1. Abdo / Pelvis Trauma

2. Learning Objectives At the end of this session, participants will be able to: Describe the initial evaluation and management of the patient with abdominal trauma Differentiate between haemodynamic and radiographic/orthopaedic instability in pelvic fracture Describe the management of haemodynamically unstable pelvic fracture in the ED

3. Simple... Find the bleeding Stop the bleeding

4. Causes Blunt injury is common (70-90%) MVA Pedestrian vs motor vehicle impacts Falls from height (>2m) Assaults

5. Solid organ Bowel Liver Spleen Kidneys Small bowel Large bowel Stomach BLEEDING PERITONITIS

6. Assessment Is there an intra-abdominal injury? Does the patient need a CT Does the patient require a laparotomy? Does the patient require embolisation

7. History Blunt Speed Restraint Position / Ejection Airbags Damage Penetrating Weapon type Length of blade Type of ammunition / firearm

8. Serial exam (may be unreliable in obtunded / intoxicated) Rib fractures - think liver, spleen, diaphragm Seatbelt sign - intra-abdominal injury in 25% FAST IDC Examination

10. Management Find the bleeding Stop the bleeding

11. Management (C)ABCs Unstable patients + positive FAST Laparotomy Stable patients Serial exam FAST CT

12. Imaging Does the patient need a CT? Clinical gestalt plus: Hypotensive GCS < 14 Seatbelt bruising Positive FAST (and stable) Abnormal chest and / or pelvis x- ray Haematuria Femoral fracture FASTCT SCAN Advantages Bedside Non invasive Accessible Repeatable High sensitivity and specificity Can identify injuries accurately Able to assess retroperitoneum Allows simultaneous imaging of thoracolumbar spine Disadvantages Operator dependent Cannot assess retroperitoneum Not good for assessing hollow viscus injury, diaphragmatic injury, pancreas Difficult to transport unstable patient Not ideal for hollow viscus, diaphragm and pancreatic injury Contrast allergy Contrast nephropathy Haematocrit < 30% Raised white cell count Increased base deficit or lactate

13. Management Solid organ injury Non-operative management Interventional angiography (if available) Laparotomy (for ongoing bleeding) Hollow viscus, or suspicion of Laparotomy

14. Management Indications for emergency laparotomy Evisceration Gunshot wound Peritonism Hypotension + penetrating injury Hypotension + blunt abdominal trauma + positive FAST Ruptured diaphragm

15. 36 yr female, thrown from horse HR 120, BP 90/60, RR 22, GCS 14/15 O2 sat 99 Abdominal tenderness Pelvic Trauma

18. Key Issue Terminology: Haemodynamic vs Radiographic Instability

19. Source of blood loss from pelvis Venous bleeding in 90% Arterial bleeding in 10% (majority posterior) Remember intra-peritoneal bleeding (around 30%)

20. Pelvic Trauma Other bleeding sites in unstable patient with pelvic fracture External Chest Abdomen/retroperitneum Long bone (femur) fracture – up to 40%

21. Management Haemostatic resuscitation Pelvic binder, tie feet together Pre-peritoneal packing External fixation Interventional angiography Laparotomy for concurrent intra-abdominal injury

22. Controversy Can you apply pelvic binder and femoral traction devices simultaneously? Can you apply pelvic binder to a displaced “vertical shear” pelvic fracture

23. Summary Assessment Management Bleeding pelvis

25. Learning Objectives You will now be able to: Describe the initial evaluation and management of the patient with abdominal trauma Describe the management of haemodynamically unstable pelvic fracture in the ED F i n d t h e b l e e d i n g S t o p t h e b l e e d i n g