Open Pelvic Fracture

Intern 蕭福慶

Brief History

42 y/o female, denied systemic disease

Pedestrian hit by car on 94.12.9

Lower limbs numbness, back pain

Open pelvic fracture, bilateral scapular fracture

Operation in 和平 Hospital

Event 1

X-ray: L’t pelvic fracture

Spine CT: no obvious abnormality

12.11: hypotension, tachycardia

12.12: fecal material in drain

Abd CT: gas at rectal wall

Laparotomy with sigmoid and colostomy

Question 1

Does rectal injury have correlation with open pelvic fracture?

Open Pelvic Fracture

A direct communication between a skin, rectal, or vaginal wound and the fractureMotality: 5% to 50% (25~30%)

The American Journal of Surgery 190 (2005) 833

Risk

Incidence of anorectal injury: 18~64%

Incidence of urogenital injury: 23~53%

Rectal injury: pubic symphysis, SI joint

Bladder injury: SI joint, pubic symphysis,

fractures of the sacrum

Urethral injury: superior, inferior pubic rami,

pubic symphysis

Examination

Anteroposterior pelvic X-ray

Inspection of the perianal tissues

Digital rectal examination

Sigmodoiscopy or proctoscopy,

Pelvic CT: localised extraluminal gas

haemorrhage

bowel wall thickening

Treatment

Pelvic fracture stabilization

Wound debridement

Selective diverting colostomy

Colostomy takedown (6weeks~3months)

Brief History

12.12: Shock, dopamin was used (hypotension, respiratory failure, elevated liver function, oliguria, pancytopenia, limbs discoloration)

Doppler: no flow at bilateral dorsa pedis, medial, lateral malleolus arteries in ankles

12.17: tentative fasciotomy

Event 2

94.12.22: CVS: PGE1, pletaal

NS: suspect T8 injury

12.23: Wound: Proteus mirabilis, Klebsiella pneumoniae, Pseudomonas aeruginosa

12.27: Left AK amputation

95.1.2: Right AK amputation

Question 2

Why does her four limbs have gangrene change?

Symmetrical Peripheral Gangrene

Symmetrical distal ischemic damage in two or more sites Absence of large vessel obstruction

Rare(?)Motality: up to 40% with DICAmputation: 50% Ischemia of other organ (gut)

Mechanism

Vasospasm

Pathology in microcirculation

Slugging of platelet or fibrin degeneration product

Risk

Disseminated intravascular coagulationSepsis (Streptococcus, Staphylococcus)VasopressorMalignant disease(paraneoplastic syndrome)ErgotismProtein C deficiencyCold injuryScleroderma, polymyalgia rheumaticaImpaired renal functionSplenectomyDiabetes mellitusImmunosuppressionAlcoholism

Course

Marked coldness, pallor, cyanosis or pain in the extremity

Progress rapidly to acrocyanosis

Gangrene

Treatment

Control underlying problem (DIC, sepsis, vasopressor)

Local or intravenous infusion of an α-blocker (phentolamine, chlorpromazine)

Intravenous infusion of prostaglandin (epoprostenol)

Sympathetic blockade (ganglion block or intravenous trimethaphan therapy)

Intravenous nitropruside therapy

Topical nitroglycerine ointment

Amputation (usually not emergency)

Brief History

12.12: Shock: oliguria

12.14~: H/D

BUN/Cre: 127.6/5.6

U/O: 250-300ml

Bilateral pleural effusion, pitting edema

Event 3

12.27: Left AK amputation

Contrast CT was need to evaluate the situation of infection (possible abscess)

Question 3

Can we perform contrast CT on the patient with acute renal failure?

Contrast-induced Nephropathy

Within 48 hours after administration of contrast media.

Increased Serum creatinine > 44μmol/L (0.5 mg/dl)

Relative increase of at least 25%

Oliguria 2~5 days, recover on Day 7

Mechanism

Renal hemodynamic change: medullar hypoxia

Direct toxic effect: tubular epithelial cell

Osmolality: compress intrarenal microcirculation decreased glomerular filtration rate

Prevention

Hydration (U/O>150 mL/hr for the first 6 hours after the procedure)

IOCM, iso-osmolar contrast medium(Iodixanol)

Low contrast volume (<100 mL, Spacing at least 10 days)

N-acetylcysteine(NAC)(600 mg, by mouth, twice a day (two dosages before and two doses after contrast exposure))

Hemofiltration for critical ill or ICU

Treatment

Supportive management

Hemodialysis (eGFR<15)

Take home message 1

Open pelvic fracture: High motality Stabilize hemodynamics Complete examination(rectal, vaginal, wound) Colostomy, debridement

Take home message 2

Symmetrical peripheral gangrene Early notice of ischemic sign Beware of multiple organ ischemia Control DIC, sepsis Decrease the use of vasopressor as possible Amputation rate: 50%

Take home message 3

Contrast-induced nephropathy Evaluate risk Alternative examination Hydration if could tolerate Low contrast volume N-Acetylcysteine Hemofiltration in critical ill

Thanks for your attentionThank you

Reference-1

Bircher et al. Pelvic trauma management within the UK: a reflection of a failing trauma service; Injury, Int. J. Care Injured (2004) 35, 2—6

Collinge et al. Soft tissue injuries associated with pelvic fractures; Orthop Clin N Am 35 (2004) 451 – 456

Rubesin et al. Radiologic diagnosis of gastrointestinal perforation; Radiol Clin N Am 41 (2003) 1095–1115

Mirza et al. Initial management of pelvic and femoral fractures in the multiply injured patient; Crit Care Clin 20 (2004) 159– 170

Kudsk et al. Management of Complex Perineal Injuries; World J. Surg. 27, 895–900, 2003

Grotz et al. Open pelvic fractures: epidemiology, current concepts of management and outcome; Injury, Int. J. Care Injured (2005) 36, 1—13

Dente et al. The outcome of open pelvic fractures in the modern era; The American Journal of Surgery 190 (2005) 830–835

Aihara et al. Fracture Locations Influence the Likelihood of Rectal and Lower Urinary Tract Injuries in Patients Sustaining Pelvic Fractures; J Trauma. 2002;52:205–209.

O’Sullivan et al. Major pelvic fractures IDENTIFICATION OF PATIENTS AT HIGH RISK; J Bone Joint Surg [Br]2005;87-B:530-3.

Reference-2

Davis. Peripheral Symmetrical Gangrene; Mayo Clin Proc. July 2004;79(7):914Davis. Symmetrical Peripheral Gangrene Due to Disseminated Intravascular Coagulation; Arch Dermatol. 2001 Feb;137(2):139-40Morris-Stiff et al. Symmetrical Peripheral Gangrene Following Perineal Wound Infection; J Infect. 1998 May;36(3):350-1Parmar. Symmetrical peripheral gangrene: a rare but dreadful complication of sepsis; CMAJ OCT. 29, 2002; 167 (9);1037-8Knight et al. Symmetrical peripheral gangrene: a new presentation of an old disease; Am Surg. 2000 Feb;66(2):196-9.O’Hare et al. Postoperative Mortality after Nontraumatic Lower Extremity Amputation in Patients with Renal Insufficiency; J Am Soc Nephrol 15: 427–434, 2004Sandnes et al. Survival after Lower-Extremity Amputation; J Am Coll Surg 2004;199:394–402.

Reference-3

Katzberg. Contrast Medium–induced Nephrotoxicity: Which Pathway?; Radiology 2005; 235:752–755

Goldenberg et al. Nephropathy induced by contrast media: pathogenesis, risk factors and preventive strategies; CMAJ2005;172(11):1461-71

McCullough et al.Contrast-Induced Nephropathy; Crit Care Clin 21 (2005) 261– 280Asif et al. Prevention of Radiocontrast-Induced Nephropathy; Am J Kidney Dis 44:12-24.

Itoh et al. Clinical and Experimental Evidence for Prevention of Acute Renal Failure Induced by Radiographic Contrast Media; J Pharmacol Sci 97, 473 – 488 (2005)

Vriese. Prevention and Treatment of Acute Renal Failure in Sepsis; J Am Soc Nephrol 14: 792–805, 2003

Venkataraman. Prevention of Acute Renal Failure; Crit Care Clin 21 (2005) 281– 289

Heyman et al. Regional alterations in renal haemodynamics and oxygenation: a role in contrast medium-induced nephropathy; Nephrol Dial Transplant (2005) 20 [Suppl 1]: i6–i11

Bettmann. Contrast medium-induced nephropathy: critical review of the existing clinical evidence; Nephrol Dial Transplant (2005) 20 [Suppl 1]: i12–i17

Thomsen. How to avoid CIN: guidelines from the European Society of Urogenital Radiology; Nephrol Dial Transplant (2005) 20 [Suppl 1]: i18–i22

Revised Trauma Score

Injury Severity Score

Head & Neck

Face

Chest

Abdomen

Extremity

External

Square Top Three(0-75)

Faringer

Zone I: pubic tubercles, perineum, sacrum, injuries to the rectum or vaginaZone II: medial thigh and groin creasesZone III: lateral buttocks, iliac crest

Young

APC: anterior-posterior compressionLC: lateral compressionVS: vertical shear

Estimate GFR

Cockcroft-Gault formula (15.6)

(140-age)*BW/(72*cre) (*0.85 in female)

Modification of Diet in Renal Disease (MDRD) (11)

186.3*serum Cr-1.154*age-0.203 (*0.742in female)

Emergent Hemodialysis

Refractory hypervolemia

Refractory hyperkalemia

Refractory metabolic acidosis

Uremic syndrome

(bleeding, encephalopathy, pericarditis)

Brief History

12/9 12/11 12/12 12/14 12/15 12/17 12/22

Open pelvic fracture Hypotension Fecal meterial in drain H/D Ischemia Fasciotomy

Operation Laparotomy No flow

Septic shock

12/22 12/23 12/26 12/27 12/29 1/2

PGE1,pletaal H/D Hip debride Left AK Contrast CT Right AK

Suspect T8 injury Right pleural centesis