I TRAUMI DEL BACINO E DELL ADDOME INFERIORE

Transcription

1 I TRAUMI DEL BACINO E DELL ADDOME INFERIORE Dr. Luca Ansaloni, MD USC Chirurgia I Ospedale Papa Giovanni XXIII, Bergamo

2 Lower Abdomen Trauma Hemodynamically Unstable Pelvic Trauma Results of the First Italian Consensus Conference Bergamo 13 april 2013

3 WHICH UNSTABILITY? 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. Hemodinamically Unstable Pelvic Trauma

4 Organization Organising Commitee Papa Giovanni XXIII Hospital Luca Ansaloni Roberto Agazzi Claudio Arici Claudio Castelli Federico Coccolini Stefano Magnone Roberto Manfredi Gianmariano Marchesi Dario Piazzalunga Valter Sonzogni Scientific Committee Marco Barozzi (SIMEU) Giovanni Bellanova (ACOI) Fausto Catena (WSES) Salomone Di Saverio (SPIGC) Giuseppe Nardi (SIAARTI) Panel Gregorio Tugnoli (ACOI) Walter Biffl (WSES) Tiziana Mastropietro (SPIGC) Giorgio Berlot (SIAARTI) Giuseppe Dodi (SIC) Raffaella Niola (SIRM- Interventistica) Sergio Ribaldi (SICUT) Luigi Rizzi (SIOT) Gennaro Rispoli (SIC) Andrea Fabbri (SIMEU) Antonio Rampoldi (SIRM- Interventistica) Osvaldo Chiara (SICUT) Alessandro Massè (SIOT) Bibliographic search by Chiara Bassi (Modena) and Franca Boschini (Bergamo) 1980-november 2012 Medline Embase Cochrane Tripdatabase Nationale Guidelines Clearinghouse NHS Evidence Trauma.org Uptodate

5 Hemodynamically Unstable Pelvic Trauma DEFINITION Systolic blood pressure < 90 in the ED inspite of Transfusion of 2 U of RBC Cristalloid infusion (1-2 L) Presence of a pelvic fracture (portable Xray) Identify other source of bleeding in the ED Peritoneum (FAST exam) Chest (portable Xray)

6 TIMETABLE November January 2013 The Organizing Committee reviewed the abstracts and retrieved the papers The Scientific Committee was split in 3 groups to prepare 3 statements to be submitted to the Panel answering 3 questions: 1. Which hemodynamically unstable patient needs a preperitoneal packing? 2. Which hemodynamically unstable patient needs an external fixation? 3. Which hemodynamically unstable patient needs an angiography? January - September 2013 The Organizing and Scientific Committee prepared 3 presentation with the review of the literature and the statements The Panel during the conference day (13th april 2013) debated the statements and an algorythm was proposed. After the conference the algorythm was modified according to the consensus of all the members. There is unanymous consensus in some of the statements and the algorythm

7 Preperitoneal pelvic packing (PPP) Gänsslen A, Hildebrand F, Pohlemann T. Management of hemodynamic unstable patients "in extremis" with pelvic ring fractures. Acta Chir Orthop Traumatol Cech. 2012;79(3):

8 Preperitoneal pelvic packing (PPP) PPP is effective in controlling hemorrhage when used as part of a multidisciplinary clinical pathway including angiography and external fixation. (GoR B LoE IV) PPP is effective in controlling hemorrhage when used as a salvage technique. (GoR B, LoE IV)

9 External fixation (EF) Pelvic binder should be applied as soon as pelvic mechanic instability is assessed (GoR A, LoE III) Anterior or posterior EF should be accomplished according to fracture pattern (APC II-III, LC II-III, VS, CM) and to local expertise as a completion/substitution of pelvic binder (GoR B, LoE IV) EF can be accomplished in the ED or in the OR in minutes and appear to be a quick tool to reduce venous and bony bleeding (GoR A, LoE IV) EF should be accomplished as soon as possible in patients with haemodinamic instability and a mechanically unstable pelvic fracture (GoR A, LoE IV)

10 Angiography After non pelvic sources of blood loss have been ruled out, patients with pelvic fractures and haemodynamic instability or signs of ongoing bleeding should be considered for pelvic angiography/embolization. (GoR A, LoE III) Patients with CT-scan demonstrating arterial intravenous contrast extravasation in the pelvis, may require pelvic angiography and embolization regardless of haemodynamic status. (GoR A, LoE IV) After non pelvic sources of blood loss have been ruled out, patients with pelvic fractures who have undergone pelvic angiography with or without embolization, with persisting signs of ongoing bleeding, should be considered for repeat pelvic angiography/embolization (GoR B, LoE IV)

11 Hemodinamically UNSTABLE PELVIC TRAUMA ALGORYTHM PELVIC BINDER + FAST Legend FAST: focused assessment sonography for trauma PPP: prepeeritoneal pelvic packing OR: operating room Ex Fix: external fixation ER: emergency room FAST + OR LAPAROTOMY + PPP+ExFix if amenable FAST - PPP O.R. (+ ExFix if amenable) E.R. UNSTABLE STABLE UNSTABLE ANGIO NO BLUSH CT Scan ICU BLUSH FAST still - ANGIO OR for Ex Fix if not yet done

12

13 Hemodinamically Unstable Pelvic Trauma How are pelvic fractures classified? Answer and interpretation 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