Date: Sun, 25 May 2003 22:04:37 -0400
Subject: T-POD vs Ex-Fixator
We have replaced using sheets in the ED to wrap a sprung pelvis with a T-POD. This is a velcro based pulley system that is very effective in closing down the pelvis. Recently had a 89yo woman who lost her battle with an SUV. Open book pelvis, bilat femur fx, wide mediastinum, hypotension. Fluid resuscitation only transiently effective. FAST was neg for fluid. The question that i have of the list is where would you go now? If we have xrays that show the pelvis is closed down do we still go to the OR for an Ex Fix and then consider angio or are people with experience in pelvis wrapping happy that this is enough to tamponade venous bleeding and the next place to be is in angio. Will include xrays if there is a desire.
Thanks
Ron Simon, MD
Jacobi Medical Center
From: Zsolt Balogh
Date: Sun, 25 May 2003 19:27:01 -0700 (PDT)
Ron,
If it is a true open book (no vertical instability at the back and intact posterior iliosacral ligaments) the non-invasive pelvic stabilisation with sheet or whatever works well to stop venous bleeding temporarily. If the patients remains hypotensive, there must be arterial bleeding if other sources are excluded. Ex-fix does not help in that too much. You need to go for angio to embolize the bleeders most likely at IIA and pelvic floor vessels. It still worth to stabilize the pelvis on the same day for optimal outcome.
Zsolt Balogh
From: KMATTOX
Date: Sun, 25 May 2003 22:36:09 EDT
Subject: Re: T-POD vs Ex-Fixator
In the hypotensive patient with a pelvic fracture, we all need to consider a multicenter study to keep the BP lowish and the venous pressure low. The "Pop the Clot" concept in patients with dilutional coagulopathy may be more true in this patient that any other. The hypothesis would be that aggressive fluid resuscitation (as in pulmonary contusion, penetrating trauma, etc.) actually INCREASES blood requirements, INCREASES LOS, INcreases death, and Increases complications, and increases the need for arteriography.
k
Date: Sun, 25 May 2003 20:09:17 -0700 (PDT)
From: Zsolt Balogh
The "pop the clot" concept should be true in blunt pelvic trauma as well. If you see a hypotensive patient in the angio without obvious bleeding all you need to turn on the level 1 and you will see them... The problem, that eventually you should resuscitate these hypotensive patients somehow. The sitation is slightly easier in penetrating trauma where we fix the hole and then we can catch-up with fluids. Massive pelvic fractures are rarely isolated injuries. How long should we permissive with hypotension in these cases? When can you say that the haemorrhage is controlled?
Zsolt Balogh
From: SJASMD
Date: Sun, 25 May 2003 23:12:34 EDT
Ron Simon writes: If we have xrays that show the pelvis is closed down do we still go to the OR for an Ex Fix and then consider angio or are people with experience in pelvis wrapping happy that this is enough to tamponade venous bleeding and the next place to be is in angio.
Ron
go to angiography and embolize immediately after mechanical stabilization. Don't waste the time for fixator. Treat arterial hemorrhage before contained venous bleeding.
Sal Sclafani
Date: Sun, 25 May 2003 23:40:05 -0400
From: Bill Burman
Reference link to the AAST-OTA pelvic injury symposium.
From: ecthompson
Date: Mon, 26 May 2003 01:01:42 -0500
I was wondering if there was a blush on the CT of the pelvis.
E
Errington C. Thompson, MD
Trauma Surgeon
Trinity Mother Frances
Tyler, Tx
From: SJASMD
Date: Mon, 26 May 2003 03:07:28 EDT
E
I don't believe that a CT blush is too reliable. I have added this to my indications for angiography arbitrarily but there are too many false negatives. When there is a blush there is a good chance that bleeding will be seen on angio, but not always. I have seen many cases in which angio is positive and CT is negative for bleeding.
in pelvic fractures trust your clinical judgment, hardly necessary advice for you
Sal
Date: Mon, 26 May 2003 07:20:10 -0500
From: George Rodman
Ron,
1. Persistent hypotension + neg FAST + unstable pelvis, all means to me next stop in ANGIO ASAP
2. Any means of pelvic stabilization, low or high tech type, is sufficient in the first 15-20 min in trauma bay as first step
3. Pelvic immobilization is important step in trauma bay; reestablishing 'pelvic geometry' to control bleeding is overrated.
GR
George H Rodman Jr MD
Dir., Trauma Program
Clarian-Methodist Hospital
Indianapolis, IN 46202
Date: Mon, 26 May 2003 09:43:37 -0400
From: Ronald Simon
ecthompson wrote: I was wondering if there was a blush on the CT of the pelvis.
I would get blasted for taking an unstable pt into the CT scanner. Was that a Trick question? :) No CTs were done. I was having trouble deciding whether to ex fix in OR or go directly to angio in light of the fact that the T POD was already doing much of what an ex fix would be expected to do. My bias was to go to angio and skip the formal ex fix.
Ron
From: Errington Thompson
Date: Mon, 26 May 2003 11:25:52 -0500
No trick just stupid!! I'll have to do better. I agree with everyone. To angio suite.
E
Errington C. Thompson, MD
Trauma Surgeon
Trinity Mother Frances
Tyler, Tx
Date: Mon, 26 May 2003 12:21:45 -0400
From: carl hauser
Zsolt Balogh wrote: The pop the clot concept should be true in blunt pelvic trauma as well. If you see a hypotensive patient in the angio without obvious bleeding all you need to turn on the level 1 and you will see them... The problem, that eventually you should resuscitate these hypotensive patients somehow. The sitation is slightly easier in penetrating trauma where we fix the hole and than we can catch-up with fluids. Massive pelvic fractures are rarely isolated injuries. How long should we permissive with hypotension in these cases? When can you say that the haemorrhage is controlled?
Right on !
I think the "limited" or "controlled" resuscitation mode is great for a while, but not forever. The faster you can achieve definitive control and fully resuscitate the patient while avoiding further injury the better they'll do. So another huge difference from the penetrating thoracic scenario is that we have a very effective and relatively atraumatic method of controlling pelvic hemorrhage. That is angioembolization. Ex-fixes are clearly worthless in most cases and I don't think they even bear discussion any more. (yeah, I know - but how do you really feel...)
I see no rationale at all for watching these patients continue to bleed once we determine they are indeed bleeding at any substantial rate. The question for me is how much they're going to bleed, how much ischemia / reperfusion they're likely to suffer, and how likely they are to need fluids or (especially) blood transfusions, all of which will contribute to inflammatory / organ failure morbidity, and therefore how aggressive to be about pelvic embo. So the appropriate study (from my perspective) would examine where to draw that line.
If they're hypotensive or have a blush I have no hesitation - to IR (interventional radiography) we go. The question now for me is whether to go to angio if they're only acidotic or if they only have a high risk fracture. Right now, I angio for acidosis on a presumed basis of pelvic hemorrhage but not simply for 'high risk' fractures. I admit freely however, that this approach is without prospective validation because none exists. So I would happily participate in a prospective trial aimed at specifying the exact indications for angio in pelvic injuries. We'd need to look at VS, U/O, BE, fracture type, blush, and #units PCs transfused as well as outcome. It's potentially a great study.
CJH
From: SJASMD
Date: Mon, 26 May 2003 13:18:52 EDT
Carl
hausercj writes: The question for me is how much they're going to bleed, how much ischemia / reperfusion they're likely to suffer, and how likely they are to need fluids or (especially) blood transfusions, all of which will contribute to inflammatory / organ failure morbidity, and therefore how aggressive to be about pelvic embo.
i also worry about abdominal compartment syndrome related to RPH. Nothing more discouraging for me than to control the arterial hemorhage only to require laparotomy to relieve abdominal pressure for ventilation and then having to deal with the exacerbation of venous bleeding previously tamponaded and under control.
hausercj writes: So the appropriate study (from my perspective) would examine where to draw that line.
If they're hypotensive or have a blush I have no hesitation - to IR (interventional radiography) we go. The question now for me is whether to go to angio if they're only acidotic or if they only have a high risk fracture. Right now, I angio for acidosis on a presumed basis of pelvic hemorrhage but not simply for 'high risk' fractures.
my experience parallels yours - the yield for angiography done for fracture pattern does not come close to the yield for clinical criteria. Also the size of hematoma seen on CT does not correlate with yield ofangio either
hausercj writes: So I would happily participate in a prospective trial aimed at specifying the exact indications for angio in pelvic injuries. We'd need to look at VS, U/O, BE, fracture type, blush, and #units PCs transfused as well as outcome. It's potentially a great study.
count me in. I would also like to look at outcome related to duration of time in angio, technique of embolization: coils vs gelfoam, selective embo vs proximal embo
sal
Date: Tue, 27 May 2003 07:32:29 -0400
From: carl hauser
SJASMD wrote: i also worry about abdominal compartment syndrome related to RPH. Nothing more discouraging for me than to control the arterial hemorhage only to require laparotomy to relieve abdominal pressure for ventilation and then having to deal with the exacerbation of venous bleeding previously tamponaded and under control.
Agreed. My guess is also that the earlier these folks get their bleeding controlled, the less chance of ACS, both from direct expansion of the RPH and from edema due to ischemia-reperfusion, inflammation, SIRS, fluids etc. But we're still only talking about a subset of 10% of all pelvic fractures. The question is how to identify them without squirting them all...
CJH
From: SJASMD
Date: Tue, 27 May 2003 08:12:19 EDT
hausercj writes: Agreed. My guess is also that the earlier these folks get their bleeding controlled, the less chance of ACS, both from direct expansion of the RPH and from edema due to ischemia-reperfusion, inflammation, SIRS, fluids etc. But we're still only talking about a subset of 10% of all pelvic fractures. The question is how to identify them without squirting them all...
The indications for angio in pelvic fractures were taught to me by Gerry Shaftan and Winston Mitchell at Kings County in January 1979: These clinical criteria have been pretty reliable for more than 20 years. I am pretty satisfied with them. A negative angio (no extravasation) is pretty uncommon.
Using these scenarios, angio is usually performed in the first few hours and our incidence of finding extravasation on angio is about 90%. The extravasations are much smaller, (even subtle) than what my colleagues show when they angio later than I do.
Using any other criteria, such as fracture pattern, surgical enthusiasm, large hematoma on CT, unstable fracture, co-morbidities, mechanism of injury, age, or surgical gestalt, usually leads to a very much lower, maybe 10% yield. I groan when the chief resident calls me at 2 am using with any of these as the indication for angio.
Sal
Date: Tue, 27 May 2003 08:32:47 -0500
From: Adam J. Starr, M.D.
The literature seems to point to 3 groups at increased risk of mortality.
1. Patients with high energy fracture patterns of Tile C, Young Burgess anteroposterior compression type 3, lateral compression type 3, or vertical shear (reported mortality rate 15-43%).
2. Elderly patients of age greater then 55 of 60 years (reported mortality 21-28%).
3. Patients in hemodynamic shock of systolic blood pressure less than 90mm Hg (reported mortality rate 41-57%).
So the question is, what to do to limit that risk?
Immediate provisional stabilization might tamponade bleeding and protect fracture hematoma, and can be used in patients at risk for mortality. These simple maneuvers carry little risk and, best of all, they can quickly be employed by health care providers early in the patientís care.
This can be either provisional stabilization with a sheet and towel clips or with a pelvic binder. Whether you believe binders work or not, they WILL provide a measure of stability - my view is that they probably provide equal or better stability than a clamp or an anterior ex fix frame.
Since binders carry little risk, and they can be applied in minutes, I see little reason NOT to use them in these types of patients. When the risk of death is very high, in my opinion it makes sense to go ahead and apply a binder to give the patient whatever benefit may be offered by stabilization. You take that treatment option and apply it immediately, then move on to consider other treatments. Binders are faster than ex-fix, faster than angio, faster than the OR. You can train a nurse or paramedic to apply a binder.
(The question of whether binders "work" - save lives - is a question we don't have the answer for for ANY of these maneuvers. Maybe binders don't do ANY good at all. Then again, maybe angio doesn't, either. Right now we don't know. Even the simplest thing, IV fluid resuscitation, is open to disagreement. Is it good or bad to keep systolic blood pressure around 120mm Hg? I agree we need multi-center studies to assess our treatments. We're have such a study set up right now - I hope we can get it funded).
Provisional surgical stabilization - with an external fixator frame or clamp - requires more time and equipment, but may interfere less with later maneuvers such as pelvic angiography or exploratory laparotomy. These maneuvers require surgical preparation, time and expertise. In my view, the binder offers as much or more correction/protection of the pelvic anatomy and clot, so I'd rather use a binder. Even better, binders are fast - surgery to apply an ex-fix is not as fast.
So, the question becomes, who goes to angio first and who goes to the OR first, if the indicator you're following (SBP, lactate, base deficit, etc) shows the resuscitation method and provisional stabilization aren't working?
This assumes both options are ready. In some centers, the angio suite is not kept ready 24/7. You have to call in a tech, which takes time. Other centers are very fast, and have angio ready essentially "immediately".
And, even if both options are available, will a general surgeon take a hypotensive patient to the angio suite first? At most centers, I think the strong urge is to get hypotensive patients to the OR first. Less sick patients allow more time for doctors to try other maneuvers.
But, maybe angio for patients in shock isn't such a bad idea? Both Bassam and Eastridge have suggested that for hypotensive patients with anything OTHER than a stable fracture pattern (anything other than a Young Burgess lateral compression type 1) angiography first may decrease mortality, since the source of bleeding in these patients is commonly due to pelvic vessels. For patients with LC 1 fractures (a large portion of this patient population, since LC 1 fractures are so common) ex lap first may be best, since the source of bleeding in these patients is often intra-abdominal.
Date: Tue, 27 May 2003 11:54:43 -0400
From: carl hauser
SJASMD wrote: The indications for angio in pelvic fractures were taught to me by Gerry Shaftan and Winston Mitchell at Kings County in January 1979 . . .
Sal
My approach is somewhat similar. Jerry Shaftan's a smart guy, and I'd agree with at least 80% of his criteria, which is remarkable when you considering that his algorithm is at least 25 years old! But there have been some changes over time. For one thing, I'm increasingly reliant on acidosis in young persons as a sign of continuing hemorrhage rather than waiting for the BP to drop or for them to bleed 4-6 units of PRBC's. Also, I just don't think that you can justify 4-6 units of blood as a temporizing measure anymore. Obviously, Shaftan's recommendations preceeded concerns about HIV, but I'd be more concerned with the immune / inflammatory effects of transfusion in sick patients. There are individual 'extenuating circumstances' as well. For instance, I'd be less tolerant of ongoing slow pelvic fracture hemorrhage in a TBI patient with a high ICP, or in an elderly patient with ST-segment changes. I think that what is clear is that the historic approach of looking at the AP pelvis film and determining the "Tile Classification" to figure out if a patient is bleeding or needs an angio is non-specific, insensitive, and totally outmoded. Unfortunately, in the non-trauma center world, where pelvic fractures are seen primarily by Orthopedists rather than Trauma Surgeons, that's what happens.
CJH
Date: Tue, 27 May 2003 12:02:52 -0400
From: carl hauser
Zsolt Balogh wrote: Sal, Pelvic fx itself and RPH has not too much to do with ACS if there is no hemorrhagic shock and massive resuscitation.ACS however is a frequent problem in haemodynamically unstable patients with displaced pelvic fractures even with early embolization.
Zsolt -
I'd agree that a good deal of hemodynamically significant pelvic fracture bleeding is actually into the flank and buttocks, and that the hematomas themselves are often not as important to ACS as is the shock, resuscitation and bowel edema. On occasion however, the intra-pelvic hematoma component can be substantial. If that occurs it can make a substantial contribution to ACS.
CJH
From: mahmoud al-salhi
Date: Tue, 27 May 2003 08:51:44 -0700
Dear Dr. Adam Starr
I have read your excellent and nice comments with a great pleasure , please give more information about the binder. Thanks.
Date: Tue, 27 May 2003 22:16:57 +0530
From: rajesh
Looking at pictures of the Dallas Binder,like most of the other belts,it is applied around the iliac crest.I seem to remember reading (recently , but can't remember where !) that binders applied around the greater trochnter (like the London belt) were more efficient in controlling haemorrhage compared to those arund the crest. Any thoughts on this?
I was looking through the AAST-OTA pelvic injury symposium and I am amazed at the amount of work that has gone into it.It is immensely useful but some of the questions dont seem to have answers (or I could not find them) like:
"Given the accuracy of FAST, when the patient becomes hemodynamically unstable after negative FAST examination, why does the Scalea algorithm call for an open diagnostic peritoneal lavage instead of a repeat FAST?" - (just an example,there are quite a few more !!)
Are the answers somewhere in those massive number of links or those simply rhetoric?
Really amazing bit of work.
rajesh
Date: Tue, 27 May 2003 13:31:58 -0400
From: James Carr
A tough problem because trauma centers vary in their strengths and capabilities. And very tough to get level I or II evidence for many reasons. Like most, I primarily speak from experience gained in treating these patients. I think the main take home lesson is quick recognition and prompt treatment -whatever the protocols may be at your hospital. In my experience, there is a subgroup of patients who respond well to orthopedic closing of the pelvic volume. Their pressure stabilizes, the pulse drops, and don't need angio. Level I proof?? I don't have any, but I know it can work, and we'll keep doing it. At the other end of the spectrum is a group that orthopedic intervention has little effect, and these patients should go straight to angio/fast etc. It takes a minute or two to try the sheet in these cases, and see it doesn't work. In patients where a ruptured retroperitoneal hematoma is encountered at laparotomy, I have found that bleeding is controlled well with skeletal fixation and packing as needed- similar to the Hanover experience. I also have not observed wildly uncontrollable bleeding in cases where the retro peritoneum was entered for other reasons-eg communication with a ruptured bladder or ORIF of the iliac wing. I wonder if the difference is the presence of a stable skeleton so that packing can be effective. This begs the question of the "best fixation", and that again will depend on the skill of the surgeon involved. Whatever means is chosen to treat these patients, it needs to be done rapidly, with a thoughtful step by step pathophysiologic guided plan involving all the important MD's.
Date: Tue, 27 May 2003 12:58:19 -0500
From: Adam J. Starr, M.D.
Dear Mahmoud al-Salhi,
There are a couple binder types available. The ones I'm aware of are the TPOD and the Pelvic Binder. Both work on similar principles. I like the Pelvic Binder best - it's simpler and less expensive.
Basically, these devices wrap around the hips and squeeze the pelvic ring down. We put them on so they fit so you can slip one finger in between the binder and the patient's skin.
They work great at closing open book type fractures down, and they also can prevent fracture motion in lateral compression types.
The only complication we've seen is skin blistering from leaving them on for too long. In general, we remove them after 24 hours of hemodynamic stability. If you leave a snug binder on for too long you can see skin blistering. In my mind, skin blistering is a small price to pay for getting stability in high risk patients such as these. And, the blistering is rare.
Other surgeons use sheets. Chip Routt published a nice article in JOT that shows how he puts the sheets on.
Date: Tue, 27 May 2003 13:01:17 -0500
From: Adam J. Starr, M.D.
Rajesh,
There's no question - it's better to put them on around the trochanters, not over the crest. You get much better compression of you place them over the greater trochs.
Adam
Date: Tue, 27 May 2003 14:58:04 -0700 (PDT)
From: Zsolt Balogh
CJH wrote: I'd agree that a good deal of hemodynamically significant pelvic fracture bleeding is actually into the flank and buttocks, and that the hematomas themselves are often not as important to ACS as is the shock, resuscitation and bowel edema. On occasion however, the intra-pelvic hematoma component can be substantial. If that occurs it can make a substantial contribution to ACS.
I agree Carl! My data comparing patients with ISS~28 without abdominal injury and laparotomy with or without pelvic fracture related RPH shows (all had more than 6U of PRBC during the first 12 hours and all initial base deficit was > 8 and all had the same computerized resuscitation protocol) that patients with pelvic Fx and RPH had significantly higher IAPs during the first 24 hour but the difference is only 3 mmHg (15 vs 18 or 14 vs 17). 20 patients in both groups. BUT pelvic fx related RPH is not an independent predictor of postinjury ACS, like the other variables in our prediction model.
Zsolt
From: SJASMD
Date: Tue, 27 May 2003 19:10:25 EDT
CJH wrote: But there have been some changes over time. For one thing, I'm increasingly reliant on acidosis in young persons as a sign of continuing hemorrhage rather than waiting for the BP to drop or for them to bleed 4-6 units of PRBC's. Also, I just don't think that you can justify 4-6 units of blood as a temporizing measure anymore.
Carl: two points:
I'll consider lactic acidosis as an indicator of hemodynamic instability: something that Tom Scalea advocated a long time ago at KCHC. So there is no disagreement or variance with Gerry's recs on that issue
Most patients reach those threshholds 4U/24h, 6U/24 far sooner in their course than 24 or 48 hours later. Those were estimates of blood loss beyond which one could reasonably conclude that the hemorrhage was not venous. If you do angio for NO transfusions, you will do a lot of negative angios. So if the patient is on the third unit and we anticipate more transfusion we will move the process toward the radiology suite.
I think that our protocol remains pretty timely. Got another idea?
sal