Management of Pelvic Fracture with Hemodynamic Martin A

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16 14 – 12 1171 Nearly a quarter of ,Miami,Florida Trauma-induced co- 9 – 10 5 15 Potential lethal injury pat- bilization of pelvic fractures 3 ecause of the applied concentric Nicholas Namias, MD Recent studies suggest tissue hypoperfusion 4 11 and B. Noninvasive external pelvic stabilization with commer- A. The years since 2008 have seen an explosion in the use LGORITHM agulopathy (TIC) is athe hypocoagulable first state 24 that hours of occurs injurycauses within as such a response as to a tissuetion variety of hypoperfusion, of interlinked inflammation, the andhypothermia neurohumoral during activa- resuscitation further system. exacerbate the ongoing Acidosis,coagulopathy. hemodilution, and terns include those with iliacsacral wing fractures. fractures and transforaminal trauma patients present with acute coagulopathy, whichciated with is a asso- 4-fold increase in mortality. leading to protein CTIC. Other activation proposed may mechanisms play include anfactor hyperfibrinolysis, clotting important dysfunction, role in and endothelial glycocalyx degradation. cially available wrappingsheets devices has become or standard and can improvisation bearena. applied with in Commercially the available prehospital bed devices offer aproach, with standardized clear ap- instructions fornient application, and fasteners have conve- forsheeting is maintaining applied at closure. the level Alternatively,cured of pelvic with the large greater trochanters Kelly and clamps se- to avoid pressure from knots. of physiologically guided massiveviscoelastic transfusion coagulation protocols, with testingand [thromboelastography thromboelastometry (ROTEM)] (TEG) guidance tailoring defined ratio protocols to physiologic endpoints. Circumferential pelvic sheeting and binders arein contraindicated lateral compression fractures b force, which can worsen the deformity.comparing A the cadaveric efficacy study of in circumferential 2013 pelviccommercial sheeting pelvic versus a binder (T-POD; Pyng MedicalBritish Corp., Columbia, Canada) Richmond, for sta demonstrated no significant differences during motion-generated Early recognition of TIC byROTEM may viscoelastic potentially testing be including used to TEGand guide and blood-product reduce transfusion mortality. Abeen published randomized showing that controlled viscoelastic assay guided resuscitation trial of has trauma patients recentlyprotocol requiring had use a of lower mortalityon a than conventional coagulation massive a assays. transfusion group resuscitated based ligaments that bindtion the iliac of bones thesesignificant to sacral-iliac the pelvic sacrum. ligamentous hemorrhage. Disrup- complexes can cause 2016 updates s ’ — WTA 2015 A instability Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved. The internal iliac vasculature 2 the approach in general has not 1 6, 2015, in Telluride, Colorado. – Management of pelvic fracture with hemodynamic Martin A. Schreiber, MD, David V. Shatz, MD, Roxie M. Albrecht, MD, Mitchell J. Cohen, MD, Western Trauma Association Critical Decisions in Trauma: Thai Lan N. Tran, MD, Karen J. Brasel, MD, PhD, Riyad Karmy-Jones, MD, Susan Rowell, MD,

Pelvic ring injuries range from low-energy pubic ramus ince the publication oftion the algorithm 2008 for Western Trauma the Associa- management of pelvic fracture with

recommendations for particular areas but doesThe not WTA establish the algorithms standard are ofthe based care. expert on opinion the of evidence theThe available task in force WTA the in considersdetermination literature the regarding and recent its use time application frame is of ofand to the health the publication. be care professionals made with algorithm by full the to consideration treating of physician be the individual patient voluntary. The ultimate Published online: August 18, 2016. Florida; Oregon Health and ScienceOregon; University (K.J.B., Legacy S.R., Health M.A.S.), Portland, Systemsof (R.K.-J.), Vancouver, California Washington; University Davis (D.V.S.), Sacramento,(R.M.A.), California; Oklahoma University City, of Oklahoma;(M.J.C.), Oklahoma San University Francisco, of California; Harvard California University anderal San Massachusetts Hospital Gen- (M.A.D.), Boston, Francisco Massachusetts; University of Hawaii andMedical Center Honolulu, Queens (W.L.B.), Hawaii; and University of Colorado and Den- ver Health (E.E.M.), Denver, Colorado. Association, March 1 clinical status and available institutionalto resources. Moreover, it take is the nottreating particular intended place patients. of judgments of healthand Surgical care Critical Care, providers MillerBox in School 016960 of D-40, diagnosing Miami, Medicine/University of FL Miami, and 33101; PO email: [email protected]. Marc A. DeMoya, MD, Walter L. Biffl, MD, Ernest E. Moore, MD, and the presacral venous plexus are located just anterior to the changed, but several componentsinto of sharper focus, the and approach ation have new in component come a is few gaining centers somedate (Fig. trac- 1). to This manuscript recognize isgraphic an some is interim up- of markedand where the explanatory text it changes. follows. differs The from accompanying the 2008fractures algorithm, to high-energy unstable patternsmodynamic that instability. can The result Young and infied Burgess he- system identi- injuryapplied patterns force. This correlating classificationinjury system with described patterns: four anterior the pelvic compression posterior (LC), compression direction vertical (APC), shear of (VS), lateral LC and and combined the APC injuries. numbered injuries stages are from further I classifiedplacement to and into III, severity of progressively which injury. represent increasing dis- hemodynamic instability, J Trauma Acute CareVolume Surg 81, Number 6 The Western Trauma Association (WTA) develops algorithms to provide guidance and DOI: 10.1097/TA.0000000000001230 Submitted: February 3, 2016, Revised: May 24, 2016,From Accepted: the of University Miami June and Jackson N.N.), 29, Miami, Memorial Hospital (T.L.N.T., 2016, This algorithm was presented at the 45th annual meeting of the Western Trauma Address for reprints: Nicholas Namias, MD, MBA, FCCM, FACS, Division of Trauma S

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Figure 1. Management of pelvic fracture with hemodynamic instability. activities.17 No differences in outcomes have been demonstrated In contrast to early percutaneous external pelvic fixation, between pelvic sheeting and commercial devices. preperitoneal pelvic packing has become increasingly popular C. After a negative FAST or DPA in appropriate patients, as it is easy to perform, no specialty consultants are needed, and there are three complementary, and not mutually exclusive, op- the feedback on the success or failure of the procedure is immedi- tions that can be performed immediately: pelvic stabilization, ate. It also allows the general surgeon to go to the place where he preperitoneal packing, or REBOA. Angiographic embolization or she is most comfortable with the unstable patient, the operating remains a mainstay either as the initial phase of stabilization or room.25–31 In a study of 40 hemodynamically unstable patients as a follow-up to preperitoneal packing.18–20 Angiography targets with pelvic fractures, direct retroperitoneal pelvic packing was bleeding from an arterial source, whereas preperitoneal packing as effective as angiography in stabilizing pelvic bleeding.27 controls bleeding from venous and bony sources (85% of pa- Preperitoneal packing is performed by making an 8-cm midline tients). Patients who do not respond to fluid resuscitation and incision starting above the pubis extending toward the umbilicus. prompt implementation of mechanical stabilization should be Skin, subcutaneous tissue, and fascia are opened in the midline. considered candidates for angioembolization. Many authors rec- Care is taken to avoid entry into the peritoneal cavity. The bladder ommend early angiography and embolization to improve patient is retracted laterally and three laparotomy pads are placed sequen- outcome. However, angiography is a lengthy procedure preclud- tially deep to the pelvic brim toward the iliac vessels on each side, ing other simultaneous therapeutic interventions. In addition, with the sacrum defining the posterior limit of the packing. The there can be considerable delay getting to the angiography suite, fascia and skin are then closed. Removal or exchange of the packs which may not be tolerated in hemodynamically unstable pa- should take place in 24 to 48 hours. In experienced hands, the pro- tients. The most appropriate timing of angiography remains an cedure can be performed in 20 minutes.1 Packing should be ongoing debate. The development of a hybrid trauma operating followed by application or reapplication of a binder, or external room is an emerging trend to avoid delay in hemorrhage control fixation, depending on local resources and clinical condition. from unnecessary patient movements. This hybrid OR model of- D. Resuscitative endovascular balloon occlusion of the fers resuscitation with angiographic and operative capabilities. aorta (REBOA) is a surgeon-performed endovascular approach Temporary fracture stabilization can be achieved by appli- to aortic inflow occlusion to the pelvis. The aim of REBOA is cation of a percutaneous external fixator. Anterior external fixa- to temporarily control arterial hemorrhage and preserve cerebral tion performed through the iliac wings or supra-acetabular and myocardial perfusion. REBOA deployed in Aortic Zone 3 region is indicated in open book fractures with intact posterior lig- (just above the aortic bifurcation) has the potential to provide im- aments. In posterior pelvic ring disruption, the pelvic C-clamp is mediate hemorrhage control in hemodynamically unstable pa- applied to the dorsal iliac bones. The frame design and pin loca- tients with pelvic fractures. Although REBOA effectively tion are selected on the basis of pelvic injury pattern, patient body increases systolic blood pressure in the setting of hemorrhagic habitus, available imaging, and surgeon experience.3,16,21 The ap- shock, there is no clear evidence suggestive of a reduction in plication of orthopedic hardware in the setting of hemodynamic mortality.32 The role of REBOA in this algorithm remains uncer- instability has fallen out of favor because of the technical de- tain and the optimal method to train practitioners to perform this mands and time-consuming nature of the procedure in the emer- procedure in a timely fashion has not yet been defined. Experi- gency setting.22–24 ence with this new technique is limited, but growing. In a

Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved. J Trauma Acute Care Surg Volume 81, Number 6 Tran et al. research setting, trained acute care surgeons are able to perform 10. Brohi K, Singh J, Heron M, Coats T. Acute traumatic coagulopathy. J – this procedure in 6 minutes. With proper preparation and avail- Trauma. 2003;54(6):1127 1130. 11. Hess JR, Brohi K, Dutton RP, Hauser CJ, Holcomb JB, Kluger Y, ability of local resources, REBOA can be an effective adjunct Mackway-Jones K, Parr MJ, Rizoli SB, Yukioka T, et al. The coagulopathy in the management of hemorrhagic shock, prolonging survival of trauma: a review of mechanisms. JTrauma. 2008;65(4):748–754. until definitive hemostasis can be obtained through preperi- 12. Moore HB, Moore EE, Gonzalez E, Chapman MP, Chin TL, Silliman CC, 33–37 toneal packing or angiographic embolization. Banerjee A, Sauaia A. Hyperfibrinolysis, physiologic fibrinolysis, and fi- In summary, emerging state-of-the-art management of the brinolysis shutdown: the spectrum of postinjury fibrinolysis and relevance – hemodynamically unstable patient with a pelvic fracture in 2016 to antifibrinolytic therapy. J Trauma Acute Care Surg. 2014;77(6):811 817; discussion 817. includes hemostatic resuscitation guided by viscoelastic testing, 13. Mann KG, Freeman K. TACTIC: Trans-Agency Consortium for Trauma- external pelvic stabilization with wrapping devices, and defini- Induced Coagulopathy. JThrombHaemost. 2015;13(Suppl 1):S63–S71. tive hemorrhage control with angiographic embolization and/or 14. Noel P, Cashen S, Patel B. Trauma-induced coagulopathy: from biology to preperitoneal packing. During resuscitation, TIC can be recog- therapy. Semin Hematol. 2013;50(3):259–269. nized early by the use of viscoelastic assay such as TEG and 15. Gonzalez E, Moore EE, Moore HB, Chapman MP, Chin TL, Ghasabyan A, ROTEM to guide blood-product transfusion. Noninvasive exter- Wohlauer MV,Barnett CC, Bensard DD, Biffl WL, et al. Goal-directed hemo- nal pelvic stabilization with pelvic sheeting or commercially avail- static resuscitation of trauma-induced coagulopathy: a pragmatic randomized clinical trial comparing a viscoelastic assay to conventional coagulation assays. able devices can be applied in the prehospital setting to provide Ann Surg. 2015;263(6):1051–1059. temporary stabilization and reduce hemorrhage from bony sur- 16. Rajab TK, Weaver MJ, Havens JM. Videos in clinical medicine. Tech- faces and venous disruption. Early angiography and emboli- nique for temporary pelvic stabilization after trauma. NEnglJMed. 2013; zation along with preperitoneal packing are complementary 369(17):e22. techniques in definitive hemorrhage management. Although 17. Prasarn ML, Conrad B, Small J, Horodyski M, Rechtine GR. Comparison promising, the role of REBOA as an adjunct in the manage- of circumferential pelvic sheeting versus the T-POD on unstable pelvic injuries: a cadaveric study of stability. Injury. 2013;44(12):1756–1759. ment of hemorrhagic shock secondary to pelvic fractures re- 18. Westhoff J, Laurer H, Wutzler S, Wyen H, Mack M, Maier B, Marzi I. Inter- mains uncertain. Temporization with REBOA is a promising ventional emergency embolization for severe pelvic ring fractures with arte- new frontier whose exact role is yet to be determined. rial bleeding. Integration into the early clinical treatment algorithm. Unfallchirurg. 2008;111(10):821–828. 19. Hauschild O, Aghayev E, von Heyden J, Strohm PC, Culemann U, DISCLOSURE Pohlemann T, Suedkamp NP,Schmal H. Angioembolization for pelvic hem- The authors declare no conflicts of interest. orrhage control: results from the German pelvic injury register. J Trauma There are no external sources of funding for this work. 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