DIMAS PRIYANTONO

FRAKTUR PELVIS
Objectives:

Review assessment of pelvic injury.

Understand concept of different
types of stability.
Management algorithm.
Diagnosis:
Made during primary survey.
Airway with c-spine control.
Breathing (oxygen).
Circulation
IV access
Crystalloid
Control external loss
Look for major pelvic injury
Assess pelvis:
History
Suspect in high energy injury
Examination
External bruising/wounds
(anterior/posterior)
Test for vertical/horizontal instability
Rectal examination
Vaginal examination
Radiographs:
Every polytrauma patient should
have
Lateral c-spine
Chest
AP Pelvis
AP pelvis is done to detect major
(and potentially life-threatening)
pelvic injury.
Inlet
view:

Patient flat on trolley.

XR plate under pelvis.
Direct XR beam at 60
degrees to plate.
Effectively transverse
section through sacrum.
Will show sacral #.
Will show any posterior
shift of hemi-pelvis.
Will show internal/external
rotation of hemi-pelvis.
Outlet
view:

Patient flat on trolley.

XR plate under pelvis.
Direct XR beam at 45
degrees to plate.
Effectively true AP view of
sacrum.
Will show vertical shift of
hemi-pelvis.
Will reveal any bucket-
handle injury.
Will help in assessing leg
length discrepancy.
Pelvic fracture
classification: Type A.

Stable.
Minimally
displaced.
Posterior arch
intact.
 Pelvic fracture
classification: Type B.

Can be unstable.
Incomplete
disruption of
posterior arch.
Actual or potential
horizontal
translation.
No vertical
translation.
Pelvic fracture
classification: Type C.

Unstable.
Complete disruption
of posterior arch.
Actual or potential
horizontal and
vertical displacement.
Type B injuries:
B1: open book injury (external rotation).
Can be mechanically unstable.
B2: lateral compression injury (internal
rotation) - includes ipsilateral and
contralateral (bucket-handle) types.
Usually mechanically stable.
B3: bilateral Type B injuries (includes
windswept pelvis). External rotation
injury can be mechanically unstable.
Type C injuries:
C1: unilateral complete disruption of
posterior arch.
C2: unilateral complete disruption of
one posterior arch, with incomplete
disruption of contralateral posterior
arch.
C3: bilateral complete disruption of
posterior arch.
All are mechanically unstable.
 Management of major pelvic
fracture:

You have to be an orthopaedic

surgeon, a urologist, a vascular
surgeon, a colo-rectal surgeon and
(sometimes) a gynaecologist!
Initial management:

Save life.
Do not do anything to compromise
definitive reconstruction.
Most important piece of equipment
to master?
 Signs and Symptoms
Spectrum from abdominal pain, signs of
peritoneal irritation, to hypovolemic shock
Nausea or vomiting
Labored respiration from diaphragm
irritation or upper abdominal injury
Left shoulder pain with inspiration (Kehr
sign) from diaphragmatic irritation owing
to bleeding
Delayed presentation possible with small
bowel injury
 Essential Workup
Evaluate and stabilize airway, breathing, and
circulation (ABCs).
Primary objective is to determine need for operative
intervention.
Examine abdomen to detect signs of intra-abdominal
bleeding or peritoneal irritation.
Injury in the retroperitoneal space or intrathoracic
abdomen is difficult to assess by palpation.
Abrasions or ecchymoses may be indicators of intra-
abdominal injury:
Bowel sounds may be absent from peritoneal irritation
(late finding).
Foley catheter (if no blood at the meatus, no perineal
hematoma, and normal prostate exam) to obtain urine
and record urinary output
 Essential Workup
Plain film of the pelvis:
Fracture of the pelvis and gross hematuria may
indicate genitourinary injury.
Further evaluation of these structures with
retrograde urethrogram, cystogram, or
intravenous pyelogram
CT most useful in assessing need for
operative intervention and for evaluating
the retroperitoneal space and solid organs:
Patient must be stable enough to make trip to
scanner.
Also useful for suspected renal injury
 FAST (focused abdominal sonography for
trauma) to detect intraperitoneal fluid
Ultrasonography is rapid, requires no contrast
agents, and is noninvasive.
Operator dependent
Diagnostic peritoneal lavage (useful for
revealing injuries in the intrathoracic
abdomen, pelvic abdomen, and true
abdomen) primarily indicated for unstable
patients:
Positive with gross blood, RBC count of
>100,000/mm3, WBC count of 500/mm3, or
presence of bile, feces, or food particles
 Tests
Lab
Hemoglobin/hematocrit, which initially may
be normal owing to isovolemic blood loss
Type and cross is essential.
Urinalysis for blood:
Microscopic hematuria in the presence of shock
is an indication for genitourinary evaluation.
Arterial blood gases:
Base deficit may suggest hypovolemic shock
and help guide the resuscitation
 Treatment
Pre Hospital
Aggressive fluid resuscitation is still considered standard
of care.
Normal vital signs do not preclude significant intra-
abdominal pathology.
Initial Stabilization
Ensure adequate airway:
Intubate if needed.
O2 100% by nonrebreather face mask
Two large-bore intravenous lines with crystalloid infusion
Begin infusion of packed RBCs if no response to 2 L of
crystalloid.
If patient is in profound shock, consider transfusion of O-
negative or type-specific blood.
 ED Treatment
Continue stabilization begun in field.
Nasogastric tube to evacuate
stomach, decrease distention, and
decrease risk of aspiration:
May relieve respiratory distress if caused
by a herniated stomach through the
diaphragm
 Medication (Drugs)
Tetanus toxoid booster: 0.5 mL IM for
patients with open wounds
Tetanus immune globulin: 250 units IM
for patients who have not had
complete series
Intravenous antibiotics: broad-
spectrum aerobic with anaerobic
coverage such as a second-generation
cephalosporin
Abdominal Trauma,
Penetrating
 Description
Solid organ injury usually results in
hemorrhage.
Hollow viscus injury can lead to
spillage of bowel contents and
peritonitis.
Associated conditions:
Injury to both thoracic and abdominal
structures occurs in 25% of cases.
 Etiology
Eighty percent of gunshot wounds and 2030% of stab
wounds result in significant intra-abdominal injury.
Commonly injured structures include:
Liver (37%)
Small bowel (26%)
Stomach (19%)
Colon (17%)
Major vessel (13%)
Retroperitoneum (10%)
Mesentery/omentum (10%)
Other:
Spleen (7%)
Diaphragm (5%)
Kidney (5%)
Pancreas (4%)
Duodenum (2%)
Biliary (1%)
 Signs and Symptoms
Penetrating wound from knife, gun, or other
foreign object
Spectrum of presentation ranging from localized
pain to peritoneal signs:
High-velocity projectile can cause extensive direct
tissue damage.
Secondary missiles and temporary cavitation of
effected structures
Exit wound may be larger than entrance wound, but
small entrance and exit wounds can conceal
massive internal damage.
Remember the borders of the abdomen: superior
from the nipples (anteriorly) or inferior tip of
scapula (posteriorly) to inferior gluteal folds
 Workup
Diagnosis of intra-abdominal injury from
gunshot wounds to the abdomen are made
by celiotomy in the operating room.
Locally explore stab wounds to abdomen:
If the wound penetrates anterior fascial layer,
the patient should undergo diagnostic
peritoneal lavage or bedside ultrasound.
Diagnostic laparoscopy is useful in
diagnosing diaphragmatic injury and
spleen and liver lacerations:
May help avoid unnecessary surgery.
 CT is useful in the evaluation of patients
with a suspected retroperitoneal injury:
Not reliable for detection of hollow viscus or
diaphragmatic injuries.
If 10,000 RBC/mm3 or more are found in
the diagnostic peritoneal lavage fluid, the
patient should under go laparotomy.
If <10,000 RBC/mm3 are present, the
patient should be observed for 8 - 24 hours
for the development of peritoneal signs.
 TEST
Lab
Hemoglobin or hematocrit:
Repeated measurements to assess for ongoing
hemorrhage
Urinalysis for blood to assess for possible
genitourinary tract damage
Arterial blood gases:
Base deficit may be helpful in assessing
hypovolemia and guide volume resuscitation.
Type and cross-match for all patients with
significant intra-abdominal injuries
 TEST
Imaging
Plain films:
Obtain after placement of markers for localization of
foreign bodies, missiles, associated fractures, and
free air.
Intravenous pyelogram:
For possible renal injury
Bedside abdominal ultrasound (FAST: focused
abdominal sonography for trauma):
May reveal intraperitoneal blood or fluid
CT with IV contrast in experienced facilities and
with stable patients:
For possible retroperitoneal and solid organ injuries
 Treatment
Pre Hospital
Controversies:
Military antishock trousers (MAST) should not be
used.
Current standard of care for treatment of
hypovolemic shock is volume resuscitation with
crystalloid solutions.
Caution:
Apply sterile dressings to open wounds and
eviscerated bowel.
Secure impaled foreign objects in place; do not
remove them.
 Treatment
Initial Stabilization
Two large-bore intravenous lines with
crystalloid infusion
If no response to 2 L of crystalloid, infuse
two to four units packed red blood cells:
May use O-negative blood initially if patient
unstable
Type-specific and cross-matched blood when
it becomes available
One hundred percent oxygen by
nonrebreather face mask
 ED Treatment
Nasogastric tube placement:
Will decrease aspiration risk
Place nasogastric tube before performing diagnostic
peritoneal lavage to decompress stomach and reduce
risk of iatrogenic injury.
May relieve respiratory distress in cases of
diaphragmatic injury with herniated abdominal
contents in the thorax
Foley catheter placement:
Insert after ruling out urethral injuries
Facilitates rapid assessment of genitourinary injury
Assists in monitoring of urinary output
Tetanus toxoid if appropriate; tetanus immune
globulin if primary tetanus series not administered
 Medication ( Drugs )
Tetanus toxoid: 0.5 mL intramuscularly
Tetanus immunoglobulin: 250 units
intramuscularly for patients who have
not had a complete series
Intravenous antibiotics: broad-
spectrum aerobic with anaerobic
coverage such as second generation
cephalosporin
Head injury
 Pathophysiology
Acute brain injury is usually divided into primary
and secondary phases:
1.Primary injury direct tissue damage from
traumatic mechanism ( eg: contusion, tissue
shearing, hemorrhage)
2.Secondary injury
Tissue damage which occurs minutes to hours after
the primary injury
Ischemia from elevated ICP and/or systemic
hypotesion
Metabolic toxin : eg release of excitotoxic
transmitter, free radical, and calicium derangement
GCS
Head Trauma, Blunt

Blunt trauma to head

resulting in a variety of
injuries ranging from closed
head injury to death
 Etiology
Blunt trauma to head may cause several
types of closed head injuries:
Concussion: transient loss of consciousness
or amnesia with normal head CT
Subdural hematoma: tearing of subdural
bridging veins and bleeding into the
subdural space
Epidural hematoma: dural arterial injury,
especially the middle meningeal artery
often associated with a skull fracture:
Classically, transient loss of consciousness
followed by a lucid interval, then rapid demise
 Subarachnoid hemorrhage: bleeding into
the subarachnoid space following trauma
Cerebral contusion: focal injuries to the
brain characterized as coup (beneath area
of impact) or contrecoup (area remote from
impact)
Intracerebral hemorrhage: mass
intracranial lesion with bleeding into the
brain parenchyma
Diffuse axonal injury: microscopic injuries
scattered throughout the brain in a patient
in deep coma
 Signs and Symptoms
Evidence of trauma to head includes:
Scalp laceration, cephalohematoma, or
ecchymosis
Raccoon eyes: bilateral ecchymosis of orbits
associated with basilar skull fractures
Battle sign: ecchymosis behind the ear at
mastoid process associated with basilar skull
fracture
Hemotympanum
Cerebral spinal fluid rhinorrhea or otorrhea
 Evidence of increasing intracranial
pressure includes:
Decreasing level of consciousness,
falling Glasgow coma scale score
Cushing response, bradycardia,
hypertension, and diminished
respiratory rate
Dilated pupils associated with
decorticate or decerebrate posturing
 Lab
Rapid check of blood glucose level
Complete blood count, platelet
count, and coagulation parameters
Type and cross-match for surgical
candidates.
Baseline electrolytes, blood urea
nitrogen, and creatinine levels
Blood alcohol level if indicated
 Imaging
Cervical spine radiographs or helical CT when
indicated
Head CT should be performed in patients with any
of the following:
Loss of consciousness or amnesia of events
Progressive headache
Alcohol or drug intoxication
Unreliable history or dangerous mechanism
Posttraumatic seizure
Repeated vomiting
Signs of basilar skull fracture
Possible skull penetration or depressed skull fracture
Glasgow coma scale score <15
Focal neurologic findings
 Patients on Coumadin or heparin or
those with a history of bleeding
dyscrasias must undergo imaging.
Older patients (>age 6065 years)
and alcoholics are at higher risk of
intracranial hemorrhage:
Have a low threshold for obtaining CT
scan
 Differential Diagnosis
Penetrating head trauma
Any condition that alters mental
status that may have produced a fall
and caused external evidence of
head trauma (e.g., hypoglycemic
episode, seizure)
 Treatment : Pre Hospital
Blunt head trauma patients with risk for
intracranial lesion must go to a trauma center:
High-risk patients include those with depressed
consciousness, focal neurologic signs, multiple
trauma, or palpable depressed skull fractures.
Moderate-risk patients should go to a hospital
with availability of prompt neurosurgical
consultation:
Moderate-risk patients include those with
progressive headache, alcohol or drug intoxication,
unreliable history, posttraumatic seizure, repeated
vomiting, posttraumatic amnesia, signs of basilar
skull fracture
 Protect and manage the airway including
intubation:
Routine hyperventilation without signs of
cerebral herniation should be avoided.
If evidence of cerebral herniation (see Signs
and Symptoms) or progressive neurologic
deterioration, then initiate measures to
decrease intracranial pressure:
Mild hyperventilation to keep PaCO2 about 35:
16 - 20 breaths per minute in adults
20 - 24 breaths per minute in children
24 - 26 breaths per minute in infants
Elevating head of bed 20 - 30
 Cervical spine precautions must be
maintained in all patients.
Cautions:
Avoid hypotension (systolic blood
pressure <90 mm Hg); use intravenous
crystalloid solutions to maintain blood
pressure.
Avoid hypoxia (oxygen saturation
<90%); administer 100% oxygen.
Check blood glucose level.
 Initial Stabilization
Control airway as needed:
Rapid-sequence intubation if Glasgow coma
scale score <8, unable to protect airway, or
evidence of hypoxia
Normalize PCO2, avoid hyperventilation and
hypoventilation.
Treatment with etomidate or fentanyl as
induction agent, succinylcholine (pretreat
with minidose paralytic), rocuronium, or
vecuronium; morphine for ongoing
sedation
 Caution with fentanyl in
hemodynamically labile patients
Intravenous catheter placement with
crystalloid solution as needed to
avoid hypotension (keep systolic
blood pressure >90 mm Hg)
Cervical spine precautions
 ED Treatment
Early neurosurgical consultation
If patient has evidence of cerebral herniation
(see Signs and Symptoms), initiate measures
to decrease intracranial pressure:
Mild hyperventilation: 1620 breaths per
minute in adults, 2024 breaths per minute in
children, and 2426 breaths per minute in
infants to keep PaCO2 about 35, which correlates
to an end tidal CO2 of 3235 mm Hg
Elevating head of bed 2030
Mannitol boluses intravenously: Do not administer
mannitol unless systolic blood pressure >100 mm
Hg and patient is adequately fluid resuscitated
 Phenytoin to prevent early posttraumatic
seizures
The use of glucocorticoids is not
recommended to lower intracranial pressure
in head trauma patients.
Barbiturates are not recommended in the
initial emergency department treatment of
head-injured patients.
If definitive neurosurgical care is not
immediately available, a single burr hole may
preserve life until neurosurgical intervention
can be obtained:
Perform only in comatose patients with
decerebrate or decorticate posturing on the side
of a known mass lesion who have not responded
to hyperventilation and mannitol.
 Transfuse as needed to keep
hematocrit >30%.
Avoid hypothermia, which will increase
risks of coagulopathy during surgery.
Maintain NPO status.
Surgery:
Surgical procedure based on findings of CT
scan and neurosurgical consultation
 Medication (Drugs)
Etomidate: 0.2 - 0.3 mg/kg IV
Fentanyl
Mannitol: 0.25 - 1 g/kg IV bolus
Morphine sulfate: 2 - 20 mg IV (peds: 0.1
mg/kg IV up to adult doses)
Phenytoin: 15 - 20 mg/kg IV up to 1,000 mg
Rocuronium: 0.6 mg/kg IV
Succinylcholine: 1 - 2 mg/kg IV
Vecuronium bromide: 0.1 mg/kg IV;
minidose pretreatment: 0.01 mg/kg IV
Head Trauma, Penetrating
 Description
Penetrating injury to intracranial
contents:
High-velocity penetration: usually
bullets, which cause trauma directly to
brain tissue, but also have a shock
wave injury to local surrounding brain
Low-velocity penetration: usually knives,
picks, or other sharp objects, with direct
local trauma to brain tissue
 Etiology
Direct penetration of the skull into the
intracranial cavity by foreign object:
Direct or local damage to brain tissue
Intracranial hemorrhage, including
subdural, epidural, and intraparenchymal
bleeds
A bullet that hits the skull, ricochets
off, and does not fracture the skull can
still cause significant trauma to the
underlying brain tissue.
 Pathophysiology
Acute brain injury divided into primary and
secondary phases.
Primary cell death is irreversible and only
preventing the injury event and mitigation of the
injury forces on the brain reduce morbidity and
mortality.
Secondary injury cascades can extend the
damage to cells that are not initially irreversibly
damaged. In the hours to weeks after the injury,
local tissue ischemia from compressive forces or
vascular injury lead to secondary cellular death.
Prevention of the ischemia and hypoxia are the
main therapeutic goals for treating patients with
TBI.
 Signs and Symptoms
Alteration in level of consciousness and
neurologic exam varies based on object
and location.
Evidence of increasing intracranial
pressure:
Decreasing level of consciousness
Falling Glasgow coma scale score
Cushing response: bradycardia, hypertension,
and diminished respiratory rate
Blown pupil associated with decorticate or
decerebrate posturing
 Evidence of penetrating injury to head or
basilar skull fracture, or object still
remaining in head:
Raccoon eyes: bilateral ecchymosis of orbits
associated with basilar skull fractures
Battle sign: ecchymosis behind the ear at
mastoid process associated with basilar skull
fracture
Hemotympanum
Cerebral spinal fluid rhinorrhea or otorrhea
 Essential Workup
Determine the weapon type or caliber
of weapon at scene.
Thorough exam to assess extent of
injuries
Neurologic exam:
Alteration in level of consciousness and
neurologic exam varies based on object
and location.
Evidence of penetrating injury to head
 Lab
Complete blood count
Platelet count
Coagulation perimeters
Type and cross-match.
Electrolytes, blood urea nitrogen, and
creatinine baseline levels
 Imaging
CT of head depicts location of lesion and
extent of damage.
Skull radiographs may reveal depth of
impalement, location of bone fragments,
and presence of fragments within the
cranium.
Cervical spine evaluation (when indicated):
Helical CT scanning or anteroposterior, lateral,
and odontoid views plain radiographs
Algorithm for imaging patients
with mild TBI
 Differential Diagnosis
Blunt head trauma
Basilar skull fracture
Any condition that alters mental
status that may have induced a fall
and caused secondary penetrating
trauma
 Pre Hospital
Stabilize, but do not remove, foreign object
(e.g., knife).
Determine the weapon type or caliber of
weapon at scene.
Protect and manage the airway to avoid
hypoxemia.
Avoid hyperventilation.
Maintain cervical spine precautions.
Transport to trauma center.
Avoid hypoxia (oxygen saturation <90%):
100% oxygen
Avoid hypotension (systolic blood
pressure<90 mm Hg):
Intravenous crystalloid solutions
 Initial Stabilization
Airway, breathing, and circulation
management
Rapid-sequence intubation:
For Glasgow coma scale <8, inability to protect
airway, hypoxia or cerebral herniation
Medications include etomidate or fentanyl as
induction agent, succinylcholine (pretreat with
minidose paralytic), rocuronium, or vecuronium;
and morphine sulfate for ongoing sedation
Caution with fentanyl in the hemodynamically
labile patient
Normalize PCO2. Avoid hyperventilation or
hypoventilation
 Intravenous catheter placement
Crystalloid solution to maintain
systolic blood pressure >90 mm Hg
Address other sources of associated
trauma.
Cervical spine precautions should be
maintained
 ED Treatment
Early neurosurgical consultation
If patient has evidence of cerebral herniation
(see Signs and Symptoms), initiate measures to
decrease intracranial pressure:
Mild hyperventilation: 16 20- breaths per minute in
adults, 20 - 24 breaths per minute in children, and
24 - 26 breaths per minute in infants to keep PaCO 2
about 35, which correlates to an end tidal CO 2 of 32 -
35 mm Hg
Elevating head of bed 20 - 30
Mannitol boluses intravenously: Do not administer
mannitol unless systolic blood pressure >100 mm
Hg and patient is adequately fluid resuscitated.
 Phenytoin intravenously to prevent
early posttraumatic seizures
Glucocorticoids are not recommended
to lower intracranial pressure in head
trauma patients.
Barbiturates are not recommended in
the initial emergency department
treatment.
Transfuse as needed to keep
hematocrit >30%.
 If definitive neurosurgical care is not
immediately available, a single burr hole
may preserve life until neurosurgical
intervention can be attained:
Perform only in comatose patients with
decerebrate or decorticate posturing on the
side of a known mass lesion/hematoma who
have not responded to initial treatment.
Avoid hypothermia, which will increase
risks of coagulopathy during surgery.
Maintain NPO status.
Surgery:
Based on clinical and radiologic findings and
neurosurgical consultation
 Medication (Drugs)
Etomidate: 0.2 - 0.3 mg/kg IV
Fentanyl
Mannitol: 0.25 - 1 g/kg IV bolus
Morphine sulfate: 2 - 20 mg IV (peds: 0.1
mg/kg up to adult doses)
Phenytoin: 15 - 20 mg/kg IV up to 1,000 mg
Rocuronium: 0.6 mg/kg IV
Succinylcholine: 1 - 2 mg/kg IV
Vecuronium bromide: 0.1 mg/kg IV:
Pretreatment minidose: 0.01 mg/kg IV