In history of substantial trauma of any form, whether it is motor vehicular accident or fall from height should always alert the physician or health worker to rule out all life threatening conditions. As per protocol patient is assessed for airway, breathing and circulation at the sit of accident.
A head to toe examination is carried out to look for any gross injury in any other part of body.
Pelvis is tested by direct palpation,Pelvic Compression and Distraction Tests.
In case of injury the pelvis would reveal tenderness. If compressssion or distraction tests are positive for pelvis, it indicates instability of the pelvis.
If there is an overt bleeding , a pressure bandage should be applied. Pelvis should be quickly and temporarily stabilized by wrapping sheet a tightly around it and securing it with a clamp.
On arrival in the emergency department, the patient may be in a pneumatic antishock garment.
Deflate it carefully to avoid precipitous hypotension. If hypotension does occur, reinflate the garment and transfer the patient to the operating room so that, upon removal of the suit, immediate alternative surgical measures to restore hemodynamic stability can be undertaken.
Sidenote: Pneumatic Antishock Garments may not be available in many centers. In India, many tertiary care centers do not have it.
The diagnosis of intraabdonminal hemorrhage can be made by ultrasound, peritoneal lavage, or minilaparotomy. Abdominal and pelvic CT scans are useful as well.
Emergency Pelvic Stabilization
External pelvic fixation is a highly effective method to control intrapelvic bleeding associated with a major pelvic fracture.
The external fixation is for temporary haemodynamic stability. It should be followed by suitable internal fixation.
Reduction of the pelvic fracture produces an increase in interstitial tissue pressure and provides a tamponade of the retroperitoneal bleeding. It also markedly reduces the volume of the true pelvis in which extravasated blood may accumulate.
Reduction and compression of the cancellous fracture surfaces reduces the rate of bleeding.
Relative contraindications to external pelvic fixation for control of acute hemorrhage
- Fracture of iliac crest and anterior inferior spine that eliminates any realize site for insertion of a pin
- Bilateral sacroiliac dislocations or comparable bilateral posterior injuries
- Bilateral both-column or high anterior column acetabular fractures
- Stable pelvic ring with source of intrapelvic hemorrhage
- Bleeding of a major pelvic vessel (i.e., aorta, iliac, or femoral vessels)
- Late presentation
- Marked osteoporosis
- Small child
In the presence of iliac comminution and florid osteoporosis, the pins do not achieve sufficient pelvic anchorage. In a small child, the disproportionately small pelvis is not a realistic target for effective anchorage of the pins.
Control of Bleeding
Bleeding in pelvic fracture can be controlled directly by use angiographic embolization of autologous blood clots or Gelfoam clots.
For the management of bleeding from vessels that are greater than 5 mm in diameter, such as the femoral and common iliac arteries, operative intervention is usually necessary.
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