Instability of the pelvic ring combined with hemodynamic instability

The initial treatment in this condition is to focus on immediate control of pelvic hemorrhage. Although any single method is not effective for controlling the bleeding. Different treatment protocols for emergency hemostasis have been documented recommending a wide variety of methods. On a combination of treatments like early pelvic stabilization followed by surgical hemostasis if required and then a priority-based procedure should be followed which can prove favorable in the patient’s survival. But to evaluate the efficiency of these methods, continue evaluation of resuscitation procedure is significant.

Treatment Protocol

For patients admitted in multi-trauma condition, a standardized protocol is used for initial clinical treatment. This protocol can be expanded by a complex pelvic fracture module if hemodynamic instability is caused by the pelvic fracture. In this case, three prompt decisions are to be made within 30 minutes after the admission of the patient. While in the rare case of critical pelvic hemorrhage, immediate surgical intervention is required. Generally, a primary diagnostic evaluation including clinical examination, pelvis AP x-rays, ultrasound abdomen is performed. But if there is unstable hemodynamics due to pelvic instability, emergency stabilization must be done as soon as possible.

Effective stabilization can be attained using the pelvic C-clamp or the simple external fixator within 10–15 minutes in case of emergency. If these devices are not available at hand then other non-invasive techniques such as traction and ring closure with a sheet or pelvic sling, pneumatic anti-shock garment, and vacuum splints, can be used for immediate stabilization. Though the amount of pelvic blood loss is reduced after mechanical stabilization but does not provide complete hemostasis therefore, if even after 10–15 minutes of application, the patient’s hemodynamics is not stable then immediate surgical hemostasis with reconsideration and repair of the pelvic retro-peritoneum should be followed.

The technique of pelvic packing in a hemodynamically unstable patient

For pelvic packing in a hemodynamically unstable patient. The patient needs to be positioned supine with the entire abdomen and pelvis draped. If little or no intra-peritoneal free fluid is discovered in primary or controlled ultrasound examination then, a lower midline incision is used to center the origin of bleeding to the pelvic region. A formal laparotomy is administered together with intraperitoneal hemorrhage, and the extension of incision is done to the pubic symphysis region.

 As disruption of all para-pelvic fascial planes is common so through the right or left para-vesical space down to the pre-sacral region, direct manual access is obtained without further dissection. Rare arterial bleeding should be the primary concern which can be managed by clamping, ligature, or a vascular repair. In case of mass bleeding, provisional clamping of the infra-renal aorta proves useful but in such case, laparotomy is required.  Usually, diffuse bleeding originates from the surfaces of fracture or the venous plexus. in type C injuries the bleeding usually originates from the pre-sacral region. Mostly in external rotation-type injuries, the source of bleeding is close to the anterior pelvic ring. Tight pre-sacral and para-vesical packing can be used to control the hemorrhage. If the posterior pelvic ring is stable enough then tamponade can be effective. If considerable posterior displacement still occurs which can be examined by palpation, the reduction needs to be optimized by loosening the clamp, and then prior to the application of tamponade, the further manual reduction is done.

At last, a symphysis orthopedic implant plate is applied for the stabilization of the anterior pelvic ring, and an external fixator is used in case of trans-pubic instabilities. General surgical rules are applicable for repairing the additional intra-abdominal organ injuries. And the patient’s general condition should be considered for further surgery. Damage control procedures such as insertion of a transurethral catheter, suprapubic urine drainage, and suture of the bladder after urological injuries or, in rectal injuries, a diverting colostomy with prograde wash-out and drainage are recommended at an early stage. The tamponade packs can be left for 24–48 hours. These can be removed or replaced in planned second-look surgery. If a subsequent and considerable pelvic blood loss continues even after the effective tamponade, then angiography and embolization are strongly advised.