Case #4: Poly-Trauma
Hx: 40’s yo M presents with auto v. pedestrian
PE: VS: Manual BP 80/40, HR 140, B LE Open Deformities, 2+ in all 4, pelvis stable, GCS 7 (2, 2, 3)
***Case Discussion of Polytrauma with Dr. Prest with Emory Trauma Surgery***
Teaching Point #1: Problems with airway may be secondary to problems with circulation, especially with no signs of trauma above the clavicle.
Teaching Point #2: Hypotensive blunt trauma patients are either bleeding, pneumothorax, or pericardial tamponade.
Teaching Point #3: Sites of bleeding? Scene, Chest, Pelvis, Abdomen, Retroperitoneum, Long Bones, Scalp. Find the bleeding and stop it.
Clinically Focused Review Article: The Management of Exsanguinating Pelvis Injuries: http://www.trauma.org/index.php/main/article/668/Pelvic
Think of the pelvis as a ring made up of the SI joint posteriorly, the arcuate line laterally and the superior pubic ramus/symphysis anteriorly. It’s hard to break a ring in just one spot, always look for a second break.
Young-Burgess Classification: Fractures classified based on mechanism of injury: A: Lateral Compression B: Anterior Posterior Compression C: Vertical Sheer
Management: Unstable VS and an unstable pelvis? Place a binder, call surgery, ortho and interventional radiology to discuss IR versus OR for definitive bleeding control.
How and when should I use a pelvic binder? Any pelvic fracture that results in widening of the pelvis resulting in hemodynamic instabillity. For example, an “open book” anterior posterior compression fracture with widening at the pubic symphysis. The binders at Grady come one-size fits all, so you may have to trim some of the excess yellow material. Place the binder lower than you might expect: over the greater trochanters. Cinch down the strings. Sheets wrapped tightly and towel clipped is another alternative. (Choi SB, Cwinn AA. Pelvic Trauma. In: Marx, JA Hockbberger RS, Walls RM eds. Rosen’s Emergency Medicine – Concepts and Clinical Practice, 8th. Philadelphia, PA: Elsevier Saunders. ) 656-671.
What about vertical shear pelvis fractures? These are unstable pelvic fractures that result in extensive damage to the rich venous arterial and nerve plexi coursing into the pelvic ring. These are tricky because the pelvis may not feel unstable on exam and the x-ray findings may be subtle. Pelvic binders are contraindicated. These patients need interventional radiology and trauma surgery. Arterial hemorrhage is better served by interventional radiology, however, venous hemorrhage is better addressed with open packing. Call IR and trauma surgery.
Case Resolution: Large bore IV’s, uncrossmatched blood, FAST- in chest and equivocal in abdomen. Taken emergently to OR for DPL which turned into an Ex-Lap. Vertical shear fx, large retroperitoneal hematoma rupturing into the abdominal cavity. Unable to control bleeding after extensive packing, bradycardic arrest intraoperatively.