical plastics and orthopedics teams, which are needed for immediate primary closure, make this option forbiddingly expensive and in many cases impractical for no additional benefit.
We believe that the best management of large contaminated high‐energy extremity wounds continues to be repeated debridements followed by early definitive fracture stabilization and soft tissue coverage in a delayed primary fashion.
The Exsanguinating Patient: Get Me to the Theatre on Time: Hemostatic Resuscitation in “Extreme” Trauma The Road to Damage Control Surgery
C. William Schwab, MD, FACS
Professor of Surgery, Department of Surgery, University of Pennsylvania School of Medicine, Chief, Division of Traumatology & Surgical Critical Care, University of Pennsylvania Medical Center, Philadelphia, PA, USA
Exsanguination is the “loss of the entire blood volume within minutes” and connotes a highly lethal event. Patients who are exsanguinating, especially from major vascular injury, or with massive visceral injury sustain a catastrophic physiologic insult that must be halted rapidly to save life. This insult is marked by severe and continuous hypotension, which quickly propagates cell shut down and loss of cell metabolism and tissue function. Hypothermia, acidosis and coagulopathy result, sometimes within minutes of wounding. Three parameters in the face of massive injury signify physiologic exhaustion and impending death. The point at which this physiologic insult becomes irreversible remains ill defined, however recent observations indicate that the process must be recognized and interrupted earlier in the resuscitation for improved survival.
Resuscitation is an intense period of medical and surgical care where initial and continuous patient assessment by experienced people directs concurrent diagnostic and therapeutic procedures and at times the commencement of surgery to save life or limb. Resuscitation of the trauma patient has traditionally described that phase in acute injury care that links the prehospital and hospital environments. Resuscitation is the group of coordinated actions performed to secure airway, support breathing, restore circulation and assess brain and spinal cord function; all done within minutes of arrival. This is a dynamic time and requires the trauma team leader and trauma team to rapidly develop a differential diagnosis based on the treatment effectiveness and results of simple diagnostic tests.
Centers with significant experience with penetrating injury from gunshot wounding have contributed to the development and application of Damage Control. Many papers are available that describe the technical aspects of performing the abbreviated laporatomy and a cadre of tricks and “pearls” to stop bleeding. Few papers delineate the techniques of “ABBREVIATED” resuscitation that is necessary to span the gap between arrival and incision. Fewer have attempted to define an “exsanguination syndrome” and thus allow early decision to perform Damage Control. Now in Iraq performing the Damage Control trilogy frequently, the trauma military teams have gained experience identifying this critical group of patients and developed an abbreviated resuscitation approach using a “hemostatic” resuscitation approach. Most important, time to the operating room and incision has become the critical performance factor and focuses the team on efficiency and proficiency in every maneuver. These efforts have resulted in considerable improvement in outcome with these devastating injuries.
This lecture will include the following objectives and demonstrate the abbreviated resuscitation on the road to Damage Control.
Objectives:
Define the term “exsanguination” in the modern context.
Demonstrate the clinical parameters to identify the exsanguination “syndrome”.
Review newer our resuscitation and DX protocols.
Discuss how the clinical parameters validate the use of Damage Control or salvage surgery.
Exsanguination: the loss of one's blood volume within minutes!
Figure 1 Damage Control.
Selected Reading: Early massive trauma transfusion: current state of the art. J Trauma (supplement) 60(2) June 2006
The Role of the Medical Helicopter in Trauma and Emergency Care: the US Experience
C. W. Schwab, MD, FACS
Professor of Surgery Department of Surgery, University of Pennsylvania School of Medicine, Physician‐in‐Chief, Pennstar Flight Program, University of Pennsylvania Health System, Philadelphia, PA, USA
History:
The first use of helicopters to evacuate a wounded solider occurred in World War II in Southeast Asia. During the Korean conflict, helicopters began routine frontline evacuation missions. Their use was then greatly expanded in the Vietnam War where the patients were moved inside the helicopter and treated enroute to the hospital. Mortality decreased from 4.5 deaths per 100 casualties in World War II to 2.5 deaths per 100 casualties in the Korean War to less than 1 death per 100 casualties in the Vietnam War. Although many factors contributed to this phenomenon, the increase in the rate of transfer to definitive care and prehospital treatment by advanced personnel were certainly factors.
Helicopters were first used exclusively for patient care in Europe in the late 1960s and began in the United States at St. Anthony's Hospital in Denver in 1972. The aircraft was based at the hospital and the crew was comprised of a physician and nurse. As of October 2005, the Atlas and Database of Air Medical Services (ADAMS) reports that there are 272 rotor wing services in the U.S. comprising 614 air medical bases and 753 aircraft.
Baxt and Moody, The Impact of a Rotorcraft Aero medical Emergency Care Service on Trauma Mortality, JAMA, 1983;249, 3047–3051.
Varon J, Wenker OC, Fromm RE, Aero medical Transport: Facts and Fiction, Internet J of Emer and Intensive Care Med, 1997; Vol 1, Num 1.
Atlas & Database of Air Medical Services, October 2005
Presumptions of Medical Helicopter Services:
Three presumed advantages of helicopter transport are consistent throughout the medical literature. 1) Modern helicopters are capable of flying at greater than 150 mph and therefore decrease the transport time and offer more patients a chance to get to a definitive care center within one hour. 2) They have access to remote locations secondary to their ability of vertical take‐offs and landings. Not only does this allow landing on highways and fields, but they also has been shown to be invaluable for mountain rescues. 3) Staff on medical helicopters are more highly trained than their ground transport colleagues. In addition, the helicopters tend to carry more sophisticated equipment. The combination of these two factors allows earlier initiation of more advanced treatments. There are however, several disadvantages of medical helicopters. 1) Medical helicopters are the most expensive form of patient transport. 2) Helicopter crashes are a significant risk to the crew and patient. 3) Helicopters are often grounded for weather related reasons.
Cunningham et al, A comparison of the association of helicopter and ground ambulance transport with the outcome of injury in trauma patients transported to the scene, J of Trauma, 1997; 43, 940–946.
Arfken et al, Effectiveness of helicopter versus ground ambulance services for interfacility transport, J of Trauma, 1998; 45, 785–790.
Helicopter Transport, Patient UK, www.patient.co.uk
The makeup of the crew has also been debated in the literature over whether or not a physician on board improves outcome. Hamman et al compared crews with and without a physician on board. The patient demographics and injuries were similar. They found that having a physician on board had no impact on patient improvement or deterioration during transport. The overall mortality outcomes were also equal. Harris reviewed 20 crews made up of a combination of nurses, paramedics, and physicians. The crews then flew and provided care to ResusciAnne manikins. He found that the outcomes were improved based on the level of aero medical experience and not the level of training of the crewmember. On the other hand, Snow et al and Rhee et al found improved outcomes with physicians on boards. These outcomes were primarily because of judgment decisions and not clinical interventions.
Hamman B, Cue J, et al, Helicopter Transport of Trauma Victims: Does a physician make a difference? J of Trauma; 1991, 31:490–494
Harris, Performance of Aero medical Crewmembers: Training or experience? American Journal of Emergency Medicine, 1986;4, 409–411.
Snow N, Hull C, Severns J, Physician presence on a helicopter emergency medical service: necessary or desirable? Aviation, Space, and Environmental Med, 1986;Dec, 1176–1178.
Rhee et al, Is the flight physician needed for helicopter emergency medical services, Annals of Emer Med, 1986, 15:174–177.
Schwab CW, Peclet, M, Zackowski, SW et al, The impact of an Air Ambulance on an Established Trauma Center, J Trauma, 1985, 25, 580–586.
Medical Helicopter Facts
In 1987, there were 154 aero medical services in the U.S. This number has increased to 272 services in October 2005 according to the Association of Air Medical Services (AAMS), which is a voluntary non‐profit organization that makes up approximately 85% of the industry. These 272 services operate 753 rotor wing EMS aircraft. Fifty‐three percent of the services operate one aircraft, 18% operate two aircrafts and 5% operate greater than 10 aircrafts. (see chart). The 272 services are owned and operated by the following groups; hospital (138), private (74), hospital/private (17) (see chart).
The helicopters are used for scene transports, interhospital trauma transports and interhospital medical transports. In the United States in 2000, 78% of transports were interhospital and 28% were scene responses. Baxt et al found a 21% reduction in mortality in patients transferred by helicopter when compared with the expected death rate. Jacobs et al reviewed 10 years of an aero medical system and found a 13% overall mortality reduction. They found a 35% mortality reduction for patients with a Trauma Score between 4 and 13. Cunningham et al found a trend toward improved survival only for patients with a Trauma Score between 5 and 12. Arfken et al found no stastical difference for improved outcomes for interhospital transfers.
Economically, there has been much debate about the cost effectiveness of the helicopter transports. Certainly the studies that have found no difference in outcomes between patients transported via ground versus air would not have an economically advantage. The average cost of a flight is between $5,000 and $10,000. Rosenberg et al reviewed the economic input on the University of Michigan Health System (UMHS) for 2001. The mean inpatient revenue for each transported patient was $46,279. Overall, the patients accounted for only 3% of the admissions but 15% of the UMHS revenues totaling $62 million. They also reviewed downstream patient generated revenue for both inpatient and outpatient services for the years 1997, 1998, 1999, 2000, and 2001 of patients that were brought to UMHS via air transport. Return activity generated an additional $22 million and $27 million for inpatient and outpatient services respectively. A somewhat unquantifiable economical consideration of medical helicopters is the public's positive perception of institutions that have flight programs and whether a helicopter increases an institution's “status.” To date there is no study that addresses the financial implications of this perception.
ADAMS (Atlas & Database of Air Medical Services) Database as of Oct 2005
The Association of Air Medical Services (AAMS) website
Rosenberg, et al. Aero medical service: How does it actually contribute to the mission? J of Trauma, 2003;54:681–688.
Baxt et al, Hospital‐based rotorcraft aero medical emergency care services and trauma mortality: a multicenter study, Ann of Emerg Med, 1985;14:859–864.
Cunningham et al, A comparison of the association of helicopter and ground ambulance transport with the outcome of injury in trauma patients transported to the scene, J of Trauma, 1997; 43, 940–946.
Arfken et al, Effectiveness of helicopter versus ground ambulance services for interfacility transport, J of Trauma, 1998; 45, 785–790.
Rosenberg, et al. Aero medical service: How does it actually contribute to the mission? J of Trauma, 2003;54:681–688.
Jacobs et al, Helicopter air medical transport: ten‐year outcomes for trauma patients in a New England program, Connecticut Medicine, 1999; 63, 677–682.
Unfortunately, medical helicopters have a high crash rate. Between January 1983 and April 2005, there 182 EMS rotorcraft crashes. Of these, 39% had fatalities killing 184 occupants (45% of the 44 patients and 32% of the 513 crewmembers). When the accident occurred at night, the fatality risk tripled and when there was bad weather involved, the risk increased eight fold. Wright found that between 2000 and 2004 there were 1.8 fatal helicopter crashes per 100,000 flight hours. As such, a pilot flying 20 hours per week for 20 years, has a 37% chance of being in a fatal crash (20×52×20×1.8/100,000 = 37%) Between 1993 and 2002, Bledsoe found that the cause of all medical helicopter crashes were pilot error (64%), mechanical failure (22%), undetermined (12%), and other (2%) of the time.
Because of the increasing rate of helicopter crashes, the FAA has made several recent changes (2004–2006) in policy to try and improve safety; 1) creation of a new task force to review and guide government and industry agencies, 2) required meetings with HEMS (Helicopter Emergency Medical Service) to discuss safety issues, 3) support teams for increased guidance of helicopter inspection programs, and 4) new rules for bad weather and night flights have been developed.
Baker et al, EMS Helicopter Crashes, Annals of Emergency Medicine, 2006;47, 351–356
Bledsoe and Smith, Medical Helicopter Accidents in the United States: A 10 Year Review; 2004;56, 1325–1329
FAA, EMS Helicopter Safety, January 24, 2006
Wright, Air medical service, an industry under scrutiny. Rotor Winter 2004–2005:6–8.
American Helicopter System:
The size of the aero medical system in the United States has dramatically increased over the last several years. As stated above, this is in part because of the financial and marketing benefits of a center owning a helicopter. However, access to trauma centers in the U.S. has become a central issue both in the medical literature and the lay press. Branas et al recently reviewed the percentage of U.S. citizens who have access to a trauma center within 45 minutes and 60 minutes. They found that 69.2% and 84.1% of the residents had access within those time frames if transport was by helicopter. This leaves nearly 47 million people without access to a center within an hour. One of the main conclusions that Branas made was that a significant number of residents could be within 60 minutes of a center if additional base helipads and helicopter systems were developed.
The aero medical crews in the United States are made up of the following configurations; nurse/paramedic (61%), nurse/nurse (17%), nurse/physician (9%), and other (13%). The oldest aero medical service in the world is the Swiss Army Aero medical Service. Unlike the U.S. systems, their crew makeup almost exclusively includes a physician and a nurse. Similarly, Germany uses a physician/nurse crew. Schmidt et al compared the standard U.S. crew to the German crew and found that the German system had improved overall survivor outcomes. It was unclear if the difference in outcome is because of the physician or the earlier interventions by the German teams.
Branas et al, Access to Trauma Centers in the United States, JAMA, 2005;293, 2625–2633.
Schmidt et al, On‐scene helicopter transport of patients with multiple injuries—comparison of a German and an American system, J of Trauma, 1993;33:548–555.