CHHS16/192

Canberra Hospital and Health ServicesClinical ProcedurePelvic Injury – Management of the Unstable Trauma Patient (16 years and over)Contents

Contents....................................................................................................................................1

Purpose.....................................................................................................................................2

Alerts.........................................................................................................................................2

Scope........................................................................................................................................ 2

Definition of terms....................................................................................................................3

Section 1 – Treatment algorithm..............................................................................................5

Section 2 – Primary Survey........................................................................................................6

Section 3a – The responsive patient who is safe for diagnostic CT scan...................................6

Section 3b – Critically unwell patient with positive FAST or DPA..............................................7

Section 3c – Critically unwell with negative FAST or DPA.........................................................8

Caveat....................................................................................................................................... 9

Implementation........................................................................................................................ 9

Evaluation............................................................................................................................... 10

Related Policies, Procedures, Guidelines and Legislation.......................................................10

References.............................................................................................................................. 10

Search Terms.......................................................................................................................... 16

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Purpose

Blunt abdominal trauma resulting in life threatening haemorrhage is not an uncommon presentation to the emergency department. Pelvic fractures with major blood loss leading to haemodynamic instability require a multi-disciplinary management approach that is time critical. A well designed clinical practice guideline allows for a more efficient path to definitive haemorrhage control.

The purpose of this document is to guide treatment of critically unwell trauma patients with pelvic fractures, based on reliable scientific evidence. It is tailored to the skill base and facilities available at The Canberra hospital. The guideline is designed to support the trauma team in making decisions. It does not supersede clinical judgement and trauma clinician experience.

Back to Table of ContentsThis document pertains to patients 16 years and over that require emergent management and admission for suspected pelvic injuries, which includes single system injury and polytrauma. The management of paediatric pelvic fractures is an orthopaedic decision and will depend on the patient’s haemodynamic status, stability of the pelvic ring, type of fracture and the patient’s age. Patients aged less than 16 years are therefore excluded from this guideline.

The document relies upon senior clinician decision making and collaboration between subspecialty teams including Emergency Physicians, General/Trauma Surgeons, Orthopaedic Surgeons, Interventional Radiologists and Intensivists. This should be initiated early in the management of such a patient and consultant attendance at Trauma Code is strongly encouraged to facilitate optimal collaboration and time critical decision-making.

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This Standard Operating Procedure (SOP) describes for staff the process to

CHHS16/192

Trauma Team Leader (ED Registrar/Consultant) / Nursing Team Leader Airway Doctor (ED, ICU or Anaesthetics Registrar/Consultant) / Airway Nurse Circulation Doctor (ED or ICU Registrar/Consultant) / Circulation Nurse Procedure Doctor (ED or Surgical Registrar/Consultant) / Procedure Nurse Radiographer Wardsperson (blood bank runner and patient transport)

Other clinical teams directly involved in the treatment pathway are from the following areas: Interventional Radiology Orthopaedics Radiology nursing staff Theatre nursing staff Blood Bank and Pathology staff

The processes suggested in these guidelines will always be secondary to the direction of the trauma team leader (see Trauma Team Activation Guideline), who may deviate from these guidelines if clinical circumstances require it.

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Definition of terms

All interventions suggested in this guideline are performed under the direction of senior proceduralists. Both arterial embolisation and extra-peritoneal packing with pelvic external fixation are complementary, meaning if haemorrhage control is unable to be gained by the initial procedure, the patient should immediately undergo the alternate procedure.

1) The trauma team is the central element of trauma care and management and refers to a multidisciplinary group of health care professionals who aim to provide the multi-trauma patient with immediate, expert assessment, resuscitation and treatment. Trauma team activation occurs from the Emergency Department and is initiated by the triage nurse prior to, or on, patient arrival.

2) The haemodynamically compromised patient is defined as:The adult trauma patient with a systolic blood pressure that is not responsive to the initial fluid and resuscitative measures taken prior to arrival to and in the emergency department. These measures may include the massive transfusion protocol (MTP).

3) Pelvic fracture is diagnosed by a senior medical staff member. E.g. supervising emergency consultant and senior trauma surgical registrar

4) The presence or absence of blood loss in other compartments will be established during the primary survey upon patient arrival in the Emergency Department. a. External blood loss – Assessed by general inspection after adequate exposure

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b. Thoracic blood loss – Assessed by plain chest xray or volume output from intercostal catheter (ICC)

c. Intra-abdominal blood loss – Assessed by focused assessment with sonography in trauma (FAST) scan and/or diagnostic peritoneal aspirate (DPA). The choice of which will be dependent on the level of experience of the trauma team members.

d. Long bone fractures – Assessed by general inspection and confirmed on plain Xray.

5) Extravasation of contrast material in the pelvis at contrast-enhanced CT is an accurate indicator of ongoing arterial haemorrhage in patients with pelvic fractures and is referred to within the algorithm as intravascular contrast extravasation (ICE)

6) Definitive haemorrhage control in pelvic arterial bleeding is by catheter angiography and arterial embolisation. This procedure is performed in the angiography suite in the Medical Imaging department by an interventional radiologist

7) Definitive haemorrhage control from intra-abdominal sources is by exploratory laparotomy. This procedure is performed in the Operating Theatres by the Trauma/General surgeon. During this procedure the pelvic ring will be stabilised by external fixation performed by the orthopaedic surgeon.

8) Haemorrhage arising simultaneously from intra-abdominal and pelvic sources will be managed initially by exploratory laparotomy followed by extra-peritoneal pelvic packing. This procedure is performed in the Operating Theatre by the Trauma/General surgeon at the time of exploratory laparotomy.

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Section 1 – Treatment algorithm

The algorithm below describes the key steps to the management guideline:

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Section 2 – Primary Survey

The objectives of the primary survey are to synchronously evaluate and resuscitate the patient. The approach to the primary survey is in accordance with the internationally recognised and Royal Australasian College of Surgeons endorsed Emergency Management of Severe Trauma (EMST) principles.

The evaluation for circulatory compromise aims to localise the site or sites of blood loss. This includes:1. Adequate patient exposure and general inspection for external blood loss2. Chest Xray for intra-thoracic blood loss3. FAST scan and/or DPA for intra-abdominal blood loss4. Pelvic Xray for pelvic/extra-peritoneal blood loss

Upon completion of the primary survey, the trauma leader should estimate the relative degree of haemodynamic compromise based upon clinical assessment and anticipate the potential location/s of major haemorrhage and the need for massive transfusion protocol activation (see CHHS12/138: Massive Transfusion Protocol).

This guideline can be used to support the decisions of the trauma team leader in patients with pelvic fractures who have potential major haemorrhage from an abdomino-pelvic source.

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Section 3a – The responsive patient who is safe for diagnostic CT scan

Patients who respond to initial resuscitation or are deemed by the trauma team leader as safe to undergo diagnostic CT scan can be transferred to the CT scanner. This arm of the algorithm provides the greatest diagnostic information. For this reason aggressive resuscitative measures will be implemented to allow patients access to this management pathway.

ApproachFollowing the primary survey and initial resuscitation, patients with a systolic blood pressure of greater than 90mmHg or patients deemed safe by the trauma team leader will be directed for transfer to the CT scanner. The patient will be escorted to and from the CT scanner by all members of the trauma team whilst the trauma code remains active.

If possible, the patient will be transferred on to the CT table feet first with attached relevant monitoring equipment. The images of the CT scan will be reviewed and relevant findings directed to the trauma team leader prior to the patient transferring off the CT table.

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Staff involved in this procedure are:1. Trauma team 2. Wards men 3. Emergency department nursing staff4. CT radiographers5. Radiology registrar/ Consultant

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Section 3b – Critically unwell patient with positive FAST or DPA

Transfer for Exploratory laparotomySeverely compromised pelvic trauma patients who are considered by the trauma team leader as unsafe to undergo diagnostic CT scan follow the second arm of the treatment pathway. The priority in these patients is urgent definitive haemorrhage control.

Patients with concurrent blood loss from pelvic and Intra-abdominal sources should be urgently transferred to the operating theatres for1. Emergency exploratory laparotomy2. Pelvic external fixation3. Pelvic extra-peritoneal packing

ApproachUpon completion of the primary survey, a pelvic fracture proven on x-ray and positive findings on FAST or DPA suggest that the source of major blood loss could be both the pelvis and/or the abdominal cavity. Controlling intra-abdominal haemorrhage is the priority in this setting and exploratory laparotomy is indicated. The Critical Bleeding Massive Transfusion Procedure should also be activated immediately if not already active.

Pelvic external fixation is performed while in the operating theatres by senior orthopaedic surgeons. After pelvic external fixation, extra-peritoneal pelvic packing is performed by appropriately trained general/trauma or orthopaedic surgeon.

The patient will be escorted to the operating theatre by members of the trauma team whilst the trauma code remains active. The patient is then either handed over to the on call Trauma Consultant, anaesthetist and the operating surgeons as appropriate.

Staff involved in this procedure are:1. Trauma team2. Theatre nursing team3. Wards men 4. Anaesthetist and team5. Trauma surgeon and team6. Orthopaedic surgeon7. Pathology/ blood bank

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Section 3c – Critically unwell with negative FAST or DPA

Severely compromised pelvic trauma patients who are agreed by the trauma team leader and the interventional radiologist on call to be unsafe to undergo diagnostic CT scan follow the second arm of the treatment pathway. This will apply to only a very small proportion of patients who are too unstable to undergo CT. This must be done with close collaboration of Senior Consultant staff involved in procedural management of these patients. The priority is definitive haemorrhage control. CT angiography should be performed if at all possible to confirm the site of bleeding so that the patient undergoes the most appropriate treatment to control haemorrhage and time is not wasted.

In collaboration with the interventional radiologist on call and given feasibility to proceed with the procedure in a timely manner, patients suspected of imminent exsanguination from a pelvic source without other significant sites of blood loss, should be emergently transferred to the angiography suite for:1. Catheter angiography2. Embolisation as appropriate

It should be recognised that there may be occasions when Interventional Radiology cannot respond within the specified timeframe i.e. when they are already engaged in a procedure. See caveat below.

ApproachUpon completion of the primary survey, a pelvic fracture proven on xray and negative findings on FAST or DPA in a haemodynamically unstable patient suggests that the source of major blood loss could be isolated to the pelvis/ extra-peritoneal space. In the case of patients agreed to be too unstable to undergo CT, controlling pelvic haemorrhage is the priority in this setting and urgent catheter angiography and embolisation is indicated.

The patient will be escorted to the angiography suite by all members of the trauma team whilst the trauma code remains active. The trauma team leader continues to oversee the care of the patient whilst the trauma code remains active. The patient may be handed over to Trauma Consultant/Surgeon and anaesthetic team when the trauma team leader deems it to be appropriate. Under direction of Orthopaedic/Trauma Surgeon and Interventionalist, the external pelvic binder will be temporarily released (but not removed) at the beginning of the procedure, leaving the binder control at the level of the iliac crests to allow access for catheterisation. Catheter angiography and embolisation will be performed by senior Interventional Radiologist.

Staff involved in this procedure are:1. Trauma team2. Interventional Radiologist3. Orthopaedic Surgeon

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4. Angiography suite radiographer5. Angiography suite nursing team6. Wards men7. Anaesthetist and team8. Pathology/ blood bank

Following this intervention, if haemodynamic instability continues, or if pelvic bleeding remains uncontrolled, the patient should be transported to Operating Theatres urgently for pelvic external fixation +/- laparotomy, extra-peritoneal packing, or other damage control interventions.

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Caveat

In the event that Interventional Radiology is unable to provide interventional services within 45 mins e.g. when already engaged in a procedure or mechanical breakdown/maintenance, haemorrhage control should be gained through pelvic external fixation.

The patient will be escorted to the operating theatre by all members of the trauma team whilst the trauma code remains active. The patient is then either handed over to the on call Trauma Consultant or anaesthetist and the operating surgeons as appropriate.

Staff involved in this procedure are:1. Trauma team2. Theatre nursing team3. Wards men 4. Anaesthetist and team5. Trauma surgeon and team6. Orthopaedic surgeon7. Pathology/ blood bank

Note: Do not divert patient unless trauma team leader confirms, as redirection is likely to cost more time

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Implementation

Each senior member of the respective teams will be responsible for informing and distributing the information to their respective team members. The information will also be available on the hospital intranet and accessible at any time.Each department will be responsible for educating their staff in accessing and executing the relevant tasks that contribute clinical information gathered to implement this algorithm.

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Evaluation

Outcome MeasuresAppropriate documentation will be audited as a part of major trauma systems analysis.

Current Key Performance Indicators (Threshold 100%) Trauma team activation (According to activation criteria) Trauma team response - volume per minute of fluid resuscitation Emergency surgery in < 40 mins from arrival Emergency catheter angiography in < 60min from arrival

MethodThe Trauma Service will be responsible for auditing compliance, storing all identified issues on the Major Trauma Database; reporting monthly to the ACT Trauma Committee.

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Related Policies, Procedures, Guidelines and Legislation

CHHS Trauma Team Activation Guideline CHHS Critical Bleeding Massive Transfusion Procedure CHHS Fresh Blood Products Administration (Adults, Paediatrics and Neonates)

Procedure CHHS Patient Identification and Procedure Matching Policy CHHS Patient Identification and Procedure Matching Procedure

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References

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retroperitoneal pelvic packing versus pelvic angiography: A comparison of two management protocols for haemodynamically unstable pelvic fractures. Injury. 2009;40(1):54-60.

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63. Smith WR, Moore EE, Osborn P, Agudelo JF, Morgan SJ, Parekh AA, et al. Retroperitoneal packing as a resuscitation technique for hemodynamically unstable patients with pelvic fractures: report of two representative cases and a description of technique. The Journal of trauma. 2005;59(6):1510-4.

64. Starr AJ, Griffin DR, Reinert CM, Frawley WH, Walker J, Whitlock SN, et al. Pelvic ring disruptions: prediction of associated injuries, transfusion requirement, pelvic arteriography, complications, and mortality. Journal of orthopaedic trauma. 2002;16(8):553-61.

65. Stephen DJ, Kreder HJ, Day AC, McKee MD, Schemitsch EH, ElMaraghy A, et al. Early detection of arterial bleeding in acute pelvic trauma. The Journal of trauma. 1999;47(4):638-42.

66. Subedi N, Yadav B, Jha S. Application of abbreviated injury scale and injury severity score in fatal cases with abdominopelvic injuries. The American journal of forensic medicine and pathology. 2014;35(4):275-7.

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67. Subedi N, Yadav B, Jha S. Application of abbreviated injury scale and injury severity score in fatal cases with abdominopelvic injuries. The American journal of forensic medicine and pathology. 2014;35(4):275-7.

68. Suzuki T, Smith WR, Moore EE. Pelvic packing or angiography: competitive or complementary? Injury. 2009;40(4):343-53.

69. Tanizaki S, Maeda S, Hayashi H, Matano H, Ishida H, Yoshikawa J, et al. Early embolization without external fixation in pelvic trauma. The American journal of emergency medicine. 2012;30(2):342-6.

70. Tanizaki S, Maeda S, Matano H, Sera M, Nagai H, Ishida H. Time to pelvic embolization for hemodynamically unstable pelvic fractures may affect the survival for delays up to 60 min. Injury. 2014;45(4):738-41.

71. Tayal VS, Nielsen A, Jones AE, Thomason MH, Kellam J, Norton HJ. Accuracy of trauma ultrasound in major pelvic injury. The Journal of trauma. 2006;61(6):1453-7.

72. Ten Broek RP, Bezemer J, Timmer FA, Mollen RM, Boekhoudt FD. Massive haemorrhage following minimally displaced pubic ramus fractures. European journal of trauma and emergency surgery : official publication of the European Trauma Society. 2014;40(3):323-30.

73. Thorson CM, Ryan ML, Otero CA, Vu T, Borja MJ, Jose J, et al. Operating room or angiography suite for hemodynamically unstable pelvic fractures? The journal of trauma and acute care surgery. 2012;72(2):364-70; discussion 71-2.

74. Tosounidis TI, Giannoudis PV. Pelvic fractures presenting with haemodynamic instability: treatment options and outcomes. The surgeon : journal of the Royal Colleges of Surgeons of Edinburgh and Ireland. 2013;11(6):344-51.

75. Totterman A, Dormagen JB, Madsen JE, Klow NE, Skaga NO, Roise O. A protocol for angiographic embolization in exsanguinating pelvic trauma: a report on 31 patients. Acta orthopaedica. 2006;77(3):462-8.

76. Totterman A, Madsen JE, Skaga NO, Roise O. Extraperitoneal pelvic packing: a salvage procedure to control massive traumatic pelvic hemorrhage. The Journal of trauma. 2007;62(4):843-52.

77. Wong YC, Wang LJ, Ng CJ, Tseng IC, See LC. Mortality after successful transcatheter arterial embolization in patients with unstable pelvic fractures: rate of blood transfusion as a predictive factor. The Journal of trauma. 2000;49(1):71-5.

78. Yuan KC, Wong YC, Lin BC, Kang SC, Liu EH, Hsu YP. Negative catheter angiography after vascular contrast extravasations on computed tomography in blunt torso trauma: an experience review of a clinical dilemma. Scandinavian journal of trauma, resuscitation and emergency medicine. 2012;20:46.

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Search Terms

Trauma, Pelvic fracture, Blunt abdominal trauma, Blunt pelvic trauma, Traumatic pelvic fracture, Traumatic pelvic haemorrhage

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Disclaimer: This document has been developed by ACT Health, Canberra Hospital and Health Service specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

Date Amended Section Amended Approved ByEg: 17 August 2014 Section 1 ED/CHHSPC Chair

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Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register