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Name:
Bleeding Pelvic Injuries - Diagnosis and Emergency Management
Description:
Bleeding Pelvic Injuries - Diagnosis and Emergency Management
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T00H14M44S
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https://cadmoreoriginalmedia.blob.core.windows.net/061675a7-f488-4858-a0e0-473ee5976392/Bleeding Pelvic injuries Diagnosis and emergency managemen.mp4?sv=2019-02-02&sr=c&sig=bb7JtCa7d7aeiEKw%2FondbvMBG8YIgTBP7cihMN7NKcM%3D&st=2024-11-23T12%3A27%3A30Z&se=2024-11-23T14%3A32%3A30Z&sp=r
Upload Date:
2024-05-31T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
ASHOK GAVASHAR: I'm supposed to talk on how to manage a patient with an Exanguinating pelvic injury. I'll be focusing on principles of emergency management, how to integrate imaging, resuscitation and interventions, because, like when you deal with a patient you've got to examine everything intermittently. What you do not have is time, and we have seen a lot of instances, unnecessary time is being wasted on imaging modalities,
ASHOK GAVASHAR: That does offer a lot of information with regards to the injury, yes, but they are not relevant with regards to dealing with a brief pelvic fracture, that is to keep the patient alive. So I would start off by looking through these principles and give you a brief detail about it. So this is the disclaimer that Stryker India want us to add and these are my personal disclosures and none of them have any relevance to the talk.
ASHOK GAVASHAR: So if you look at the incidence of mortality after a pelvic injury, it is around 17, 17 percentage for a closed fracture and we are not including the fragility fractures that we often encounter nowadays in the elderly population. These are data about high velocity pelvic injuries and the number goes up to 45 percentage. If you add an open pelvic injury and the number is almost 60 percentage, if we have a patient has got a bleeding pelvic fracture with dynamic instability.
ASHOK GAVASHAR: So most often you would lose more than one or two patients when you're dealing with a bleeding permanent fracture. So when you treat a patient with a bleeding pelvic injury, it is all about timing, right from the pre-hospital care, which is sort of a weak link in our country. But we definitely have made a lot of strides even in this scenario over the last 5 to 10 years. And once it is in your hospital, it depends on the expertise, the resources you have, and most importantly, the team, the skill set and the ability of those individuals to work as a team.
ASHOK GAVASHAR: And also the kind of. A border constant. So I'm looking to people who think that they can do it on a case by case basis, most often than not do favor. So this is a patient who's got a bleeding pelvic fracturing placenta to what would shock be 90/60 10 unless an examination meets? And if I ask you, what would be your first choice of investigation to want to see what exactly is there?
ASHOK GAVASHAR: Would you take a pelvic radiograph in a portable manner? Would you ask for a pelvic series? Radiographs that would include an inlet and outlet use along with the pelvis or the pelvis and a quick CT if your institution allows that. So we don't have any other system here. But I can tell you, I've asked this question before. And quite a few people have opted for a pelvis with a seating for one seat is indispensable, but I can tell you it has no role when you are dealing with a patient with a bleeding pelvic injury.
ASHOK GAVASHAR: All you require is just an A/B pelvic radiograph and if you can take it in a portable manner, it's brilliant. So basically imagining the pelvic injury would depend primarily on the patient's dynamic status. So if we have a patient who's unstable dynamically, then you have to rely on imaging that typically diagnosis on primary and associated lesions, which may have an influence on the life.
ASHOK GAVASHAR: And these investigations should be able to be carried out as part of the resuscitative measures and not separate. They shouldn't take any time out of your resuscitation. If you are a stable patient by blood, then that's great. You can do whatever imaging techniques that you want to diagnose, classify and then plan more definitive treatment at lesion. So if you take a patient with an unstable bleeding pelvic fracture, if you [INAUDIBLE] that you typically get and this AP images, they can give you a lot of information.
ASHOK GAVASHAR: If you look at them deeply, you can appreciate a superior predictor of a fracture on the right. You can also see disruption of the left sacroiliac joint, even though not greatly projectile, you can appreciate something that is going on in the left iliac. You can also see the asymmetry in the opposite fore, indicating the inferior fracture as well.
ASHOK GAVASHAR: And if you can take your time and draw these lines, you can also appreciate the kind of rotational and vertical instability that this patient, as all these things, can give you a whole deal of information in order to guide, process, take treatment. So in order to guide resuscitative treatment, all you need is an application. So once you've got your pelvis, what about next? The patient is bleeding.
ASHOK GAVASHAR: You do not know where the bleeding comes from, either from the pelvis or from an external source. The most common pelvic sources are the abdomen, thorax, and the cranium. Of these abdomen is the most important. So if you want to rule out any trouble, arguably the best thing in that situation would be to do an ultrasound, preferably portable again. The problem with ultrasound is it lacks sensitivity and is extremely user dependent.
ASHOK GAVASHAR: So other thing that you can do is do a diagnostic peritoneal tap. It is reliable, but it is invasive, but it works. And if you can combine these two techniques, which can be done very quickly, it makes the entire process extremely reliable in picking up an intra-arthropic bleed. The question that often comes to our mind is like instead of doing all these things, can we subject to a prince CT scan?
ASHOK GAVASHAR: I can tell you it is not recommended because oh, what could you maybe what other good you are seeking? Maybe I can tell you it is not a great place for resuscitation. So any patient who is like hemodynamic unstable should not go out of your sight and resuscitation is the key. Investigation should be done concurrently and not separated. So you have done your first diagnostic peritoneal tap.
ASHOK GAVASHAR: It is negative ruling out an internal plan, but your patient is not improving, even dynamic. So what to do next? It is quite logical at this point that the bleeding is coming from the pelvic fracture and you can't stop it. So how to go about it, there are two schools of thought here. Depending on institutional protocol, what the team believes and what they are trained on.
ASHOK GAVASHAR: So one school of thought is to go again and do a preperitoneal pelvic packing with an external fixator. What does it do? It creates a temporary effect, closed on the pelvic wall. And since most of your blade comes from skeletal and small veins, this works most of the time, and this does not require anything great. The other school of thought is to go ahead and do an angiography and then enable resection.
ASHOK GAVASHAR: The basis for this is most of the life threatening place, even though the incidence of arterial bleeds is extremely low in a pelvic fracture. If they are present, they can be life threatening. And if you can have major embolization in your protocol, you might end up sustaining a lot of lives. So I will just look into the pros and cons of either of these two school of thoughts and also tell you what we prefer.
ASHOK GAVASHAR: If you look at the coverage of roughly the success rates of radial embolization rates between 75 and 100%, in the indicated cases, so that's brilliant. Even though there are some instances of need for repeat embolization in up to 40% data reported, this is primarily dislodgement of the delphoid. If you use it and even coils, and some papers have even reported leads at the new site.
ASHOK GAVASHAR: If you look at the mortality rates after therapeutic embolization, if you look at the earliest studies, actually this is the data from the earlier studies, it goes up up to almost 90%. And most of this mortality is not primarily due to embolization per se, but it is due to the time taken for the institute or the team to do embolization. Because like a lot of times if they are doing on a case by case basis
ASHOK GAVASHAR: and if they do not have existing protocols, it takes a lot of time to find those available interventionists, keep their expertise and then prepare them so it takes a lot of time. So timing is the key with regards to embolisation. So with regards to therapeutic angiography, the problem is like as I said, we are kind of bleeding accounts for major bleeding in the hip fracture only 15% of the time.
ASHOK GAVASHAR: So if you take all the hip fractures in total one hip, less than 2% of pelvic fractures may actually need angiography. Our patients might benefit from it. So this is quite a labor intensive and exhaustive exercise for less than 2% of patients. And if you do not have all these setups in place and if you as I said, if you do it on a case by case basis, even if your patient requires a angiography actually less than half of the patients ultimately undergo because they believe it takes a toll.
ASHOK GAVASHAR: And sometimes you will lose your patients so embolisation depends primarily on availability and a lot of expertise. So what are the role of contrast CT at this point? So contrast CT, as we know, has got a very quick turnaround time and it can predict accurately the need for angiograph. So you can if you are relying on angiograph, what you can better do is do a contrast CT scan
ASHOK GAVASHAR: and if the contrast CT scan is negative, you can forget about angiogram, you don't need it. So it saves time and a lot of expertise and if your contrast CT is positive with intravascular externalization of contrast from either large or medium sized vessels, it suggests a strong need for embolization and you've got to wrap it up.
ASHOK GAVASHAR: So what about this case textbook? School of thought pre peritoneal pelvic packing the concept of pre peritoneal pelvic packing was introduced by Tim Pohlmann from Germany and it involves application of an anti ex fix and packing the pre peritoneal pelvic area by using outbound responders. It creates a pelvic dampener, which is often sufficient to stop bleeds that are coming from small and even up to midsized vessels.
ASHOK GAVASHAR: And using these protocols worldwide, there has been a reported reduction in mortality of more than 20% compared to the previous engine optimization protocols. So how was it done? It's an extremely easy technique, like you use a midline vertical incision and then like getting to the opposing fistal area, it just takes 10 to 15 minutes to do it.
ASHOK GAVASHAR: Apply the ex fix. Unless you apply the ex fix, you can't close the pelvic region, you can't control the volume. And then once that is done, start backing the bladder area, starting from the pre sacral area, then come up anteriorly. There is enough space actually, the hematoma creates a lot of cleavage there and then pack them continuously using 4 to 6 parts.
ASHOK GAVASHAR: It is capable of stopping most of the bleeds and what we have observed is like once we do the pelvic pattern, there is a dramatic reduction in the amount of blood transfusions these patients require. So in the year when it starts, like probably when we take them to packing it, they might have already required 4 to 6 pints of blood, but once the packing is done, most often it stops abruptly and it requires no special expertise,
ASHOK GAVASHAR: no external resources are required. We can do it, it's a simple technique. The only problem is that you need to remove them. Initially, we would remove them at 48 hours, but that had an unacceptable infection rate so now the current protocol is to remove them safely at 24 hours. The other problem is infection of 10 to 15
ASHOK GAVASHAR: percentage of infection has been reported and the infection rate is quite high. If you are dealing with an open fracture or a bladder injury that requires intervention. So what we follow is sort of the pelvic plate packing pattern protocol which we learn French. I learned from the Medical Center during my fellowship. So what we do is like the patient is applied a pelvic binder or a sheet on site when they are picked up or at the earliest when they reach you at the hospital.
ASHOK GAVASHAR: And once you are 80 pelvic X-ray and fast peritoneal type is done and you have sort of like narrowed it on the pelvis but if your patient is still not improving, what I mean by not improving is like if the systolic BP doesn't go up by more than 90 milligram mercury after two units of packed RBC transfusion. So if it doesn't happen, this is the time we think about taking the patient to the OR and do an external fixator and pelvic pack.
ASHOK GAVASHAR: So once the packing is done, transfer the patient to the ICU and think about further planning, but in case if the patient continues to be unstable, even after you ship the patients on the vova, this is the time you should suspect a major risk of bleeding, either from the internal iliac or even to the superior glutoarchinator {?] And this is the time we should think about the contrast CT and thereafter embolisation.
ASHOK GAVASHAR: So what this packing does is it gives you time. It reduces the need for embolization. So this is the data from the World Medical Center. If you look at their data, their mean time data that it took for them to take the patient to 6 minutes and 1 in 13 percentage of patients subsequently required an embolization. And that, too, it could be done at a mean of 10 hours, so it gives you a great deal of window,
ASHOK GAVASHAR: apart from reducing the need for embolization. So in summary, if you have a bleeding pelvic fracture patient, if it's stable, no problem. You take an AP pelvis X-ray doing a further x-ray, similar development if you require, doing your CT scans, go ahead and plan your definitive fixation. But if you have an unstable patient with the dynamic instability, then roll out extra pelvic sources of bleed.
ASHOK GAVASHAR: If they are present, they have to be dealt with appropriately, and if you have narrowed your bleed down to the pelvic fracture and if the patient is not dynamically improving, then you need to intervene. Intervene, we prefer to do it by using an external fixator and treatment and packing. And if the patient continues to be unstable, then do a contrast CT. If there is external resolution of contrast on the CT scan, then subject them to pelvic arterial gravity and subsequent embolization.
ASHOK GAVASHAR: And once they become stable and if they become stable, then you can think about planning your definitive fixation. Thank you.
Segment:0 .
ASHOK GAVASHAR: I'm supposed to talk on how to manage a patient with an Exanguinating pelvic injury. I'll be focusing on principles of emergency management, how to integrate imaging, resuscitation and interventions, because, like when you deal with a patient you've got to examine everything intermittently. What you do not have is time, and we have seen a lot of instances, unnecessary time is being wasted on imaging modalities,
ASHOK GAVASHAR: That does offer a lot of information with regards to the injury, yes, but they are not relevant with regards to dealing with a brief pelvic fracture, that is to keep the patient alive. So I would start off by looking through these principles and give you a brief detail about it. So this is the disclaimer that Stryker India want us to add and these are my personal disclosures and none of them have any relevance to the talk.
ASHOK GAVASHAR: So if you look at the incidence of mortality after a pelvic injury, it is around 17, 17 percentage for a closed fracture and we are not including the fragility fractures that we often encounter nowadays in the elderly population. These are data about high velocity pelvic injuries and the number goes up to 45 percentage. If you add an open pelvic injury and the number is almost 60 percentage, if we have a patient has got a bleeding pelvic fracture with dynamic instability.
ASHOK GAVASHAR: So most often you would lose more than one or two patients when you're dealing with a bleeding permanent fracture. So when you treat a patient with a bleeding pelvic injury, it is all about timing, right from the pre-hospital care, which is sort of a weak link in our country. But we definitely have made a lot of strides even in this scenario over the last 5 to 10 years. And once it is in your hospital, it depends on the expertise, the resources you have, and most importantly, the team, the skill set and the ability of those individuals to work as a team.
ASHOK GAVASHAR: And also the kind of. A border constant. So I'm looking to people who think that they can do it on a case by case basis, most often than not do favor. So this is a patient who's got a bleeding pelvic fracturing placenta to what would shock be 90/60 10 unless an examination meets? And if I ask you, what would be your first choice of investigation to want to see what exactly is there?
ASHOK GAVASHAR: Would you take a pelvic radiograph in a portable manner? Would you ask for a pelvic series? Radiographs that would include an inlet and outlet use along with the pelvis or the pelvis and a quick CT if your institution allows that. So we don't have any other system here. But I can tell you, I've asked this question before. And quite a few people have opted for a pelvis with a seating for one seat is indispensable, but I can tell you it has no role when you are dealing with a patient with a bleeding pelvic injury.
ASHOK GAVASHAR: All you require is just an A/B pelvic radiograph and if you can take it in a portable manner, it's brilliant. So basically imagining the pelvic injury would depend primarily on the patient's dynamic status. So if we have a patient who's unstable dynamically, then you have to rely on imaging that typically diagnosis on primary and associated lesions, which may have an influence on the life.
ASHOK GAVASHAR: And these investigations should be able to be carried out as part of the resuscitative measures and not separate. They shouldn't take any time out of your resuscitation. If you are a stable patient by blood, then that's great. You can do whatever imaging techniques that you want to diagnose, classify and then plan more definitive treatment at lesion. So if you take a patient with an unstable bleeding pelvic fracture, if you [INAUDIBLE] that you typically get and this AP images, they can give you a lot of information.
ASHOK GAVASHAR: If you look at them deeply, you can appreciate a superior predictor of a fracture on the right. You can also see disruption of the left sacroiliac joint, even though not greatly projectile, you can appreciate something that is going on in the left iliac. You can also see the asymmetry in the opposite fore, indicating the inferior fracture as well.
ASHOK GAVASHAR: And if you can take your time and draw these lines, you can also appreciate the kind of rotational and vertical instability that this patient, as all these things, can give you a whole deal of information in order to guide, process, take treatment. So in order to guide resuscitative treatment, all you need is an application. So once you've got your pelvis, what about next? The patient is bleeding.
ASHOK GAVASHAR: You do not know where the bleeding comes from, either from the pelvis or from an external source. The most common pelvic sources are the abdomen, thorax, and the cranium. Of these abdomen is the most important. So if you want to rule out any trouble, arguably the best thing in that situation would be to do an ultrasound, preferably portable again. The problem with ultrasound is it lacks sensitivity and is extremely user dependent.
ASHOK GAVASHAR: So other thing that you can do is do a diagnostic peritoneal tap. It is reliable, but it is invasive, but it works. And if you can combine these two techniques, which can be done very quickly, it makes the entire process extremely reliable in picking up an intra-arthropic bleed. The question that often comes to our mind is like instead of doing all these things, can we subject to a prince CT scan?
ASHOK GAVASHAR: I can tell you it is not recommended because oh, what could you maybe what other good you are seeking? Maybe I can tell you it is not a great place for resuscitation. So any patient who is like hemodynamic unstable should not go out of your sight and resuscitation is the key. Investigation should be done concurrently and not separated. So you have done your first diagnostic peritoneal tap.
ASHOK GAVASHAR: It is negative ruling out an internal plan, but your patient is not improving, even dynamic. So what to do next? It is quite logical at this point that the bleeding is coming from the pelvic fracture and you can't stop it. So how to go about it, there are two schools of thought here. Depending on institutional protocol, what the team believes and what they are trained on.
ASHOK GAVASHAR: So one school of thought is to go again and do a preperitoneal pelvic packing with an external fixator. What does it do? It creates a temporary effect, closed on the pelvic wall. And since most of your blade comes from skeletal and small veins, this works most of the time, and this does not require anything great. The other school of thought is to go ahead and do an angiography and then enable resection.
ASHOK GAVASHAR: The basis for this is most of the life threatening place, even though the incidence of arterial bleeds is extremely low in a pelvic fracture. If they are present, they can be life threatening. And if you can have major embolization in your protocol, you might end up sustaining a lot of lives. So I will just look into the pros and cons of either of these two school of thoughts and also tell you what we prefer.
ASHOK GAVASHAR: If you look at the coverage of roughly the success rates of radial embolization rates between 75 and 100%, in the indicated cases, so that's brilliant. Even though there are some instances of need for repeat embolization in up to 40% data reported, this is primarily dislodgement of the delphoid. If you use it and even coils, and some papers have even reported leads at the new site.
ASHOK GAVASHAR: If you look at the mortality rates after therapeutic embolization, if you look at the earliest studies, actually this is the data from the earlier studies, it goes up up to almost 90%. And most of this mortality is not primarily due to embolization per se, but it is due to the time taken for the institute or the team to do embolization. Because like a lot of times if they are doing on a case by case basis
ASHOK GAVASHAR: and if they do not have existing protocols, it takes a lot of time to find those available interventionists, keep their expertise and then prepare them so it takes a lot of time. So timing is the key with regards to embolisation. So with regards to therapeutic angiography, the problem is like as I said, we are kind of bleeding accounts for major bleeding in the hip fracture only 15% of the time.
ASHOK GAVASHAR: So if you take all the hip fractures in total one hip, less than 2% of pelvic fractures may actually need angiography. Our patients might benefit from it. So this is quite a labor intensive and exhaustive exercise for less than 2% of patients. And if you do not have all these setups in place and if you as I said, if you do it on a case by case basis, even if your patient requires a angiography actually less than half of the patients ultimately undergo because they believe it takes a toll.
ASHOK GAVASHAR: And sometimes you will lose your patients so embolisation depends primarily on availability and a lot of expertise. So what are the role of contrast CT at this point? So contrast CT, as we know, has got a very quick turnaround time and it can predict accurately the need for angiograph. So you can if you are relying on angiograph, what you can better do is do a contrast CT scan
ASHOK GAVASHAR: and if the contrast CT scan is negative, you can forget about angiogram, you don't need it. So it saves time and a lot of expertise and if your contrast CT is positive with intravascular externalization of contrast from either large or medium sized vessels, it suggests a strong need for embolization and you've got to wrap it up.
ASHOK GAVASHAR: So what about this case textbook? School of thought pre peritoneal pelvic packing the concept of pre peritoneal pelvic packing was introduced by Tim Pohlmann from Germany and it involves application of an anti ex fix and packing the pre peritoneal pelvic area by using outbound responders. It creates a pelvic dampener, which is often sufficient to stop bleeds that are coming from small and even up to midsized vessels.
ASHOK GAVASHAR: And using these protocols worldwide, there has been a reported reduction in mortality of more than 20% compared to the previous engine optimization protocols. So how was it done? It's an extremely easy technique, like you use a midline vertical incision and then like getting to the opposing fistal area, it just takes 10 to 15 minutes to do it.
ASHOK GAVASHAR: Apply the ex fix. Unless you apply the ex fix, you can't close the pelvic region, you can't control the volume. And then once that is done, start backing the bladder area, starting from the pre sacral area, then come up anteriorly. There is enough space actually, the hematoma creates a lot of cleavage there and then pack them continuously using 4 to 6 parts.
ASHOK GAVASHAR: It is capable of stopping most of the bleeds and what we have observed is like once we do the pelvic pattern, there is a dramatic reduction in the amount of blood transfusions these patients require. So in the year when it starts, like probably when we take them to packing it, they might have already required 4 to 6 pints of blood, but once the packing is done, most often it stops abruptly and it requires no special expertise,
ASHOK GAVASHAR: no external resources are required. We can do it, it's a simple technique. The only problem is that you need to remove them. Initially, we would remove them at 48 hours, but that had an unacceptable infection rate so now the current protocol is to remove them safely at 24 hours. The other problem is infection of 10 to 15
ASHOK GAVASHAR: percentage of infection has been reported and the infection rate is quite high. If you are dealing with an open fracture or a bladder injury that requires intervention. So what we follow is sort of the pelvic plate packing pattern protocol which we learn French. I learned from the Medical Center during my fellowship. So what we do is like the patient is applied a pelvic binder or a sheet on site when they are picked up or at the earliest when they reach you at the hospital.
ASHOK GAVASHAR: And once you are 80 pelvic X-ray and fast peritoneal type is done and you have sort of like narrowed it on the pelvis but if your patient is still not improving, what I mean by not improving is like if the systolic BP doesn't go up by more than 90 milligram mercury after two units of packed RBC transfusion. So if it doesn't happen, this is the time we think about taking the patient to the OR and do an external fixator and pelvic pack.
ASHOK GAVASHAR: So once the packing is done, transfer the patient to the ICU and think about further planning, but in case if the patient continues to be unstable, even after you ship the patients on the vova, this is the time you should suspect a major risk of bleeding, either from the internal iliac or even to the superior glutoarchinator {?] And this is the time we should think about the contrast CT and thereafter embolisation.
ASHOK GAVASHAR: So what this packing does is it gives you time. It reduces the need for embolization. So this is the data from the World Medical Center. If you look at their data, their mean time data that it took for them to take the patient to 6 minutes and 1 in 13 percentage of patients subsequently required an embolization. And that, too, it could be done at a mean of 10 hours, so it gives you a great deal of window,
ASHOK GAVASHAR: apart from reducing the need for embolization. So in summary, if you have a bleeding pelvic fracture patient, if it's stable, no problem. You take an AP pelvis X-ray doing a further x-ray, similar development if you require, doing your CT scans, go ahead and plan your definitive fixation. But if you have an unstable patient with the dynamic instability, then roll out extra pelvic sources of bleed.
ASHOK GAVASHAR: If they are present, they have to be dealt with appropriately, and if you have narrowed your bleed down to the pelvic fracture and if the patient is not dynamically improving, then you need to intervene. Intervene, we prefer to do it by using an external fixator and treatment and packing. And if the patient continues to be unstable, then do a contrast CT. If there is external resolution of contrast on the CT scan, then subject them to pelvic arterial gravity and subsequent embolization.
ASHOK GAVASHAR: And once they become stable and if they become stable, then you can think about planning your definitive fixation. Thank you.
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