Trauma Grand Round“The PELVIS”

April 2016 Fran O’Keeffe

Joseph Mathew

Case 141 y/o male Working under bus, bus driven, pt dragged 150m

At scene: Unrecordable BP then SBP 70 GCS 15

En route: 5L N.Saline, Ketamine R pneumocath (poor Sats, reduced a/e right) Pelvic binder

MTP ACTIVATED

On arrival…

A Maintaining B Sats 99% on 15L Oxygen

• R pneumocath C sBP 80, HR 130

• 2 x 18G D GCS 14 E Massive truncal abrasions/degloving Large scalp wound

Arch Surg. 2012;147(9):813-818. Published online May 21, 2012

Cameron’s Textbook of Adult Emergency Medicine, 4e, Fitzgerald et al, Chest Trauma

ResusIntubation Bilateral ICC’s Right Lower Limb splint Scalp wound closure IDC insertion – frank blood

6 x PRBCs, 2 x FFP, 1 x Plat – Transient responder, ++ blood dependent – sBP 90 ! 120 ! 70 – R Subclavian MAC line ! To CT

pH 7.1Base Excess -10Bicarbonate 19 (24)INR 1.4Lactate 6.9 (<2)

Initial binary decision tree for pleural decompression, Fitzgerald et al, Pleural decompression and drainage during trauma reception and resuscitation.

Injury 2008;39:9-20

ResusIntubation Bilateral ICC’s Right Lower Limb splint Scalp wound closure IDC insertion – frank blood

6 x PRBCs, 2 x FFP, 1 x Plat Transient responder, ++ blood dependent sBP 90 ! 120 ! 70 R Subclavian MAC line ! To CT

pH 7.1Base Excess -10Bicarbonate 19 (24)INR 1.4Lactate 6.9 (<2)

Pelvic haematoma

SIJ disruption + fracture

CT scan

Extraperitoneal bladder rupture with contrast leak

OT

Pelvic Ex-Fix NOF fixation Tib/Fib IM Nail

Overnight in ICU- tachycardia/low BP Rpt CT Abdo: progression pelvic haematoma

Blush = Arterial Bleed

Angio-embolisationTheatre if fails

Case 221 y/o male Fall from 4th floor balcony (drugs/ETOH)

At scene: HR 120, sBP 120. GCS 3 ! 14

En route: Binder applied

? MTP

On arrival…

A Maintaining B Sats 98% on 15L Oxygen C sBP 110, HR 110

• eFAST +ve R PTx, abdomen • Binder

D GCS 15 E Obvious bilateral closed femur #s R LL: short + ER

Resus05.00 – 06.30 R ICC RIC Line and Art Line Intubation 4 x PRBC, 2 x Plat

! Taken to CT…

Left sided retroperitoneal haematoma with active

contrast blush

CT findingsHead Parafalcine and tentorium SDH, SAH 4mm midline shift

Chest Bilat Ptx (L = no ICC)

Abdo/Pelvis Vertical shear pelvic # (symphysis disruption) Active blush small bowel mesentery Pelvic haematoma (bladder compression) Pelvic blush at pubic symphysis Psoas haematoma with active blush (L4/5)

Parafalcine SDH4mm midline shift Sulcal effacement

CT findingsHead Parafalcine and tentorium SDH, SAH 4mm midline shift

Chest Bilat Ptx (L = no ICC)

Abdo/Pelvis Vertical shear pelvic # (symphysis disruption) Active blush small bowel mesentery Pelvic haematoma (bladder compression) Pelvic blush at pubic symphysis Psoas haematoma with active blush (L4/5)

Angio + IVC filter Lumbar artery embolisation AV fistula left internal iliac-embolisation

OT Pelvic ex-fix Laparotomy (colic artery repair)

– 300ml blood Left NOF Femur ex-fix (concern for fat emboli) EVD insertion

Total MTP = 18 PRBC, 11 FFP, 4 Plat, 2 Cryoprecipitate

CT findingsHead Parafalcine and tentorium SDH, SAH 4mm midline shift

Chest Bilat Ptx (L = no ICC)

Abdo/Pelvis Vertical shear pelvic # (symphysis disruption) Active blush small bowel mesentery Pelvic haematoma (bladder compression) Pelvic blush at pubic symphysis Psoas haematoma with active blush (L4/5)

Angio + IVC filter Lumbar artery embolisation AV fistula left internal iliac-embolisation

OT Pelvic ex-fix Laparotomy (colic artery repair)

– 300ml blood Left NOF Femur ex-fix (concern for fat emboli) EVD insertion

Total MTP = 18 PRBC, 11 FFP, 4 Plat, 2 Cryoprecipitate

pH 7.45Base Excess 2Bicarbonate 26 (24)INR 1.3Lactate 3.2 (<2)

Thank you