Evaluation and Treatment

NOTE: Refer to Appendix A: Pelvic Fracture Clinical Pathway, Appendix B: Pelvic Packing Technique, and Appendix C: Pelvic Stabilization Technique

#### The four tenets of hemorrhage control in the unstable pelvic fracture:

- Resuscitation with whole blood or balanced component blood products
- Stabilization of the bony pelvis
- Identify the sources of hemorrhage
- Hemorrhage control. 12

Mechanism of injury (e.g., IED blast, crush injury, and high velocity penetrating wounds to the pelvis) and hypotension can indicate high risk for pelvic fracture. Care for casualties with pelvic fractures ideally starts in the prehospital environment with initiation of Tactical Combat Casualty Care (TCCC) interventions to include early blood transfusion, Tranexamic acid (TXA), and pelvic binder placement. If suspicion is high for an unstable pelvic fracture (if not already placed in the prehospital setting), pre-position binders/sheet on the litter (bed) prior to transferring the patient over, so that a binder/sheet may be utilized quickly. Signs of pelvic fracture on physical exam include pain on palpation, leg length discrepancy with foreshortening and internal rotation of the lower extremity, and a perineal hematoma which can look like scrotal bruising in men.

Two key determinations must be made in patients with pelvic fractures: hemodynamic stability and if the pelvic fracture is mechanically stable. If the patient is not hemodynamically stable, it is imperative to identify all site(s) of hemorrhage, as pelvic fractures often occur in conjunction with other life-threatening injuries. Appropriate evaluation of the chest, abdomen, extremities, and other potential sites of hemorrhage cannot be overemphasized. Additionally, a thorough examination of the pelvis and perineum is required to rule out associated injuries to the rectum and genitourinary/gynecologic systems. Open pelvic fractures have a higher morbidity; if there is concern for an open pelvic fracture a rectal and vaginal exam must be performed. Additionally, injury to the urethra and bladder should be ruled out. Urethral injury is more common in men.

The steps to initially evaluate and treat patients with pelvic fractures are as follows:

HEMORRHAGE CONTROL

1. All trauma patients should undergo a rapid trauma assessment according to TCCC, Advanced Trauma Life Support (ATLS), and Joint Trauma Systems (JTS) damage control resuscitation guidelines. Sources of hemorrhage should be rapidly identified and intervened upon in a systematic way. Please see JTS Damage Control Resuscitation and Whole Blood Transfusion CPGs for more information.

2. Patients in hemorrhagic shock should be appropriately treated with blood products, preferably whole blood. Blood product administration of either whole blood (preferably) or component blood products in a 1:1:1 ratio, based on available product, should be initiated for patients who remain hypotensive (SBP < 100, or 110 in patients with suspected traumatic brain injury). Initiation of massive transfusion protocol is often required.

3. During resuscitation, place a pelvic binder or sheet (if not already in place) centered over the greater trochanters with the buckle centered over the pubic symphysis. The pelvis should be manually reduced by internally rotating the hemipelves together, having one person press the greater trochanters together after which a second person tightens down the binder or tightly secure the sheet. Taping the knees and feet together can assist in internal rotation of the lower extremities to facilitate further reduction at the pelvis and help improve the pelvic reduction achieved with a sheet or binder.14 A multidisciplinary approach with early orthopedic surgery consultation (and trauma consultation if care is being rendered prior to a Role 2) is critical for the holistic management of these complex injuries.

4. As with all trauma patients, patients with concern for pelvic injuries and those with pelvic binders in place require a pelvic x-ray as an adjunct of the primary survey. If a pelvic binder is in place, obtain the x-ray with the binder/sheet cinched down. Only if the patient is hemodynamically stable, release the binder/sheet and repeat the x-ray to evaluate for major pelvic ring disruption – if the pelvic ring is unstable, reduce the pelvis again and retighten the binder/sheet; repeat the pelvis x-ray to confirm that the pelvis is radiographically reduced. Monitor hemodynamics continuously during this process and communicate with all members of the team when the pelvic binder is released and when it is re-applied.

5. Identify all areas of potential hemorrhage. A focused assessment with sonography for trauma (FAST exam) should be completed as another adjunct to the primary survey to assess for intra-abdominal hemorrhage. There should be a detailed examination of soft tissue disruptions with special attention paid to the perineal area. Digital rectal exams and vaginal exams should be performed for all open pelvic fractures or if there is evidence of perineal trauma.

6. Hypotensive patients with a positive FAST should proceed directly to the operating room for laparotomy. Be mindful when extending the laparotomy incision infra-umbilically. A patient with unstable pelvis and in hemorrhagic shock from this will likely have a large pre-peritoneal (or retroperitoneal) hematoma, incising into this hematoma will decompress it and release tamponade, worsening hemorrhage.

a. Visualize the infraumbilical area internally when extending the laparotomy incision, or alternatively, feel for a large hematoma in this region.

b. If there is a pre-peritoneal hematoma confirmed, AVOID EXTENDING THE LAPAROTOMY INCISION INFERIORLY AND AVOID INCISING THE HEMATOMA. This is the space you must preserve for your pre-peritoneal pelvic packing to be effective.

c. Pre-peritoneal packing (PPP) should be considered if the pelvis is thought to be the major contributor to hemorrhage, which is best completed via an infraumbilical midline incision separate from a laparotomy incision. (See below for details.)

7. If PPP is being utilized, it is strongly recommended that concomitant pelvis external fixation be performed, if possible. Binders should only be used in this setting if equipment or skills for pelvic external fixation are lacking.

8. Zone 3 Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) should be considered for temporary hemorrhage control if there is hemodynamic instability when providers are appropriately trained and have surgical capability. (See the JTS REBOA for Hemorrhagic Shock CPG for details.)

NOTE: Patients are rarely suitable for definitive fixation hours after presentation to surgical capability.

9. For patients with a negative FAST who are hypotensive (SBP < 90) despite pelvic binder placement, resuscitation with blood products should be continued on the way to the OR for PPP or interventional radiology (IR) angioembolization (if capability available) and external fixation. (Reminder: a FAST exam that is negative/non-diagnostic does not definitively rule out hemorrhage.) 13

10. Remove pelvic binders and perform surgical stabilization with an external fixator as soon as possible. If a binder is left in place for more than 6 hours, the patient will need periodic skin checks at a minimum of every 12 hours by holding the pelvis reduced and taking down the binder/sheet, assessing the skin for pressure wounds and reapplying after skin assessment. If there is concern for pressure wounds, external fixation should be performed so the binder/sheet can be discontinued. Binders/sheets should not be left in place for more than 24 hours if possible.

11. Post PPP patients will need continued ICU-level monitoring of hemodynamics and may require continued resuscitation. These patients should in in an ICU. These casualties will require transfer to a higher level or care when they are stable for transport. Pelvic fracture patients who require any type of surgical intervention will require evacuation out of the combat theater.

12. In patients who undergo PPP, packs should be removed when resuscitation is complete and they are hemodynamically stable. This should always be accomplished within 48 hours.

13. In patients who are hemodynamically unstable despite adequate pelvic packing, bleeding is then likely from an arterial source. The treatment options include: temporizing uni/bilateral internal iliac artery occlusion (with vessel loops/Rommel tourniquets, atraumatic clamps) or evacuation to a higher level of care with IR capability. These are temporizing measures only. Bilateral internal iliac artery ligation should only be performed in extreme circumstances as the risk for necrosis and severe infection increase mortality. Unilateral internal iliac artery ligation can be used with less morbidity. Ideally selective vessel ligation (branches from internal iliac) is preferred but more technically challenging.

14. Definitive pelvic surgery should be deferred to a Role 4 facility with orthopaedic trauma surgery support and capabilities. There are circumstances where this could be done at a Role 3 MTF if the adequate expertise, imaging, and adjunct capabilities are present. During the GWOT these cases were performed at either Landstuhl or at a CONUS Role 4 MTF.

EVALUATION of ASSOCIATED INJURIES

1. Genitourinary - genital, urethral and bladder injuries can occur with severe pelvic injuries. A thorough examination of the genitals and perineum must be performed.

a. Urethra - A urethral injury should be suspected with blood at the urethral meatus or a high-riding prostate on the initial rectal exam. A urinary catheter should be gently inserted and if there is any difficulty with initial catheter placement, urethral integrity must be evaluated via retrograde urethrography.

b. Bladder - If gross hematuria is noted, a cystogram should be performed to rule out bladder injury. (See the JTS Genitourinary Injury Trauma Management CPG.)

c. Testicular and vaginal injuries – examine for injuries, refer to the JTS Genitourinary Injury Trauma Management CPG for more detailed information.

2. Rectal - a digital rectal examination should be performed. If defects or blood are noted, a more thorough exam is warranted with either rigid or flexible proctoscopy to evaluate for rectal injuries. (See the JTS High Bilateral Amputations and Dismounted Complex Blast Injury CPG for more details.)

3. Perineal wounds - thorough examination should be performed; perineal wounds can easily be missed and are often associated with the injuries above. See the JTS High Bilateral Amputations And Dismounted Complex Blast Injury CPG for more details.