A prospective evaluation of the clinical presentation of pediatric pelvic fractures

BACKGROUND: We sought to describe pediatric, blunt trauma patients with pelvic fracture (PF) and to evaluate pelvis examination sensitivity and specificity. METHODS: We conducted a prospective study of blunt trauma patients at a Level I pediatric trauma center. A pediatric emergency medicine physician attempted to diagnose a PF, solely on the basis of the history and pelvis examination. Patients with blunt trauma but no pelvic fracture (NPF) were used as controls. RESULTS: We enrolled 140 patients (16 PF, 124 NPF), and no significant differences were found regarding median age, gender, injury mechanism, acuity, and medical outcome. Approximately 25% of PF patients had iliac-wing fractures; 37%, single pelvic ring; 25%, double pelvic ring; and 13%, acetabular fractures. Eleven patients with PF had an abnormal pelvis examination (69% sensitivity), compared with six NPF patients (95% specificity, negative predictive value 0.91). CONCLUSION: Pediatric patients with PF have low mortality and few complex fractures. The pelvis examination appears to have both high specificity and negative predictive value.     

Surgeon-performed ultrasound for the assessment of truncal injuries: lessons learned from 1540 patients.

OBJECTIVE: To determine the accuracy of the Focused Assessment for the Sonographic examination of the Trauma patient (FAST) when performed by trauma team members during a 3-year period, and to determine the clinical conditions in which the FAST is most accurate in the assessment of injured patients. SUMMARY BACKGROUND DATA: The FAST is a rapid test that sequentially surveys the pericardial region for hemopericardium and then the right and left upper quadrants and pelvis for hemoperitoneum in patients with potential truncal injuries. The clinical conditions in which the FAST is most accurate in the assessment of injured patients have yet to be determined. METHODS: FAST examinations were performed on patients with precordial or transthoracic wounds or blunt abdominal trauma. Patients with a positive ultrasound (US) examination for hemopericardium underwent immediate surgery, whereas those with a positive US for hemoperitoneum underwent a computed tomography scan (if they were hemodynamically stable) or immediate celiotomy (if they were hemodynamically unstable- blood pressure < or = 90 mmHg). RESULTS: FAST examinations were performed in 1540 patients (1227 with blunt injuries, 313 with penetrating injuries). There were 1440 true-negative results, 80 true-positive results, 16 false-negative results, and 4 false-positive results; the sensitivity was 83.3%, the specificity 99.7%. US was most sensitive and specific for the evaluation of patients with precordial or transthoracic wounds (sensitivity 100%, specificity 99.3%) and hypotensive patients with blunt abdominal trauma (sensitivity 100%, specificity 100%). CONCLUSIONS: US should be the initial diagnostic modality for the evaluation of patients with precordial wounds and blunt truncal injuries because it is rapid and accurate. Because of the high sensitivity and specificity of US in the evaluation of patients with precordial wounds and hypotensive patients with blunt torso trauma, immediate surgical intervention is justified when those patients have a positive US examination.     

Predictive value of focused assessment with sonography for trauma (FAST) forlaparotomy in unstable polytrauma Egyptians patients

Purpose: The emergency physicians face significant clinical uncertainty when multiple trauma patients arrive in the emergency department (ED). The priorities for assessment and treatment of polytrauma patients are established in the primary survey. Focused assessment with sonography for trauma (FAST) is very essential clinical skill during trauma resuscitation. Use of point of care ultrasound among the trauma team working in the primary survey in emergency care settings is lacking in Suez Canal University Hospitals even ultrasound machine not available in ED. This study aims to evaluate the accuracy of FAST in hemodynamically unstable polytraumatized patients and to determine its role as an indication of laparotomy. Methods: This study is a cross-sectional study included 150 polytrauma patients with a blunt mechanism admitted in Suez Canal University Hospital. Firstly primary survey by airway check, cervical spine securing with neck collar, maintenance of breathing/circulation and management of life threading conditions if present were conducted accordingly to ATLS (advanced trauma life support) guidelines. The patients were assessed in the primary survey using the FAST as a tool to determine the presence of intraabdominal collection. Results: A total of 150 patients, and FAST scans were performed in all cases. The sensitivity and specificity were 92.6% and 100%, respectively. The negative predictive value was 92%, while the positive predictive value of FAST was 100%. The accuracy of FAST was 96%. Conclusion: FAST is an important method to detect intra-abdominal fluid in the initial assessment in hemodynamically unstable polytrauma patients with high accuracy.     

Diagnostic accuracy of surgeon-performed focused abdominal sonography (FAST) in blunt paediatric trauma

AIM: To study the diagnostic accuracy and clinical efficacy of surgeon-performed focused abdominal sonography (FAST) in paediatric blunt abdominal trauma (BAT). MATERIALS AND METHOD: This was a prospective, single blinded study conducted at The Children's Hospital at Westmead Sydney (CHW). All patients with BAT that justified a trauma call activated on presentation to the Emergency Department (ED) had a FAST performed by the Trauma Fellow. The attending surgical team was blinded to the result of the FAST. An independent radiologist reviewed the FAST pictures, and the findings were compared with computerised tomography (CT), ultrasound (US), laparotomy and the clinical outcome of the patient. Sensitivity, specificity and predictive values were calculated. RESULTS: A total of 85 patients (39 M; 26 F) were enrolled in the study between February 2002 and January 2003. The age ranged between 4 months and 16 years. The mean Injury Severity Score (ISS) was 6 (range 1-38). FAST was performed in a mean time of 3 min. Inter-rater agreement was 96%. FAST was positive in nine as confirmed by a CT scan of the abdomen. Three patients underwent laparotomy, two for bowel injuries and one for a Grade III liver laceration. Of the remaining 76, 19 had a CT, which showed evidence of intra-abdominal injury in seven patients. There were two false negative studies resulting in a sensitivity of 81%, specificity of 100%, negative predictive value of 97%, positive predictive value of 100% and an accuracy of 97%. CONCLUSIONS: Surgeon-performed FAST for BAT was safe and accurate with a high specificity. It would seem a potentially valuable tool in the evaluation of paediatric blunt trauma victims for free fluid within the peritoneal cavity.     

The hand-held ultrasound examination for penetrating abdominal trauma

BACKGROUND: An evaluation of hand-held ultrasonography (US) in the assessment of penetrating torso trauma has not yet been reported. METHODS: A 2.4 kg hand-held ultrasound device was used to examine penetrating trauma victims in an exam designated as the Hand-Held Focused Assessment with Sonography for Trauma (HHFAST). Results were compared with other US examinations including formal FAST (FFAST), computed tomography, diagnostic peritoneal lavage, operative and autopsy findings, and serial examination. Performance considered both the detection of fluid and injuries requiring intervention. RESULTS: The HHFAST was excellent for detecting free intraperitoneal fluid, which had 100% specificity for peritoneal penetration, but was only moderately sensitive for injuries requiring therapy. CONCLUSIONS: Hand-held sonography can quickly detect intraperitoneal fluid, which has good test performance in determining the presence of an intra-abdominal injury. Negative FAST examinations after penetrating trauma should be followed up with another diagnostic modality.     

Moderne Diagnostik des Bauchtraumas

In case of suspected intra-abdominal injury, fast transport of the patient to a suitable hospital is of high priority. The initial clinical examination aims at identifying patients with potentially life-threatening bleeding that require emergency surgery. In patients with penetrating trauma, laparoscopy is favoured to exclude suspected perforation of the peritoneum. If a peritoneal perforation is identified, exploratory laparotomy is recommended to exclude or treat lacerations of the hollow viscus. Although clinical examination should be performed its sensitivity and specificity of up to 82% and 45%, respectively, are not sufficient as the sole screening method. For the further diagnostic workup, diagnostic peritoneal lavage has been completely replaced by abdominal ultrasound examination in Germany and many other countries. Focussing not only on the detection of free abdominal fluid but also searching for parenchymal organ lesions and performing repeated examinations increases accuracy up to 96%, with specificity of 99.8% and sensitivity of 72.1%. Computed abdominal tomography with a helical scanner with and without intravenous contrast media is currently the gold standard of imaging techniques to identify traumatic abdominal injuries. A sensitivity of 97.2% and specificity of 94.7% can be achieved. False negative findings must be expected with hollow organ injuries. Serial clinical and ultrasound examinations as well as lab testing in conjunction with repeated CT may help to identify such lesions. Increased intra-abdominal pressure (IAP) with consecutive abdominal compartment syndrome and multiple organ dysfunction is a delayed complication from conditions such as severe intra-abdominal bleeding, major bleeding from pelvic ring fractures, and profuse fluid resuscitation. The IAP should be measured routinely in patients at risk, and decompression laparotomy may be indicated with pressures of higher than 20 mmHg.     

Goal-directed ultrasound in the detection of long-bone fractures

BACKGROUND: New portable ultrasound (US) systems are capable of detecting fractures in the remote setting. However, the accuracy of ultrasound by physicians with minimal ultrasound training is unknown. METHODS: After one hour of standardized training, physicians with minimal US experience clinically evaluated patients presenting with pain and trauma to the upper arm or leg. The investigators then performed a long-bone US evaluation, recording their impression of fracture presence or absence. Results of the examination were compared with routine plain or computer aided radiography (CT). RESULTS: 58 patients were examined. The sensitivity and specificity of US were 92.9% and 83.3%, and of the physical examination were 78.6% and 90.0%, respectively. US provided improved sensitivity with less specificity compared with physical examination in the detection of fractures in long bones. CONCLUSION: Ultrasound scans by minimally trained clinicians may be used to rule out a long-bone fracture in patients with a medium to low probability of fracture.     

Role of ultrasonography in penetrating abdominal trauma: a prospective clinical study

BACKGROUND: Focused Assessment with Sonography for Trauma (FAST) is rapidly establishing its place in the evaluation of blunt abdominal trauma. However, no prospective study specifically evaluates its role in penetrating abdominal trauma. METHODS: Data were collected prospectively in 75 consecutive stable patients with penetrating trauma to the abdomen, flank, or back, from December 1998 to June 1999. Those with an obvious need for emergent laparotomy were excluded. FAST was performed as the initial diagnostic study on all patients. Wound location, type of weapon, and findings of diagnostic peritoneal lavage, triple-contrast computed tomographic scan, or laparotomy were recorded. The presence of peritoneal blood was noted. Data were analyzed using the chi(2) test. RESULTS: Of the 75 patients, there were 32 stab and 43 gunshot wounds. There were 66 male patients and 9 female patients; the mean age was 30 years; 41 had proven abdominal injury and 34 had no injury; and 21 patients had a positive FAST. Nineteen had peritoneal blood and injuries requiring repair at the time of laparotomy. There were two false-positive studies. Fifty-four patients had a negative FAST. In 32 patients, this was a true-negative study. Thirteen patients had a false-negative FAST and had peritoneal blood and significant injury on further evaluation. Nine patients had a negative FAST and no peritoneal blood but still had abdominal injuries requiring operative repair, including liver (four), small bowel (four), diaphragm (three), colon (three), and stomach (one). The overall sensitivity of FAST was 46% and the specificity was 94%. The positive predictive value was 90%, and the negative predictive value was 60%. CONCLUSION: FAST can be a useful initial diagnostic study after penetrating abdominal trauma. A positive FAST is a strong predictor of injury, and patients should proceed directly to laparotomy. If negative, additional diagnostic studies should be performed to rule out occult injury.     

Predicting blood loss in isolated pelvic and acetabular high-energy trauma

OBJECTIVE: To quantify transfusion requirements in patients with isolated acetabular or pelvic fractures and correlate these requirements with fracture classification. DESIGN: Retrospective review of 382 patients with isolated pelvic and/or acetabular fractures. SETTING: Academic Level I Trauma Center. PATIENTS/PARTICIPANTS: Patients were identified from a trauma registry. Appropriate radiographs and complete transfusion data were obtained for 289 (75%) of 382 eligible patients between January 1, 1998 and December 31, 2003. INTERVENTION: Classification of pelvic fracture by Young and Burgess type and acetabular fractures by Letournel type. MAIN OUTCOME MEASUREMENT: Number of units of blood transfused in the first 24 hours after admission to the trauma center. RESULTS: Patients with isolated pelvic fractures with major ligament disruption (APC II or III, LC III, vertical shear, or combined mechanisms) were more likely to receive a blood transfusion (44%) than other fracture types (8.5 %) (P < 0.0005). Transfusion amounts were greatest in APC III (12.6 units) and vertical shear (4.6 units) injuries. Fractures classified as both column, anterior column, anterior column posterior hemi-transverse, or T type were more likely to receive a blood transfusion (56%) than other fracture types (28%) (P = 0.003). Of these fracture types, both column (8.8 units) and anterior column posterior hemi-transverse (6.4 units) received the largest transfusions. CONCLUSIONS: Patients with isolated acetabular fractures are as likely as those with isolated pelvic fractures to receive blood transfusions within the first 24 hours of admission. Higher energy pelvic ring fractures classified as APC II or III, LC III, vertical shear, or combined mechanism require more frequent transfusion than other pelvic fractures. Acetabular fractures involving the anterior column as well as T-type fractures require more frequent blood transfusions than other acetabular fractures.     

Incidence of venous thromboembolism in pelvic and acetabular fractures in the Japanese population

BackgroundThere are no detailed reports of the incidence of venous thromboembolism (VTE) in pelvic and acetabular fractures in the Asian population. The purpose of this study was to investigate the incidence of VTE in pelvic and acetabular fractures in the Japanese population.MethodsForty-six Japanese patients with pelvic and acetabular fractures treated at our hospital from February 2004 to April 2011 were analyzed retrospectively. Until April 2009, VTE screening was performed by contrast-enhanced computed tomography (CT) or ultrasonography (US) when the D-dimer value did not decline predictably, still exceeded 20 μg/ml at 5 days after trauma and surgery, or increased >20 μg/ml after a period of decline. After April 2009, contrast-enhanced CT and US were performed routinely irrespective of the D-dimer value. Physical prophylaxis was performed in all patients. The effects of the presence of pelvic and acetabular fractures, fracture types, accompanying injuries, and screening strategies on the incidences of VTE and pulmonary thromboembolism (PTE) were investigated.ResultsOverall, 19 patients (41.3%) were diagnosed with VTE and PTE in ten (21.7%). All were asymptomatic. Compared with trauma patients without pelvic and acetabular fractures treated during the same period, significantly higher incidences of VTE and PTE were observed in patients with pelvic and acetabular fractures. No significant differences were observed in the incidences of VTE and PTE between pelvic and acetabular fractures or between patients with and without accompanying injuries. Compared with the previous screening strategy, the detection rates of VTE and PTE were higher for the newer screening strategy; however, the difference did not reach statistical significance.ConclusionsWe should be vigilant for the high incidence of VTE, especially PTE, in patients with pelvic and acetabular fractures in the Japanese population.     

Minimal pelvic fluid in blunt abdominal trauma in children: the significance of this sonographic finding

PURPOSE: The aim of this study was to evaluate the significance of the ultrasonographic finding of pelvic fluid after blunt abdominal trauma in children as a predictor of an abdominal organ injury. METHODS: The clinical and imaging data of 183 children with blunt abdominal trauma were reviewed retrospectively. All children had an abdominal sonography as the primary screening study. The ultrasound results were divided into 3 groups: group A, normal examination; group B, pelvic fluid only; group C, peritoneal fluid outside the pelvis. The results of the initial ultrasound examinations were compared with the findings of the CT scan, or a second ultrasound examination or the clinical course during the hospitalization. RESULTS: Group A included 87 children; group B, 57, and group C, 39. Four abdominal organ injuries were missed by the ultrasound examination. The sensitivity and specificity of the ultrasound examinations to predict organ injury in presence of peritoneal fluid outside the pelvis were, respectively, 89.5% and 96.6%; the positive and negative predictive value were 87.2% and 97.3%. No statistically significant difference was seen between group A and group B, whereas the presence of peritoneal fluid outside the pelvic cavity (group C) was associated strongly with an organ injury (P <.001). CONCLUSIONS: A normal ultrasound examination or the presence of pelvic fluid are associated with a low probability of an organ injury. In the presence of peritoneal fluid outside the pelvis, the probability of an organ injury is very high.     

Acute Management of Hemodynamically Unstable Pelvic Trauma Patients: Time for a Change? Multicenter Review of Recent Practice

BACKGROUND: Hemorrhage-related mortality (HRM) associated with pelvic fractures continues to challenge trauma care. This study describes the management and outcome of hemodynamically unstable patients with a pelvic fracture, with emphasis on primary intervention for hemorrhage control and HRM. METHODS: Blunt trauma patients [Injury Severity Score (ISS) >or=16] with a major pelvic fracture (Abbreviated Injury Score, pelvis >or=3) and hemodynamic instability [admission systolic blood pressure (SBP) or=6 units of packed red blood cells (PRBCs)/24 hours) were included into a 48-month (ending in December 2003) multicenter retrospective study of 11 major trauma centers. Data are presented as the mean +/- SD. RESULTS: A total of 217 patients (mean age 41 +/- 19 years, 71% male, ISS 42 +/- 16) were studied. The admission SBP was 96 +/- 37 mmHg and the Glascow Coma Scale (GCS) 11 +/- 5. Patients received 4 +/- 2 liters of fluids including 4 +/- 4 units of PRBCs in the emergency room (ER). In total, 69 (32%) patients died, among whom the HRM was 19%; 29% of the deaths were due to pelvic bleeding. Altogether, 120 of the 217 (55%) patients underwent focused abdominal sonography for trauma (FAST) or diagnostic peritoneal aspiration (DPA) and diagnostic peritoneal lavage (DPL); 60 of the 217 (28%) patients were found to have pelvic binding in the ER. In all, 53 of 109 (49%) patients had no bleeding noted at laparotomy, 26 of 106 (25%) had no abdominal findings, and 15 of 53 (28%) had had no prior abdominal investigation (FAST/DPL/computed tomography). Angiography was positive in 48 of 58 (83%) patients. The HRM was highest in patients with laparotomy as the primary intervention (29%) followed by the angiography group (18%), the combined laparotomy/pelvic fixation group (16%), and the pelvic fixation-only group (10%). CONCLUSION: HRM associated with major pelvic trauma is unacceptably high especially in the laparotomy group. Hence, nontherapeutic laparotomy must be avoided, concentrating instead on arresting pelvic hemorrhage. Standards of care must be implemented and abided by.     

Free abdominal fluid on ultrasound in unstable pelvic ring fracture: is laparotomy always necessary?

BACKGROUND: In unstable pelvic ring fractures free abdominal fluid on ultrasound (US) may be caused by retroperitoneal hematoma that passes into the abdominal cavity or by an additional intraabdominal lesion. In this study a clinical pathway for the therapy of potentially combined lesions was analyzed. PATIENTS AND METHODS: All patients treated in the ED for severe trauma underwent basic sonographical and radiologic diagnostics within 15 minutes. of admission. Data were prospectively documented. According to the treatment protocol unstable pelvic ring fractures with initial free fluid on US received laparotomy. Patients with stable vital conditions had abdominal CT-Scan before surgery. RESULTS: 1472 consecutive severely injured patients (ISS 20, age: 39 years) were included. Eighty subjects had sustained type B (47) or C (33) pelvic ring fracture. Early free abdominal fluid on US was absent in 49 cases. Three patients in this group required celiotomy later on, during ICU treatment. In 31 patients free fluid was present. All of them had laparotomy. Only one patient showed retroperitoneal hematoma alone, while all others had one or more significant lesions (rupture) that required surgical repair. Simultaneously with laparotomy pelvic stabilization was performed by external (19) or internal (6) fixation. In all cases with massive pelvic hemorrhage and free fluid in US bleeding was controlled by internal tamponade and external fixation. CONCLUSION: The finding of intraperitoneal fluid on US in the emergency department strongly correlates with significant intraabdominal lesions requiring surgical intervention. Early laparotomy appears indicated in these cases. Shock control in pelvic bleeding can be sufficiently achieved by internal tamponade and external fixation.     

Begleitverletzungen beim schweren Beckentrauma

There has been a marked increase in the incidence of pelvic fractures over the last few years. Associated injuries to the urogenital and vascular system as well as nerve injuries worsen the prognosis. Over a five year period 126 patients with severe pelvic trauma were treated. Out of these 39 (30.9%) sustained additional peripelvic injuries and represent the study sample. Type B injuries according to the AO classification occurred in 16 (41%) patients, type C fractures in 23 (59%) patients. The spleen, liver and kidney were the most frequently injured organs (58.9%), followed by urogenital lesions (46.6%), nerve injuries (25.6%) and vascular lesions (15.3%). The most common extrapelvic lesions were thoracic injuries in 56.4% and severe head injuries (GCS < 8) in 33.3%. The mean Hannover Polytrauma score was 35.6 points, the mean Injury Severity Score 27.6 points. Osteosynthesis was performed in 21 pelvic ring fractures (53%), eight procedures (50%) in type B fractures and 13 (56%) in type C fractures. In type B injuries the anterior pelvic ring was stabilized with a tension band wiring in four cases, in two patients with an external fixator and with plate osteosynthesis in one case. In type C injuries the external fixator was applied as the only stabilizing procedure in six patients. In four cases the anterior ring was fixed with tension band wiring or plates and the dorsal aspect of the pelvic ring with sacral bars. Three patients had their additional acetabular fracture plated through a anterior approach. All surviving 28 patients were followed up for an average of 18 months (range 7-59 months) after the trauma. The patients were classified using the pelvic outcome score proposed by the German Society of Trauma Surgery. 53.4% of the type B fractures showed a good clinical outcome, 47.6% a poor outcome. 15.4% with type C fractures presented with a good outcome, 84.6% with a poor outcome. 80% of the type B and 23% of the type C fractures had a good radiological outcome. 20% of type B and 77% of type C injuries had a poor radiological outcome. Five patients (12.8%) sustained persistent urological symptoms. Three of these had urinary dysfunction, two used permanent cystotomies due to their severe neurological deficit after a head injury. Ten patients with nerve injuries at the time of trauma suffered long term neurological dysfunction of the lumbosacral plexus. The mortality rate was 28%. Seven patients died in the emergency room due to uncontrollable bleeding, four in the intensive care unit from multi-organ failure. The management of complex pelvic trauma consists of fracture treatment and interdisciplinary treatment of the associated injury. Lesions of the abdominal organs or of major vessels must be addressed first if hemodynamic instability is present. Injuries to smaller vessels can be embolized percutaneously. Urinary bladder ruptures are treated as an emergency, urethral lesions electively after four to six weeks. We recommend external fixation of the pelvis in the acute phase for control of both the osseous instability and control of haemorrhage through external compression. The treatment of choice for the anterior pelvic ring is tension band wiring or plating. If this is contraindicated due to an open fracture external fixation is the treatment of choice. Type C fractures require posterior ring stabilization which should be postponed until four days post admission.     

A protocol for angiographic embolization in exsanguinating pelvic trauma: a report on 31 patients

Background The indication for acquiring angiographic embolization in the initial treatment of severe pelvic fractures is controversial. We describe the characteristics and outcome of 31 patients with traumatic pelvic bleeding who underwent percutaneous angiography with embolization according to a standardized protocol.

Patients and methods During an 8.5-year period, 1,260 patients were treated for pelvic trauma. We performed a prospective registration of the 46 patients who underwent angiography, and report the 31 patients who had signs of significant arterial injury on angiography, necessitating embolization.

Results The rate of significant arterial injury after pelvic trauma was 2.5%. All patients had been subjected to high-energy injuries and all were severely injured as measured by the Injury Severity Score: 41 (17-66). Pelvic arterial injury was observed with all types of pelvic trauma, including isolated acetabular (4/31) and sacral fractures (3/31). The internal iliac artery or its branches was injured in 28 of 31 patients. Survival rate after embolization was 84%, and correlated inversely with increasing patient age. None of the patients died of bleeding.

Interpretation Our findings show that significant pelvic arterial injuries occur in a minority of patients after pelvic trauma, and predominantly affect patients with multiple high-energy injuries regardless of fracture type. The effect of angiographic embolization was good.     

A protocol for angiographic embolization in exsanguinating pelvic trauma: A report on 31 patients

Background?The indication for acquiring angiographic embolization in the initial treatment of severe pelvic fractures is controversial. We describe the characteristics and outcome of 31 patients with traumatic pelvic bleeding who underwent percutaneous angiography with embolization according to a standardized protocol.

Patients and methods?During an 8.5-year period, 1,260 patients were treated for pelvic trauma. We performed a prospective registration of the 46 patients who underwent angiography, and report the 31 patients who had signs of significant arterial injury on angiography, necessitating embolization.

Results?The rate of significant arterial injury after pelvic trauma was 2.5%. All patients had been subjected to high-energy injuries and all were severely injured as measured by the Injury Severity Score: 41 (17–66). Pelvic arterial injury was observed with all types of pelvic trauma, including isolated acetabular (4/31) and sacral fractures (3/31). The internal iliac artery or its branches was injured in 28 of 31 patients. Survival rate after embolization was 84%, and correlated inversely with increasing patient age. None of the patients died of bleeding.

Interpretation?Our findings show that significant pelvic arterial injuries occur in a minority of patients after pelvic trauma, and predominantly affect patients with multiple high-energy injuries regardless of fracture type. The effect of angiographic embolization was good.     

Significance of physical examination and radiography of the pelvis during treatment in the shock emergency room

AIM. Physical examination and radiography of the pelvis is part of most routine protocols in the emergency room (ER) management of blunt trauma patients. The purpose of this study was to determine the usefulness of these diagnostic tests with respect to diagnostic accuracy, therapeutic consequences, and prognosis in severely injured patients. METHOD. In a prospective study including all trauma patients admitted to the ER, physical examination and clinical management were evaluated. All patients underwent physical examination of the pelvis and were grouped into two categories: patients without (group I) and with (group II) clinical pelvic instability. A comparison between these two groups was made for standard demographic data, indices of shock, diagnostic and therapeutic procedures, and results. RESULTS. During a 45-month period a total of 1160 patients were enrolled: 979 subjects (ISS 21+/-16) with blunt trauma were included in this analysis. Of these, 929 patients had negative (group I) and 51 (group II) positive examination results for clinical stability of the pelvis. When comparing these two groups, group II patients had a higher injury severity score, higher incidence of shock with a lower initial systolic blood pressure, a lower initial hemoglobin, and a higher rate of associated severe chest and abdominal injuries (AIS > or = 3). Among the 51 patients with abnormal pelvis instability, there were 6 type A, 16 type B, and 27 type C fractures, whereas in two cases no pelvic fracture could be found. Of the 928 patients without positive clinical signs, 866 (93%) had no pelvic fracture. There were 40 type A, 19 type B, and 3 type C fractures missed on clinical examination. The physical examination had a sensitivity of 44% and specificity of 99% for detecting pelvic fracture. A comparison between groups I and II showed the patients with positive physical pelvic examination to have greater transfusion requirements and a higher rate of surgical intervention for pelvic stabilization and blood control. CONCLUSION. The clinical diagnosis of pelvic instability should result in an immediate order for blood products, taking surgical intervention into account. Pelvic radiographs in the ER are required for early surgical management. In patients with negative pelvis examination results, a routine pelvic radiograph is recommended because clinical examination cannot reliably rule out surgically significant pelvic fractures (20%) in the severely injured and intubated blunt trauma patient.     

Evolution of a Multidisciplinary Clinical Pathway for the Management of Unstable Patients With Pelvic Fractures

OBJECTIVE: To determine whether the evolution of the authors' clinical pathway for the treatment of hemodynamically compromised patients with pelvic fractures was associated with improved patient outcome. SUMMARY BACKGROUND DATA: Hemodynamically compromised patients with pelvic fractures present a complex challenge. The multidisciplinary trauma team must control hemorrhage, restore hemodynamics, and rapidly identify and treat associated life-threatening injuries. The authors developed a clinical pathway consisting of five primary elements: immediate trauma attending surgeon's presence in the emergency department, early simultaneous transfusion of blood and coagulation factors, prompt diagnosis and management of associated life-threatening injuries, stabilization of the pelvic girdle, and timely insinuation of pelvic angiography and embolization. The addition of two orthopedic pelvic fracture specialists led to a revision of the pathway, emphasizing immediate emergency department presence of the orthopedic trauma attending to provide joint decision making with the trauma surgeon, closing the pelvic volume in the emergency department, and using alternatives to traditional external fixation devices. METHODS: Using trauma registry and blood bank records, the authors identified pelvic fracture patients receiving blood transfusions in the emergency department. They analyzed patients treated before versus after the May 1998 revision of the clinical pathway. RESULTS: A higher proportion of patients in the late period had blood pressure less than 90 mmHg (52% vs. 35%). In the late period, diagnostic peritoneal lavage was phased out in favor of torso ultrasound as a primary triage tool, and pelvic binding and C-clamp application largely replaced traditional external fixation devices. The overall death rate decreased from 31% in the early period to 15% in the later period, as did the rate of deaths from exsanguination (9% to 1%), multiple organ failure (12% to 1%), and death within 24 hours (16% to 5%). CONCLUSIONS: The evolution of a multidisciplinary clinical pathway, coordinating the resources of a level 1 trauma center and directed by joint decision making between trauma surgeons and orthopedic traumatologists, has resulted in improved patient survival. The primary benefits appear to be in reducing early deaths from exsanguination and late deaths from multiple organ failure.     

Deep-vein thrombosis in high-energy skeletal trauma despite thromboprophylaxis

We report the incidence and location of deep-vein thrombosis in 312 patients who had sustained high-energy, skeletal trauma. They were investigated using magnetic resonance venography and Duplex ultrasound.Despite thromboprophylaxis, 36 (11.5%) developed venous thromboembolic disease with an incidence of 10% in those with non-pelvic trauma and 12.2% in the group with pelvic trauma. Of patients who developed deep-vein thrombosis, 13 of 27 in the pelvic group (48%) and only one of nine in the non-pelvic group (11%) had a definite pelvic deep-vein thrombosis. When compared with magnetic resonance venography, ultrasound had a false-negative rate of 77% in diagnosing pelvic deep-vein thrombosis. Its value in the pelvis was limited, although it was more accurate than magnetic resonance venography in diagnosing clots in the lower limbs. Additional screening may be needed to detect pelvic deep-vein thrombosis in patients with pelvic or acetabular fractures.     

The role of prehospital ultrasound in reducing time to definitive care in abdominal trauma patients with moderate to severe liver and spleen injuries

BackgroundThe role of prehospital focused assessment sonography for trauma (FAST) is still under debate and no definitive recommendations are available in actual guidelines, moreover, the availability of ultrasound machines in emergency medical services (EMS) is still inhomogeneous. On the other hand, time to definitive care is strictly related to survival in bleeding trauma patients.This study aimed at investigating if a positive prehospital FAST in abdominal trauma patients could have a role in reducing door-to-CT scan or door-to-operating room (OR) time.MethodsThis retrospective observational study included all the patients affected by an abdominal trauma with an abdominal abbreviated injury score ≥ 2 and a spleen or liver injury admitted to Maggiore Hospital Carlo Alberto Pizzardi, a level 1 trauma centre between 2014 and 2019. Prehospital and emergency department (ED) clinical and laboratory variables were collected, as well as in-hospital times during the diagnostic and therapeutic pathways of these patients.Results199 patients were included in the final analysis. Of these, 44 had a prehospital FAST performed and in 27 of them, peritoneal free fluid was detected in the prehospital setting, while 128 out of 199 patients had a positive ED-FAST. Sensitivity was 62.9% (95% CI: 42.4%–80.6%) and specificity 100% (95% CI: 80.5% - 100%). Patients with a positive prehospital FAST reported a significantly lower door-to-CT or door-to-OR median time (46 vs 69 min, p < 0.001). Prehospital hypotension and Glasgow coma scale, first arterial blood lactate, ISS, age, positive prehospital and ED FAST were inserted in a stepwise selection for a multivariable Cox proportional regression hazards model. Only ISS and prehospital FAST resulted significantly associated with a reduction in the door-to-CT scan or door-to-operating theatre time in the multivariable model.ConclusionPrehospital FAST information of intraperitoneal free fluid could significantly hasten door-to-CT scan or door-to-operating theatre time in abdominal trauma patients if established hospital response protocols are available.Level of evidenceIII, (Therapeutic / Care Management)