1. ED & Trauma combine meeting 2012/01/12
Reporter: R4 蘇怡嘉
Supervisor: 鍾 亢主任
Moderator:邱德發主任

2. Case Identification Name: 許xx Chart No: 72012xx
Age: 57-year-old Gender: female
Time arrival ER: 100/10/25 22:00 (0hr0min)
檢傷分類: 1級
Vital sign: BT:35.4 C, HR:101/min, RR:23/min,
BP109/52mm-Hg, E3V5M6, Oximeter: 96%
檢傷主訴:病患來診為病患由119人員送入，據119人員表示病患機車車禍，身體雙下肢被大型遊覽車輾過，現雙下肢粉碎性骨折及骨肉分離

3. Trauma Blue Definition in CGMH
意識不清或GCS < 13
SBP < 90
頭部或軀幹槍傷
多重部位外傷
二層樓(六公尺)以上墜落
嚴重骨盆骨折 其他

4. Chief complaint
病人被公車輾過雙腳卡在後輪中約45分鐘後方被救出

5. Present Illness 事故發生時間:2011/10/25 21:00 事故地點：街頭公路 外傷機轉：車禍 外傷機轉：鈍傷或壓砸傷
類型：機械性夾傷
坐什麼車的?：機車
坐哪個位置?：駕駛
與什麼車相撞?：公車
保護措施：安全帽

6. Present Illness 意圖：非蓄意 過去病史 :不明 過去病史 : 無 過敏史 : 無 EMT擔架送入 被公車輾過雙腳卡在後輪中
過去病史 : 無
過敏史 : 無
EMT擔架送入 被公車輾過雙腳卡在後輪中
約莫45分鐘才被救出
病人表情痛苦 雙眼緊閉

7. Physical examination General appearance : acute ill
Conscious : E3 V5 M6,  Pupil size : 3+/3+
HEENT : not anemic   
Chest  BS : clear   
Abdomen:   distended         no tenderness           no rebound pain           bowel sound : normoactive           Mcburney point : negative           Murphy sign :    negative
Lt hip huge L/W, around 30cm, persistant oozing without massive active bleeding

8. Initial impression Hypovolemic shock Unstable pelvic fracture
Left femoral open fracture
Multiple abrasion wound

9. Initial Order 22:09 (09 min) Did you agree with these order ? CBC/DC
PT / aPTT
Sugar
Cr/ALT
ABG,myoglobin,CPK
Na / K
IV challenge with N/S 1000cc stat
N/S run 120 ml/hr
ABD and pelvis CT C+/-
CXR (B)
非常緊急用血 血品 :PRB 4U.  
緊急備血PRBC 4U
O2 N/C 3L/min
On critical : 出血性休克
Consult Trauma team
On monitor
On Large bore
Did you agree with these order ?

10. We may add…
FAST
Adequate fluid resuscitation

11. ATLS Primary survey and resuscitation
A (Airway and C-spine protection)
B (Breathing and ventilation)
C (Circulation with hemorrhage control)
D (Disability: neurologic status)
E (Exposure and enviromental control)
History (AMPLE)
Secondary survey
Finger to hole
From head to toe

12. 出血性休克之評估及分期 1 2 3 4 分 期 失血量 ml ~750 750~1500 1500~2000 >2000 失血量 %
分 期 1 2 3 4
失血量 ml
~750
750~1500
1500~2000
>2000
失血量 %
~15%
15%-30%
30%-40%
>40% 心率
<100
>100
>120
>140 血壓 正常 降低
脈搏壓
正常/增加
呼吸速率/min
14~20
20~30
30~40
>35
排尿量(ml/hr)
>30
20-30
5-15 無 意識
輕微焦慮
焦慮/神智不清
神智不清/嗜睡
輸液復甦(3:1)
溫的輸液
溫的輸液/血液

13. Diagnostic guideline --- pelvic fracture

14. FAST or DPL or CT

15. FAST: role in pelvic fracture?
FAST: lower sensitivity and specificity
Cannot differentiate hemoperitoneum or uroperitoneum
Tayal VS, Nielsen A, Jones AE, et al. Accuracy of trauma ultrasound in major pelvic injury. J Trauma 2006; 61(6):1453.

16. FAST: role in pelvic fracture?
Doest not aid in determining the need for laparotomy versus pelvic angiography in patients with pelvic fracture at risk for hemorrhage.
Friese RS, Malekzadeh S, Shafi S, et al. Abdominal ultrasound is an unreliable modality for the detection of hemoperitoneum in patients with pelvic fracture. J Trauma 2007; 63:97.

17. CT: golden diagnostic test
the diagnostic test of choice for detecting pelvic and intra-abdominal injuries.
Extravasations on CT scan of the pelvis is useful in predicting which patients will require therapeutic angiography
Rosen’s Emergency Medicine, 7th ed  > chap. 52 pelvis trauma

18. Lab 100/10/25 Temperature ℃ 37 pH 7.370 pCO2 mmHG 35.7 pO2 212.5 HCO3
mm/L
20.2
TCO2
21.3
ABE
-4.6
SBE
-5.1
SBC Mm
20.9
SAT %
99.2

19. 100/10/25 CT 22:22 (0 hr 22min)
Multiple fractures in the visible pelvis, involving of the right lower lumbar transverse processes, sacrum, bilateral pubic bones, right acetabulum, left distal femur, left patella, left tibia and left fibula.
Soft tissue defect with air collection in the subcutaneous tissue and along muscle fascia in the left leg, left pubic and inguinal regions.
Fluid collection around the urinary bladder, cannot exclude urinary bladder rupture or hematoma from pelvic fracture.
No remarkable finding of liver, spleen, pancreas and both kidneys.

20. Consult Sheet – 100/10/25 22:43 Called Duty Dr., got following orders:
admit to SICU Dr  after op; emergent OP with bilaeral legs amputation after resuscitation
NPO set iv with D5S1/4 and prepare OP: sign permite and send pt to OR on call
Pre-op survey EKG, CXR, check CBC, DC, sugar, BUN , Cr, PT, APTT, GOT, GPT
well explain op procedures and risks ; op site marked after op scheduled
inform risk of internal bleeding related to pelvic fr.
arrange emergent angioembolization

21. CT: golden diagnostic test
the sensitivity for the detection of arterial bleeding by CT to be only 66% in patients who also had angiography.
Brasel KJ, Pham K, Yang H, et al: Significance of contrast extravasation in patients with pelvic fracture.  J Trauma  2007; 62:1149.

22. CXR 100/10/25 22:48 (0hr 48 min)
Exaggerated lung markings at both lungs  
Normal heart size and configuration

23. Lab 100/10/25 22:52 (0 hr 52min) 檢驗項目 1001025 WBC 5100 Segment 58 RBC
4.62
Lymphocyte 37
Hemoglobin
7.0
Monocyte 5
Hematocrit
21.4
APTT
30.3
MCV
91.5
Nor.plasma mean
27.4
MCH
31.4
P.T
12.4
MCHC
34.0
11.5
RDW
14.1
INR
1.1
Platelets
89000
檢驗項目 單位
Sugar
mg/dL
137
Creatinine
0.82
ALT/GPT
U/L 39
Na(Sodium)
mEq/L
143.3
K(Potassium)
3.32 CK
ng/mL
114
Myoglobin
404.3

24. Radiologist Consult Sheet
Consider treating lower extremity bledding first. Stablize blood pressure and correct coagulation profiles. <O>: TPR: 36/80/18 BP: 74/58 PLT: ; PT:14.0 ; INR: 1.33
<A>: FRACTURE OF OTHER SPECIFIED PART OF PELVIS, CLOSED FRACTURE OF UNSPECIFIED PART OF FEMUR, OPEN

25. Time line radiologist Trauma team 22:00 0 min 22:09 09min 22:22 22min
放射科醫師不建議作angiography 抵達
送手術室
TAE standby
CT complete
B/T PRBC8u
94/48, HR:81
101/50, HR:84
74/58, HR:80
74/58, HR:80
74/48, HR:80

26. Surgical guideline in CGMH

27. Angiography indication
inadequate response to initial resuscitation (SBP< 90 mm Hg after the administration of 2 U of packed red cells)
the presence of contrast extravasation on admission CT
Miller PR, Moore PS, Mansell E, et al: External fixation or arteriogram in bleeding pelvic fracture: Initial therapy guided by markers of arterial hemorrhage.  J Trauma  2003; 54:437

28. Management guideline in pelvic fracture
In North America:
Angiography with embolization is the approach preferred for patients with rapid pelvic fracture bleeding and/or an inadequate response to pelvic volume reduction.
In Europe:
Preperitoneal pelvic packing/ External fixation
Lewis Flint, MD, FACS, and H. Gill Cryer, et al. Pelvic Fracture: The Last 50 Years. J Trauma. 2010;69: 483–488

29. PPP/EF v.s Angiography
PPP/EF was effective in controlling hemorrhage from unstable pelvic fractures.
Additionally, PPP/EF temporizes arterial hemorrhage, providing valuable transfer time for facilities without angiography.
With other urgent operative interventions required in 85% of patients, combining these procedures with PPP/EF for operative pelvic hemorrhage control appears to optimize patient care.
Clay Cothren Burlew, Ernest E Moore,Wade R Smith, et al. Preperitoneal Pelvic Packing/External Fixation with Secondary Angioembolization: Optimal Care for Life-Threatening Hemorrhage from Unstable Pelvic Fractures. J Am Coll Surg 2011;212:628–637.

30. OP record 23:10 入手術室： 74/48 HR: 80 01:18 出手術室： 84/58 HR:110
OPERATIVE  PROCEDURE: We applied Slatis frame for pelvic fracture first.
The crushed left lower leg was amputated via knee disarticulation
The huge wound of the left thigh was debrided. Wounnd were closed with PDS.
The right crushed lower leg was amputated at the 10 cm below knee.
The open wounds of the vagina and inguinal area due to open pelvic fracture were impacted with Karlex.

31. Admission course 08:49 profound shock 10/25 OP 10/26 01:50 入SICU
dopamine line
06:10 FFP 2u , plt 24U
08:49 profound shock

32. TAE Imp: Pelvic fracture with active bleeding Pseudoaneurysm formation
S/P  successful  embolization.
09:40 TAE完成
122/68 , HR: 110, RR:22

33. Admission course 11/4- 11/28 received 7 times wound debridement
12/12 extubation
12/13 transfer to ordinary ward
12/14~ still admission

34. Pelvic fracture Rosen's Emergency Medicine, 7th ed.
Lewis Flint, MD, FACS, and H. Gill Cryer, et al. Pelvic Fracture: The Last 50 Years. J Trauma. 2010;69: 483–488

35. Risk factor Increased patient age :due to osteoporosis
Female gender :decreased resistance of pelvic bones and ligaments to forced disruption
Increased impact forces.

36. Initial accessment
control hemorrhage and temporarily stabilize the fracture.

37. Associated pelvic injuries
Urologic: bladder or urethral rupture 5~6%
Neurologic: Cauda equina syndrome
Gynecologic: especially in pregnant women

38. The combination of posterior arch fracture plus hypotension is associated with a mortality rate of approximately 50%.

39. Significant pelvic fracture bleeding can occur from veins, bone edges, lacerated arteries
Major pelvic arterial or venous trunks are unusual and can be effectively in angiography.
Lewis Flint, MD, FACS, and H. Gill Cryer, et al. Pelvic Fracture: The Last 50 Years. J Trauma. 2010;69: 483–488

40. Managment Detection and management of pelvic fracture hemorrhage
Definitive fixation of pelvic fracture