Recognition

• Penetrating extremity injury (e.g. stab or gunshot) or severe blunt trauma (e.g. arterial injury due to associated fracture)
• Cold, pale and pulseless distal extremity or a rapidly expanding hematoma suggests arterial compromise — look for ‘hard signs’ (Q7 below) and ‘soft signs’ (Q8 below)
• Check arterial pressure index (API) (Q9 below).
• Assess for hemorrhagic shock
• Angiography can be performed only if the patient is hemodynamically stable

—

Management

• Immediate surgical consult
• Apply direct pressure and elevation
• Consider applying adrenaline soaked gauze or hemostatic dressings if available
• Tourniquets may be life saving
• Reduce and splint long bone fractures, apply a pelvic binder for pelvic fractures
• Correct coagulopathy and commence hemostatic resuscitation as required
• Do not clamp or tie off a vessel in a bleeding wound, unless it is superficial and clearly visible. Blindly clamping an artery may damage a nerve that often runs alongside the artery.

Learn more:

• Broome Docs — Clinical Case 018: Life and limb (not life OR limb)

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Direct digital pressure is the best method initially

• Take universal precautions (wear sterile gloves, goggles and gown)
• Ensure there are no hazardous objects in the wound
• Use one finger, with interposed gauze, to press directly on the bleeding vessel just proximal to the bleeding point
• Maintain this for 10 minutes

—

I like the ‘nugget method‘ described by Shokrollahi et al (2008) as follows:

• The occluding finger should be substituted with a dental roll or tightly folded “nugget” of gauze.A tourniquet may be temporarily applied proximally to facilitate this.
• Once the positioning is correct and no further bleeding is occurring, slightly larger or less folded pieces of gauze can be placed one on top of the other, creating an inverted pyramid of gauze.
• The layers of gauze are secured with a loose bandage. Only very light pressure need be applied to the top layer of gauze to maintain hemostasis, as the pressure is “focused” onto the bleeding point. This technique is based on the equation: Pressure=Force/Area
• The tightness of the bandage can be judged from the amount of pressure needed to maintain hemostasis when applying the top layer of gauze.

From Shokrollahi et al (2008) — click image to enlarge

Hat tip to Scott Weingart for this one. I’ve used it on a few bleeding AV fistulae and it works like a charm.

—

The easiest way in the ED is to apply a blood pressure cuff proximal to the bleeding point.

• Inflate the cuff above systolic blood pressure
• Clamp the tubing with a hemostat to prevent leakage and loss of pressure

An alternative is to use a pneumatic cuff, like that used for Bier’s blocks.

When applying a tourniquet ensure the following:

• Record the time of application
• Perform a neurological exam at the time of application
• Do not leave the tourniquet on for more than 120 minutes

—

These are the two transition points

• Femoral artery at the inguinal ligament
• Axillary artery as it emerges from under the clavicle

Bleeding points proximal to these sites cannot be controlled by externally applied direct pressure or tourniquets. Call a surgeon!

—

Hard signs

• Absent pulses
• Bruit or thrill
• Active or pulsatile hemorrhage
• Signs of limb ischemia/ compartment syndrome (the 6 Ps)
• Pulsatile or expanding hematoma

These patients require operative intervention. Imaging is not needed unless the site of bleeding is uncertain.

—

Soft signs

• Proximity of injury to vascular structures
• Major single nerve deficit (e.g. sciatic, femoral, median, ulna or radial)
• Non-expanding hematoma
• Reduced pulses
• Posterior knee or anterior elbow dislocation
• Hypotension or moderate blood loss at the scene

Patients with soft signs may or may not need imaging, depending on the API (arterial pressure index)

• those with an otherwise normal physical exam and API >0.9 can be observed following appropriate wound care.
• API < 0.9 indicates possible vascular injury: requires further evaluation, preferably by computed tomography angiogram (CTA)

The incidence of arterial injuries in such patients ranges from 3% to 25%, depending on which soft sign or combination of soft signs is present.

—

Arterial pressure index (API) is also known as DPI (Doppler Pressure Index) or Arterial Brachial Index or Ankle Brachial Index (ABI) – despite the last name, the same procedure can be performed for upper extremity injuries.

The procedure is performed as follows for an injured upper extremity:

• The patient is placed supine with the cuff placed on the injured upper extremity
• The ipsilateral brachial artery is detected with a Doppler device until the brachial artery is clearly heard. Alternatively the cuff can be placed on the forearm and the ulnar or radial arteries are assessed (the cuff has to be distal to the injury!).
• The cuff is pumped up 20 mmHg past the point where the Doppler sound disappears. The cuff is slowly released until the Doppler device picks up the arterial sound again (the systolic pressure)
• The pressure at which this sound occurs is recorded and the procedure is repeated for the opposite uninjured upper extremity.

IT can also be performed for an injured lower extremity:

• The patient is placed supine with the cuff placed on the injured lower extremity.
• The ipsilateral dorsalis pedis or posterior tibial artery is detected with a Doppler device until the artery is clearly heard
• The cuff is pumped up 20 mmHg past the point where the Doppler sound disappears. The cuff is slowly released until the Doppler device picks up the arterial sound again (the systolic pressure)
• The pressure at which this sound occurs is recorded and the procedure is repeated for the opposite uninjured lower extremity
• The blood pressure is also measured at the brachial artery in an uninjured upper extremity.

The API is calculated as

API = the systolic pressure of the injured extremity (ankle or forearm) divided by the brachial systolic pressure in the uninjured upper extremity

i.e.

API = Injured SBP / Uninjured brachial SBP

The magic number is 0.9

• API > 0.9 is highly unlikely to have a vascular injury and may be observed/ discharged depending on the nature of any other injuries, premorbid and social factors.
• API < 0.9 indicates possible vascular injury: requires further evaluation, preferably by computed tomography angiogram (CTA). Doppler ultrasound (50-100% sensitive, 95% specific) can be used as an alternative, and surgeons can perform intraoperative angiograms under fluoroscopy.

How good is API?

The performance characteristics of API vary between studies, but is quoted as 95% sensitive and 97% specific for arterial injury by Lynch and Johannsen (1991). In a small prospective study of knee dislocations ABI was 100% sensitive and specific (Mills et al, 2004). It is also cost effective (Levy et al, 2005).

API will miss non-obstructing vascular injuries and will give false positive results in patients with shock or significant peripheral vascular disease.  Some trauma centers use a difference in API of >=0.1 as an indication of arterial injury in elderly patients and those with known pre-existing peripheral vascular disease.

Below is a simplified approach to suspected arterial injury in trauma. Stabilise the patient first, and ensure that any fractures or dislocations are reduced.

The WEST guidelines (Feliciano et al, 2011) are much more complex and detail a number of exceptions. For instance, CTA may be performed in the presence of hard signs if there is a shot gun injury or multiple fractures to help localise the vascular injury before operating.

Interventions are discussed in Q10 below.

Patients discharged following a normal API require close outpatient follow up. This is because 1-4% of these patients, primarily those with penetrating wounds, eventually require an operation as the original undetected injury (i.e. small pseudoaneurysm) progresses rather than heals.

—

Injuries to most major ‘named’ arteries requiring repair or intervention include:

• extravasation
• pulsatile hematoma
• occlusion
• pseudoaneurysm
• fistula formation

The surgeon may repair damaged vessels by:

• Direct repair — sutures, patch angioplasty, interposition graft or vein patches
• Ligation — only small, distal and redundant arteries (most are repaired)
• Damage control surgery using intravascular shunts to allow immediate restoration of distal blood flow, with later definitive repair once the patient has been resuscitated and normal physiology has resumed.

Interventional radiology measures such as embolisation are also useful in certain arterial injuries.

Injuries that do not usually need immediate intervention:

• Some injuries, such as intimal defects (87-95% heal spontaneously), usually do not require intervention.
• Some arteries (profunda femoris, anterior tibial, posterior tibial, or peroneal arteries) do not require surgery but can be re-imaged at 3-5 days to check progress if occluded, or undergo embolisation if the injury involves extravasation or arteriovenous fistula.

—

Life-threatening injuries:

• Pelvic disruption with massive hemorrhage
• Severe arterial hemorrhage
• Crush syndrome

Learn more:

• Trauma Tribulation 027 — Trauma! Pelvic Fractures I
• Trauma Tribulation 028 — Trauma! Pelvic Fractures II
• Trauma Tribulation 030 —Trauma! Extremity Arterial Hemorrhage

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Limb-threatening injuries

• Open fractures/ dislocations
• Traumatic amputation and severe vascular injuries
• Compartment syndrome
• Neurological compromise due to limb injury
• Degloving injuries

Learn more:

• Bone and Joint Bamboozler 001 — Open fractures
• Bone and Joint Bamboozler 002 — Compartment syndrome

—

Crush syndrome is the complex of electrolyte disturbances, metabolic acidosis and rhabdomyolysis resulting from crush injury.

Recognition

• Suspect based on history of crush injury or entrapment
• Hyperkalemia, hypocalcemia, hyperphosphatemia, and hyperuricemia from cellular damage
• Lactic acidosis from hypoperfusion
• Elevated creatine kinase and myoglobinuria (urinalysis positive for blood on dipstick, but no red cells seen on microscopy) due to massive muscle damage
• Acute renal failure due to rhabdomyolysis
• X-rays to assess for associated fractures
• Assess for compartment syndrome
• Assess for neurological compromise (weakness, paresthesiae, loss of sensation and neuropathic pain)
• Assess for vascular compromise (hard and soft signs of vascular injury, ankle-brachial index, CT arteriography)

Management

• resuscitation of shocked patients
• IV hydration (e.g. Hartmann’s) to target urine output of 1-2 mL/kg/h (corrects hypoperfusion, lactic acidosis, ameliorates acute renal impairment)
• Urinary alkalinisation with sodium bicarbonate is controversial, and is unproven. Proponents use this treatment based on the theory that urine pH>7.0 may limit crystalinisation of uric acid and reduce breakdown of myoglobin into nephrotoxic metabolites.
• Mannitol is also sometimes used but is unproven.
• Aggressively treat potentially life-threatening hyperkalemia (calcium gluconate, salbutamol, insulin, hemodialysis)
• Calcium administration may lead to metastatic calcification in the presence of hyperphosphatemia
• Treat associated injuries including fractures/ dislocations, wounds, neurovascular injuries and compartment syndrome
• Early analgesia, antibiotics if indicated and ADT (tetanus immunisation)

—

An amputation is an injury that results in loss of the extremity distal to the wound.

Recognition

• Usually obvious!
• Check for associated neurovascular complications and crush injuries. Bleeding may be slight, thanks to arterial spasm. Severed nerves are exquisitely painful.
• Determine the time of injury. Reimplantation is less likely to be successful if warm ischemia time exceeds 6 hours (in general), but success has been achieved at up to 24+ hours.
• X-ray the amputated part and the stump to help determine the extent of injury and viability

Management

• Consult surgery (may require general surgeon, plastics and/ or orthopedics)
• Always treat an amputated part as if it may be reimplanted. It may at least be useful for achieving skin coverage of a wound.
• Handle the amputated part with care, do not debride it, irrigate with normal saline and pack loosely with sterile saline soaked gauze. Place in a water-tight plastic bag and store in an ice water slurry. Ensure ice does not directly contact the amputated part.
• Irrigate the stump with saline and control bleeding with direct pressure.
• Give AAA treatment: prophylactic IV antibiotics (e.g. cephazolin), analgesia and update ADT.

—

Consult a surgeon early so that they can make the decision whether or not to reimplant. Always treat an amputated body part as if it is a candidate for reimplantation.

Reimplantation is more likely to be performed for:

• Short ischemia time (1 hour of warm ischemia equals 6 hours of cold ischemia)
• Thumb and index fingers are usually reimplanted
• Children
• Multiple amputations
• Dominant limb involved
• Patient’s occupation depends on motor skills
• Upper limb amputations are more likely to be reimplanted than lower limb amputations, as effective prostheses are more available for the latter and they are more likely to have crush injuries

A major trauma patient requiring resuscitation and emergency surgery is generally not a candidate for reimplantation.

—

Recognition

• suspect nerve injury if vascular injury is present, as nerves tend to run in close proximity
• detailed motor and sensory exam distal to the injury site: e.g. loss of function, weakness, areflexia, paraesthesiae, sensory loss.
• consider coexistent vascular injury, compartment syndrome and associated fracture

Management

• consult orthopedic surgeon (or hand surgeon or plastic surgeon as appropriate)
• treat compartment syndrome if present
• reduce and splint fractures
• elevate limb to decrease edema
• rest affected limb in position of function
• most closed soft tissue injuries with neurological injury gradually resolve over 3 months
• transected nerves require operative repair, usually within 24 hours — unless minor sensory alterations only, which may be followed up at 1 week

—

Degloving injuries involve separation of the skin and underlying subcutaneous connective tissue from the underlying fascia. They are usually but not always open injuries causing exposure of the underlying structures. They are associated with high morbidity.

Recognition

• usually easily identifiable by exposure of underlying fascia hat invests muscles, vessels, nerves and bone
• closed degloving injuries may not be obvious and are often missed on initial assessment – suspect based on mechanism (e.g. run over by motor vehicle, limb caught in heavy machinery) that involves shearing forces and subcutaneous swelling suggesting underlying hematoma and tissue injury
• assess distal perfusion and neurological function
• x-rays to look for fractures and foreign bodies
• ultrasound may show underlying hematoma, soft tissue disruption and foreign bodies

Management

• consult orthopedic or plastic surgeon urgently
• clean and cover wounds with saline-soaked dressings
• AAA treatment: analgesia, antibiotics, ADT if needed
• splint and elevate limb
• preserve amputated parts
• treat associated injuries and complications (e.g. fractures, dislocations, compartment syndrome, crush syndrome)
• surgical treatment aims to achieve coverage by replacing the degloved tissue or through use of flaps or skin grafts to prevent necrosis of underlying structures
• closed degloving injuries may be treated by washout and drainage of the subcutaneous tissues followed by compression bandages if the overlying tissues are viable.

—

As always:

Concurrent assessment and management in an appropriately staffed and equipped trauma bay, involving activation of the trauma team and a coordinated team-based approach.

Resuscitation

• ABCDE approach with cervical spine immobilisation if indicated

Address life threats

• pelvic fracture with major hemorrhage — apply pelvic binder, hemostatic resuscitation, correct coagulopathy
• major arterial hemorrhage — direct pressure, tourniquet, elevate, hemostatic resuscitation, correct coagulopathy
• crush syndrome — fluid resuscitation to keep urine output > 1-2 mL/kg/h, treat hyperkalemia

Address limb threats

• open fractures — clean and cover wounds, reduce fracture, splint and elevate limb, antibiotics
• compartment syndrome — assess compartment pressures and neurovascular status, remove constrictions,arrange for fasciectomy
• amputation — preserve amputated part (clean, wrap in saline-soaked gauze, keep on ice), clean and cover wound, antibiotics, consider reimplantation
• vascular injury — assess for hard and soft signs, measure ABI, consider CT angiogram and surgical intervention
  (see Trauma Tribulation 030 — Trauma! Extremity Arterial Hemorrhage)
• neurological injury — assess neurovascular status, reduce fractures and relieve constrictions, consider surgical repair
• degloving injury — clean and cover wounds, antibiotics

Supportive care and monitoring

• AAA treatment: analgesia (early!), antibiotics (in severe open injuries), ADT (if tentanus immunisation is indicated)
• splint and elevate injured extremity
• FASTHUGS IN BED Please! (as needed)
• seek and treat other injuries (e.g. tendon rupture)
• seek and treat complications (e.g. compartment syndrome, neurovascular compromise)

Disposition

• urgent surgical consult for assessment, admission and operative intervention
• transfer to a specialist trauma center if appropriate

—

Reduction of pathological pelvic motion is probably most important clinically.

There are 4 main objectives:

• Prevent reinjury from pelvic motion
• Decrease pelvic volume
• Tamponade bleeding pelvic bones and vessels
• Decrease pain

Of note:

• Cadaver studies suggest that pelvic stabilisation methods does not generate sufficient pressures to tamponade bleeding.
• the increase in pelvic volume with widely diastased open book fractures is actually relatively small.
• disruption of the retroperitoneum leads to a non-compressible space for hemorrhage to accumulate.

—

In the trauma bay, simple pelvic binders are all you really need!

Methods include:

• Pelvic binder (e.g. sheet, SAM sling, T-POD, etc)
• Anterior external fixation
• C clamp
• Pneumatic Anti-Shock Garment (PASG) ­aka Military Anti-Shock Trousers (MAST) — essentially obsolete
  

Pelvic binders

• If a pelvic binding device is not available a sheet can be wrapped around the patient’s pelvis, centered on the patient’s greater trochanters. The sheet can be secured by twisting the encircling ends around one another before being tied or clamped. Taping the thighs or the feet together also helps maintain the anatomical position of the pelvis.
• There is little evidence than one form of pelvic binding is better than any other. Some proprietary pelvic binders may allow better access to the pelvis for surgery or angiography.
• Pelvic binding may exacerbate injury in iliac wing (LC) fractures and injuries with an over-riding pubic symphysis. The goal should be to approximate normal anatomic alignment.

The recent EAST guidelines made the following evidence-based recommendations regarding pelvic binders:

• they reduce fractures, provide definitive stabilization and decrease pelvic volume
• they limit hemorrhage
• They work as well or better than external fixation in controlling hemorrhage

This video demonstrates application of the T-POD (I wouldn’t recommend moving the patient’s pelvis as much as they do in the video though!):

http://www.youtube.com/watch?v=11Wn7tXDzQA

If possible, avoid rolling the patient and perform straight lifts. also, longitudinal traction on the affected side may benefit patients with acetabular fractures.

Learn more:

• Resus.ME — Pelvic splint improves shock
• Trauma.org — The Ideal Pelvic Binder
• Trauma Professional’s Blog — Compression Of The Fractured Pelvis With A Sheet

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There are 4 potential sources:

• Surfaces of fractured bones
• Pelvic venous plexus
• Pelvic arterial injury
• Extra-pelvic sources (present in 30% of pelvic fractures — remember the SCALPeR mnemonic for sources of bleeding in trauma… see Q2 of Trauma! Major haemorrhage)

Classically venous hemorrhage is said to account for 90% of bleeding from pelvic fractures, and arterial only 10%. However arterial bleeding is more common than this in patients that have ongoing hemorrhage (e.g. despite pelvic binding or mechanical stabilisation) or have hemodynamic compromise.

—

Suzuki et al (2008) point out that:

Haemorrhage from pelvic fracture is essentially bleeding into a free space, potentially capable of accommodating the patient’s entire blood volume without gaining sufficient pressure-dependent tamponade.

But why should bleeding from a pelvic fracture be considered bleeding into a free space?

• although true pelvic volume is about 1.5L this is increased with disruption of the pelvic ring
• the tamponade effect of the pelvic ring is lost in severe pelvic fractures with disruption of the parapelvic fascia
• pelvic fractures cause bleeding into the retroperitonal space, even when intact the retroperitoneal space can accumulate 5L of fluid with a pressure rise of only 30 mmHg
• hemorrhage can escape into the peritoneum and thighs with disruption of the pelvic floor (e.g. open book fractures)

Hemodynamically unstable open pelvic fractures have mortality rates as high as 70%!

…

Michael McGonigal from The Trauma Professional’s blog suggests asking 6 questions to determine if arterial hemorrhage is likely:

• What type of mechanism caused the fracture?
  — Anterior-posterior compression and vertical shear are the most common.
• Are the vital signs stable?
  — If not, rule out the other four likely sources first (chest, abdomen, multiple extremity fractures, external). Then blame the pelvis.
• Is the fracture open? Arterial bleeding is very likely.
• How old is the patient?
  — Elderly patients are more likely to have arterial bleeding, especially from gluteal artery branches.
• What part of the pelvis is broken?
  — If major sacral fractures or SI joint disruption (gluteal artery) or separation of the symphysis (pudendal artery) is present, think arterial bleeding.
• Are there CT abnormalities?
  — A vascular blush or large hematoma indicates significant bleeding.

Learn more:

• Trauma Professional’s blog — Pelvic fractures and bleeding

If the patient is hemodynamically stable

• apply a pelvic binder
• perform an abdominopelvic CT with IV contrast +/- CT cystography to identify abdominal and pelvic injuries and allow prioritisation of management. A pelvic ‘blush’ indicates the need for angiography and selective embolisation of the actively bleeding artery.

If the patient is haemodynamically unstable, then

• Commence hemostatic resuscitation
• Apply pelvic binder
• Perform bedside tests:
  — AP pelvis XR — if normal, rules out pelvic fracture as cause of hemodynamic instability
  — EFAST — check for hemo/pneumothorax and intra-abdominal free fluid.
  — If EFAST is negative, confirm absence of intraperitoneal blood using supra-umbilical DPA
• If pelvic fracture and:
  — positive EFAST, or
  — EFAST negative but DPA* positive
  then the patient requires emergency laparotomy, during which pelvic stabilization and/or pre-peritoneal pelvic packing is performed pending definitive management of the pelvic injury
• If the EFAST and DPA are negative, then the patient is treated as described in Q7 below.
•  The patient may have an abdominopelvic CT with IV contrast +/- CT cystography once stabilized.

*DPA = diagnostic peritoneal aspirate performed by a supra-umbilical open approach

Learn more:

• LITFL — Weingart on Pelvic Trauma

—

Not the CT scanner!

The approach to the hemodynamically unstable patient with isolated pelvic trauma is controversial, and varies between centers according to available resources and local protocols.

The main goal is to stop the bleeding.

First, commence hemostatic resuscitation, apply a pelvic binder and call both the trauma surgeon and the orthopod on call.

My preferred approach, if resources are available, would be to take the unstable patient to the operating theatre for preperitoneal packing and pelvic fixation (with treatment of any other injuries that may contribute to hemodynamic instability using the principles of damage control surgery) followed by urgent angiography if ongoing bleeding, instability or otherwise indicated.

There are 3 management options that can be performed in combination and in different orders:

• Angiography with embolisation
• Packing
• Mechanical stabilisation by external fixation

Angiography with embolisation

• In centers with interventional radiology capability immediately available these patients may be taken to the angiography suite for embolization.
• This treats arterial bleeding, which though still less common than venous bleeding, occurs more frequently in persistently hypotensive patients.
• Either selective embolisation or non-selective embolisation can be performed.

Packing

• Packing primarily stems venous bleeding, but the patient may be transferred for angiography post-packing.
• This may be performed by the increasingly popular and rapid technique of pre-peritoneal packing (see Weingart on Pelvic Trauma and below) or by direct retroperitoneal packing during laparotomy.

Mechanical stabilization by external fixation

• Mechanical stabilization by external fixation can be performed in the angiography suite or the operating theatre, or even in the ED in some centers.
• This helps reduce bleeding from the venous plexus and from cancellous bone. This can be performed regardless of which of the above two approaches are taken.
• External fixation does not offer any advantages over pelvic binding in the initial management of pelvic fractures, although pelvic binders may impair surgical access.

Definitive imaging (CT abdomen and pelvis with IV contrast) and treatment of pelvic fractures (e.g. open reduction and internal fixation) can be performed once the patient has stabilized following damage control resuscitation.

Here is a suggested management algorithm from White et al (2009):

Finally, remember that:

Isolated hemodynamically unstable pelvic trauma is uncommon — there are usually associated injuries due to the high energy mechanism of injury.

Learn more:

• LITFL — Weingart on Pelvic Trauma
• Resus.ME — Exsanguinating pelvis – occlude the aorta
• The Trauma Professional’s Blog — Bleeding And Pelvic Fractures
• The Trauma Professional’s Blog — Predicting Bleeding In Patients With Stable Pelvic Fractures
• The Trauma Professional’s Blog — Pelvic Fractures: OR vs Angio In The Unstable Patient
• Trauma.org — Management of exsanguinating pelvis injuries

—

These patients should have angiography performed (based on the 2011 EAST guidelines):

• hemodynamically unstable patients (probably best to perform preperitoneal packing in the operating theatre first)
• patients with a pelvic “blush” on CT with IV contrast usually require selective embolisation even if stable
• ongoing bleeding after angiography should get repeat angiography
• elderly patients (e.g. > 60 years old) with major pelvic fractures should get angio even if stable
• Pelvic hematoma volume > 500 mL predicts the need for angiography

Note that neither fracture pattern nor pelvic hematoma location reliably predicts the need for angiography, and even patients with pubic ramus fractures or isolated acetabular fractures may require angiography.

—

The pros:

• can identify and control arterial hemorrhage from pelvic fractures
• 85 to 100% effective in controlling arterial hemorrhage
• embolisation can be performed selectively (just the bleeding vessel) or non-selectively (bilateral internal iliac arteries)
• can be repeated if ongoing bleeding (e.g. a bleeding artery may have been in vasospasm during the initial procedure)
• the procedure is considered safe — reports of gluteal necrosis are likely due to trauma rather than angioembolisation, and rates of sexual dysfunction in men are not increased
• does not require laparotomy for direct retroperitoneal packing
• avoids attempts at direct surgical ligation of bleeding arteries, which results in universally poor outcomes
• may be possible to embolise other bleeding vessels (e.g. splenic or hepatic arteries)

The cons:

• not beneficial for venous or bone hemorrhage, which are the sources of most hemorrhage from pelvic trauma (up to 90%)
• limited availability
• frequently delayed even when available… even in Level 1 trauma centers in the US (1-5 hours is typically reported in the literature)
• requires skilled staff and substantial resources
• requires careful communication, coordination, on call rosters and agreed upon hospital protocols
• prolonged procedure (mean 90 minutes)
• arterial bleeding sometimes stops spontaneously, and does not always need angioembolisation
• not suitable for truly unstable patients as not performed in operating theatres where resuscitation and definitive surgery is more easily performed
• risk of complications (e.g. femoral artery injury from venous access, radiation exposure, contrast allergy, contrast induced nephropathy, ischemia from embolisation)
• selective embolisation is associated with increased rates of recurrent or ongoing hemorrhage
• access to the femoral artery may be difficult (e.g. obesity, associated trauma)

—

Pre-peritoneal packing is a method of directly packing the retroperitoneum without the need for a laparotomy.

The 2011 EAST guidelines describe the procedure as follows:

• a midline incision 8 cm in length just above the pubis extending toward the umbilicus.
• Skin and subcutaneous tissue is opened in the midline, as is the fascia.
• The bladder is retracted away from the fracture and three laparotomy pads are placed in the retroperitoneal space on each side toward the iliac vessels.
• The procedure is repeated on the opposite side and the fascia and skin are closed.

Packs are usually left in situ for 24-48 hours. Pretty simple, eh.

The pros:

• often successful at controlling hemorrhage in retrospective studies (>80% of cases)
• can be performed in 20 minutes by experienced surgeons
• easy to learn and perform
• especially useful if angiography is unavailable or if there is a delay in its availability
• can be used to rescue failed angiography
• can be performed at smaller centers prior to transfer to a trauma center for definitive angiography
• can be performed concurrently with pelvic fixation and other surgical procedures
• does not require laparotomy for direct retroperitoneal packing and is not associated with increased rates of abdominal compartment syndrome
• less invasive than laparotomy with minimal blood loss

The cons:

• fails to control hemorrhage in about 15% of cases
• unlikely to control arterial hemorrhage
• not all general surgeons are familiar with the technique
• requires operating theatre, staff and resources
• no prospective head-to-head studies with angiography for first line treatment in the management of hemodynamically unstable pelvic fractures have been performed
• may increase rate of pelvic infections
• patient needs to return to the operating theatre for removal of packs

—

Pelvic fractures are important because they are associated with:

• High energy mechanisms, such as:
  — motor vehicle crashes
  — collisions with pedestrians
  — falls from height
• Major haemorrhage, which can be difficult to control
• Other major injuries
  — Intra-abdominal organs (28%), including aortic injury
  — Hollow viscus injury (13%)
  — Rectal injury (up to 5%)
• High morbidity and mortality (overall mortality is 10-30%; up to 50% if shocked)

Note that stable pelvic fractures (Tile Class A) that do not involve the pelvic ring (e.g. pubic ramus fractures and avulsion fractures) are associated with much less morbidity.

—

With extreme care!

Inspect for

• echymoses, deformity, asymmetry, wounds

Palpate the skeletal  structures

• pubic symphysis, iliac crests, the posterior sacroiliac joints, ischial tuberosities as well as the the spine extending inferiorly to the sacrum and coccyx

Assess for mobility

• Gently compress the iliac crests to fell for instability
• If there is no pain or movement felt on compression, gently distract the iliac crests (some experts, such as Scott Weingart, advise against distraction)
• A gentle technique and cautious approach is important to avoid aggravating haemorrhage if the pelvis is fractured.

This maneuver should only be performed once, ideally by the most senior trauma doctor present. Do not ‘rock’ the pelvis! Be gentle!

Patients with suspected pelvis fractures also need careful examination of:

• Rectum — digital rectal exam to palpate for rectal injury (e.g. blood, wounds), bony fragments, sphincter function and a boggy or high-riding prostate.
• Perineum and genitalia — check for coexistent genital trauma, blood at the meatus, and scrotal or other perineal hematomas. Perform a vaginal exam in women for vaginal tears.
• Lower limb length discrepancy and malrotation, and neurology
• The abdomen, e.g. tenderness, distention, external signs of trauma

Normal examination in an alert adult patient effectively rules out significant pelvic injury (93-100% sensitivity) unless there are distracting injuries. Any injuries missed tend to be be clinically insignificant or managed conservatively anyway.

Learn more:

• LITFL: Trauma Tribulation 026 — Trauma! Genitourinary injuries
• Trauma Professional’s Blog — What the Heck? and The Answer

—

For these reasons:

• Rectal injury is common (up to 5%)
• signifies an open fracture — which are more likely to be hemodynamically unstable
• may require fecal diversion, pre-sacral drainage and perineal debridement
• Risk of death from secondary sepsis

—

As always investigations are selected based on history and examination to determine diagnosis, management and/or prognosis. Depending on the clinical situation additional investigations may be be needed.

Bedside tests

• Venous blood gas (VBG)
  — monitor hemoglobin (Hb), lactate and acidemia in major haemorrhage
• FAST scan
  — assess for intraperitoneal fluid in a hemodynamically unstable patient with suspected pelvic fracture
  — Positive scan suggests haemorrhage from intra-abdominal injury and the need for laparotomy
  — False positives may result from associated bladder rupture
• Diagnostic peritoneal aspirate (DPA)
  — can be used to rule out a false negative FAST scan in a haemodynamically unstable patient
  — DPA is performed above the umbilicus in patients with suspected pelvic fractures to avoid aspirating a pelvic hematoma
  — A positive result is the aspiration of 10 mL of frank blood or GI contents
  — this is an open procedure performed by a surgeon skilled in the technique, and may take 20 minutes

Laboratory tests

• Group and save, or cross match (4-8 units) if severely injured
• full blood count and coagulation profile
  — baseline Hb to allow monitoring for a drop over time as a result of hemorrhage
  — platelets and clotting factors may be depleted in major haemorrhage
• BhCG in women of child bearing age

Imaging

• AP pelvis x-ray
  — a normal x-ray does not exclude pelvic fractures completely, but does rule out pelvic fracture as a cause of haemodynamic instability
• CT abdomen and pelvis with IV contrast
  — performed in the haemodynamically stable patient to rule out intra-abdominal and retroperitoneal injury, and to characterize the type and severity of pelvic injury and may identify those suited to inetrventional radiology
• Angiography
  — used to identify arterial injury and to guide embolisation

Learn more:

• Resus.ME — Open book fractures and ultrasound

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Indications for pelvis x-ray include:

• Hemodynamically unstable
• Altered mental state
• Distracting injuries
• Children (physical exam is less reliable)
• Abdominopelvic CT not being done for another reason

Do not perform pelvis x-ray if:

• Normal examination and the patient is alert and able to ambulate
• Abdominopelvic CT will be performed anyway for another reason

Note that the miss rate for pelvic fractures using plain films varies from about 4 to 23% in different studies, and other studies comparing radiographs to CT scans indicates that the sensitivity of pelvic radiographs is only 64-78%. Even when an injury is detected by plain radiography, CT is generally necessary to further delineate the nature of injury and rule out other injuries.

A CT scan is the imaging modality of choice for assessing pelvic ring injury.

Learn more:

• Trauma Professional’s blog — Pelvic Trauma Radiographs Demystified

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There are various systems for classification, these are the 2 most often used:

• Tile classification
  — based on pelvic stability and useful for guiding pelvic reconstruction
• Young-Burgess classification
  — more useful in the ED as it is based on mechanism and also indicates stability (I to III subclassification)

The Tile classification

• Tile A
  — Rotationally and vertically stable
  — pubic ramus fracture, iliac wing fracture, pubic stasis diastasis <2.5 cm
• Tile B
  — Rotationally unstable, vertically stable
  B1: pubic symphysis diastasis >2.5 cm and widening of the sacroiliac joints (open book fracture due to external rotation forces on the hemipelvises)
  B2: pubic symphysis overriding (internal rotation force on hemipelvises)
• Tile C
  — Rotationally and vertically unstable
  — disruption of SI joints due to vertical shear forces
  C1: unilateral
  C2: bilateral
  C3: involves acetabulum

The Young-Burgess classification

• Anteroposterior compression (APC)
  — common feature is diastasis of the pubic symphysis or vertical fracture of the pubic rami
  APC I: Pubic symphyseal diastasis, <2.5 cm, no significant posterior ring injury (stable)
  APC II: Pubic symphyseal diastasis >2.5 cm, tearing of anterior sacral ligaments (rotationally unstable, vertically stable)
  APC III: Hemipelvis separation with complete disruption of pubic symphysis and posterior ligament complexes (completely unstable)
• Lateral compression (LC)
  — common feature is a transverse fracture of the pubic rami
  LC I: Posterior compression of sacroiliac (SI) joint without ligament disruption (stable)
  LC II: Posterior SI ligament rupture, sacral crush injury or iliac wing fracture (rotationally unstable, vertically stable)
  LC III: LC II, with open book (APC) injury to contralateral pelvis (completely unstable)
• Vertical shear injuries (VS)
  — common feature is a vertical fracture of the pubic rami
  — displaced fractures of the anterior rami and posterior columns, including SI dislocation (completely unstable)
• Combined mechanism (CM) fractures
  — massive pelvic injuries that don’t fit the other categories (completely unstable)

APC fractures typically result from ‘head on’ collisions, LS fractures from ‘side on’ impacts and VS fractures from falls from height or ‘head on’ motor vehicle crashes. The Young-Burgess classification was originally thought to predict extent of haemorrhage but this has not been supported by subsequent research. The ‘lesser’ fractures can still result in arterial haemorrhage in some cases.

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Important specific injuries associated with pelvic fractures include:

• Bladder and urethral injury (5-20%)
  — posterior urethra with pelvic fractures
  — anterior urethra with straddle injuries
• Intra-abdominal injury
  — spleen and liver (12%)
  — bowel (4%)
• About 5% of pelvic fractures are open and may involve rectal or vaginal tears

Other injuries (e.g. head, chest) may also be present, especially as the presence of pelvic fractures implies a high energy mechanism of injury.

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Acute

• major haemorrhage and shock (leading mechanism of death)
• visceral and soft tissue injury:
  — fractures may be compound into the perineum or vagina
  — lacerations into the rectum or bladder
  — urethral injuries common in males
• sacral plexus injury
• ileus
• fat embolization
• acute respiratory distress syndrome
• venous thromboembolism
• abdominal compartment syndrome

Late

• infection (second most common mechanism of death)
• fracture complications (e.g. osteoarthritis, malunion)
• disability and immobility
• incontinence
• sexual dysfunction
• dystocia following subsequent pregnancy

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The simplest trigger is when a senior clinician suspects impending or actual hemorrhagic shock in bleeding patient.

Various scoring systems have been developed to predict the need for massive transfusion, such as the ABC score, the TASH score and the McLaughlin score

Show scoring systems

There is also research that methods such as thromboelastometry can give an early warning of acute coagulopathy of trauma/ shock (ACoTS).

Learn more:

• Resus.ME — Predicting massive transfusion (thromboelastometry)

Definitions vary… They include:

• 10 unit transfusion in 24 h
• transfusion of an entire blood volume in 24 h
• replacement of 50% blood volume over 3 h

Up to 5% of civilian trauma patients require massive transfusion, and of these 25% have trauma-associated coagulopathy on assessment in ED.

• Age, gender, mechanism of injury
• Blood components given pre-hospital
• FFP and platelets are likely to be needed earlier if the patient has been transfused pre-hospital
• Known bleeding diathesis
• Bleeding disorders and coagulopathies
• Drugs, e.g. warfarin, aspirin and clopidogrel
• History of previous transfusions, antibodies, reactions if known

Administer a 1:1:1 ratio of red cells, FFP and platelets

This ratio of blood products emulates the composition of whole blood. The target is to achieve 1:1:1 ratio over 6 hours.

The protocol I’m most familiar with involves:

• Activation of massive transfusion protocol (includes alerting the hematologist on call and laboratory staff)
• Send blood tests: cross match, coags, FBC, blood gas (including iCa)
• Give initial major hemorrhage pack (4 units PRBCS and 2 units thawed FFP)
• In the presence of ongoing uncontrolled haemorrhage give alternating packs A and B, with repeat blood tests after each pack:
  — Pack A: 2 units PRBC, 2 units FFP, 1 adult bag of platelets
  — Pack B: 2 units PRBC, 2 units FFP

Note that 1 adult bag of platelets is equivalent to 4 units PRBCs for the purposes of maintaining the 1:1 ratio.

Note that the 1:1:1 concept is mainly supported by the fact that it makes sense pathophysiologically and by retrospective and observational studies. It has not been conclusively proven in the way that a large double-blind randomised controlled trial would. Indeed, there are concerns that at least some of the perceived benefit of hemostatic resuscitation and the ’1:1:1′ ratio is due to survivor bias. Cliff Reid states this eloquently:

“In some circles, ‘wuntwuntwun’ is in danger of becoming the new dogma of trauma fluid replacement (ie. 1 unit of plasma and 1 unit of platelets for every unit of red cells). Since it takes longer to thaw some plasma than it does to throw in some O negative packed red cells, some really sick patients may be dead before they get the plasma, biasing comparisons that show a reduced mortality in patients who were still alive to receive plasma. This ‘survivor bias’ has been suggested as a reason that high plasma:red cell ratios are associated with mortality reduction, although this has been challenged.”

Learn more:

• Broome Docs — Managing Traumatic bleeding: how can we apply the evidence in smaller hospitals?
• EMCrit Lecture: Haemostatic Resuscitation by Richard Dutton
• EMCrit Podcast 30 – Haemorrhagic Shock Resuscitation
• Resus.ME — Battlefield Resuscitation
• Resus.Me — Plasma: Red cell ratios (survivor bias)

Current Australian guidelines advise that tranexamic acid should be considered in trauma patients with, or at risk of, significant haemorrhage.

Tranexamic acid an antifibrinolytic that works by competitively inhibiting the activation of plasminogen to plasmin  plasmin is responsible for the degradation of fibrin. Given that tranexamic acid is cheap, one of the few interventions with proven mortality benefit (NNT = 67) and few adverse effects I think clinicians should strongly consider this using this agent in major trauma patients.

Tranexamic acid is given as 1g IV loading dose followed by 1g over 8 hours. It should be given with 3 hours of major trauma.

Tranexamic acid should be given early, within 3 hours of the time of injury.

Learn more:

• EMCrit Podcast 67 – Tranexamic Acid (TXA), Crash 2, & Pragmatism with Tim Coats
• Emergency Medicine Literature of Note — Critique of Crash-2
• Emergency Medicine Ireland — Crash-2
• ICU Rounds Podcast — EARLY use of Tranexamic Acid may improve survival from bleeding in trauma
• Resus.ME — How about pre-hospital tranexamic acid?
• Resus.ME — Tranexamic acid saves lives in trauma
• The Lancet — Crash-2: Tranexamic Acid and Trauma Patients (includes link to fulltext pdf)
• The NNT — Tranexamic acid for Trauma

Again, based on the protocol with which I am most familiar:

Platelets

• Give platelets 1 adult dose if platelets <50 x 10E9/L

FFP

• Give FFP 4 units if INR > 1.5 or APTT >50

Cryoprecipitate

• Give cryoprecipitate 8 units if fibrinogen <1.o g/L

Calcium

• Give 10% calcium chloride 10 mL if ionized calcium <1.1 mmol/L

The main difference in the Australian National Blood Authority guidelines is that FFP 15 mL/kg is recommended rather than 4 units.

Recombinant Factor VIIa may be considered for use in consultation with a hematologist if there is:

• Uncontrolled haemorrhage
• That is not amenable to surgical or interventional radiological therapies
• In a salvageable patient with
  — optimal blood component therapy (INR, APTT, platelets and fibrinogen all in the normal range),
  — pH 7.2, and
  — normothermia (T>34C)

Factor VIIa is dosed at 100 mcg/kg to the nearest vial. Further blood component therapy can be given according to serial blood test results.

Remember that Factor VIIa is very expensive and has not been proven to affect clinically meaningful outcomes in the setting of major haemorrhage.

Learn more:

• LITFL — Hematology Hoodwinker 002: Recombinant Factor VIIa to the Rescue?!

We have 3 main goals:

• Stop bleeding
• Rapid and effective restoration of blood volume
• Maintain functional blood composition to preserve blood function:
  — hemostasis, oxygen carrying capacity, oncotic pressure and biochemistry

Critical bleeding is major haemorrhage that is life threatening and may require massive transfusion.

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When assessing the major trauma patient, remember the mantra:

“FIND the bleeding, STOP the bleeding”

It is convenient to consider injuries to 6 regions which may account for major blood loss:

• ‘Street’: scalp and external sources (especially small children)
• Chest
• Abdomen
• Long bones (especially femurs)
• Pelvis
• Retroperitoneum

Don’t search satisfice and settle for one site of bleeding… be thorough and systematic.

So here’s another mantra for you:

“Think SCALPeR when finding the bleeding”

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Yet another handy tip:

Whenever you think ‘control hemorrhage’, think ‘correct coagulopathy’

Approach to hemorrhage control:

• Find the cause
• Initial measures, such as:
  — Direct pressure and elevation,
  — Adrenaline soaked gauze, hemostatic dressings
  — Reduce and splint long bone and pelvic fractures
  — Tourniquets
• Invasive measures, such as:
  — sutures
  — tamponade, by packing or foley catheter with balloon inflated
  — tie off vessels
  — cautery
  — interventional radiology
  — damage control surgery
• Correct coagulopathy

Learn more:

• Resus.ME — Simple emergency haemorrhage control (foley catheter technique for neck wounds)

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Traditional ATLS teaching held that:

• If only the carotid pulse is palpable, the systolic blood pressure (SBP) is 60-70 mmHg
• If the carotid and femoral pulses are palpable, the SBP is 70-80 mmHg
• If the radial pulse is also palpable, the SBP is >80 mmHg

In reality, the pulses are lost in that order (radial, then femoral, then carotid) but the SBP at which they disappear varies and is often lower than what ATLS advises. Thus the ATLS guide will tend to overestimate blood pressure.

Remember that perfusion is more important than blood pressure anyway!

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An easy way to remember the categories is to think of the scores in a game of tennis:

Love – 15 – 30 – 40 — game over (>40)

These stages are described in ATLS as follows:

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Unfortunately, patients in the real world don’t tend to read ATLS manuals… or if they do they often choose to ignore them!

The classic stages of hemorrhagic shock (a la ATLS) don’t bear out in reality

The reasons for this include:

• Differences in compensation for different types of injuries (e.g. blunt versus penetrating trauma)
• Age (e.g. blunted physiological responses in the elderly)
• Comorbidities
• Medications (e.g. beta-blockade may conceal shock by preventing tachycardia)

Also, bradycardia is often seen in major haemorrhage:

• One theory is that there are 2 phases of response to bleeding:
  — inital catacholamine surge with tachycardia, followed by
  — subsequent bradycardia of uncertain mechanism (parasympathetically mediated?)
• But there also seems to be a group of patients who have relative bradycardia — they fail mount the initial tachycardia. Some have also noted that bradycardia is more common in acute rapid blood loss (Thomas and Dixon, 2004).
• Some have explained the bradycardia as being due to vagal stimulation from peritoneal stimulation in intra-abdominal hemorrhage, but bradycardia has been seen in penetrating extremity trauma too (Thompson et al, 1990).

Learn more:

• Resus.ME — Evidence refutes ATLS shock classification

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The lethal triad is:

• Hypothermia
• Coagulopathy
• Acidosis

These three factors both cause, and contribute to, acute coagulopathy of trauma/ shock (ACoTS) which leads to, and result from, major hemorrhage. They feed off one another, such that bleeding begets more bleeding. This is the theoretical rationale for damage control resuscitation (see below).

image courtesy of Scott Weingart at EMCrit.org

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Prevent and treat hypothermia with the following:

• Aggressive resuscitation with blood products
• Use warmed fluids (e.g. Level 1 Fluid Warmer)
• Bair Hugger or warm blankets
• Minimise exposure
• Increase ambient temperature
• Continuous temperature monitoring

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Damage control resuscitation has 3 components:

• permissive hypotension (aka minimal normotension)
• early hemostatic 
resuscitation
• damage control surgery

The underlying principles are to limit ongoing haemorrhage, identify and correct coagulopathy and restrict the use of 
crystalloids.

Permissive hypotension

• Permissive hypotension, or minimal normotension, seeks to avoid excessive fluid administration (and the associated problems of hemodilution, fluid overload and clot disruption). Classically a target SBP of 80 to 100 mmHg is advised.
• As perfusion is more important than blood pressure, an alternate strategy (a la EMCrit) is to target a MAP >65 mmHg together with a good radial pulse and pulse oximetry waveform. If the BP is too high, use titrated aliquots of fentanyl (e.g. 25 micrograms IV) to provide sympatholysis as well as analgesia.

Damage control surgery

Damage control surgery refers to limited surgical interventions that serve to control haemorrhage and minimize contamination until the patient has sufficient physiological reserve to undergo definitive interventions. The strategy aims to bring the ‘lethal triad’ under control, so that the patient will be able to tolerate further surgery once he or she improves.

Hemostatic resuscitation and massive transfusion protocols are discussed in the Trauma Tribulation 026 — Trauma! Massive Transfusion.

Learn more:

• EMCrit Lecture: Haemostatic Resuscitation by Richard Dutton
• EMCrit Podcast 30 – Haemorrhagic Shock Resuscitation
• Resus.ME — Battlefield Resuscitation
• Broome Docs — Managing Traumatic bleeding: how can we apply the evidence in smaller hospitals?

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Traditional ATLS teaching is to initiate fluid resuscitation with 1-2 L of crystalloid such as normal saline or compound sodium lactate (Hartmann’s solution).

Potential downsides of this approach include:

• dilutional coagulopathy
• impaired oxygen delivery due to dilutional anaemia
• hypothermia
• worsening metabolic acidosis (especially hyperchloremic non-anion gap metabolic acidosis from normal saline administration)
• clot dislodgement and haemorrhage from blood pressure elevation

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