Page 1652 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

CHAPTER 121: Pelvic Ring Injuries and Extremity Trauma 1171

FIGURE 121-4. A 37-year-old man in a motorcycle accident with clinical signs of a pelvic
injury, perineal ecchymosis, and instability of the iliac wings to examination. Provisional
treatment with a sheet clamped around the pelvis to control hemodynamic shock.

other thoracic, abdominal, or extremity sources of blood loss should be
ruled out. Massive fluid replacement, including transfusions, may be
necessary.
Initial stabilization of the pelvis is important to minimize or decrease
bleeding from the pelvis and to stabilize intrapelvic vascular clots.
9,10
Historically, military antishock trousers (MAST) were used for this, but
they have been found to contribute to decreased ventilatory ability and FIGURE 121-5. A. Radiographs at presentation demonstrate an APC type II pelvic injury
lower-extremity compartment syndrome. Recently, it has been shown with right-sided sacroiliac joint widening and disruption of the symphysis pubis. B. Definitive
11
that simply wrapping and tying a sheet around the pelvis can effectively fixation of the pelvis after provisional reduction and fluid resuscitation.
provide initial provisional stability (Fig. 121-4). A variety of commer-
12
cially available pelvic binders can be used to this effect, providing easier
adjustment of compression and removal for access to the anterior pelvis.
Alternatively, a two-pin anterior external fixator or the pelvic C-clamp
can be applied quickly to the anterior pelvis in the emergency room and
provide adequate stability (Fig. 121-6). Caution should be exercised in
using the pelvic C-clamp posteriorly because improper pin placement can
easily result in visceral, neurologic, or arterial injury. There is a greater
margin of safety if the technique is applied using fluoroscopic assistance. 13,14
The next priority is the identification and treatment of all significant
sources of bleeding. If the patient is responding to the fluid resuscitation
and becomes hemodynamically stable, other imaging, such as contrast-
enhanced CT scanning, can be used to further delineate other sources of
blood loss. An intrapelvic contrast blush on contrast CT can identify an
arterial pelvic bleed. This can be used as an indication for interventional
15
angiography. Angiography for pelvic bleeding is indicated if there is ongo-
ing unaccountable blood loss after provisional stabilization of the pelvis
with a binder or external fixator. It has been shown to be an effective way
to diagnose and treat arterial sources of hemorrhage in the pelvis. 16,17
In the face of exsanguinating hemorrhage from venous pelvic bleed- FIGURE 121-6. A 46-year-old man in motor vehicle accident sustains an APC type II
ing not controllable by obtaining mechanical stability and embolization pelvic injury with hemodynamic instability on presentation. Provisional stabilization of
with angiography, open packing of the pelvis may also be considered. 18 anterior pelvis and tamponade of pelvic venous bleeding with an anterior applied C-clamp.

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