Penetrating pelvic trauma: Initial assessment and surgical management in emergency

Abstract

Penetrating pelvic trauma (PPT) is defined as a wound extending within the bony confines of the pelvis to involve the vascular, intestinal or urinary pelvic organs. The gravity of PPT is related to initial hemorrhage and the high risk of late infection. If the patient is hemodynamically unstable and in hemorrhagic shock, the urgent treatment goal is rapid achievement of hemostasis. Initial strategy relies on insertion of an intra-aortic occlusion balloon and/or extraperitoneal pelvic packing, performed while damage control resuscitation is ongoing before proceeding to arteriography. If hemodynamic instability persists, a laparotomy for hemostasis is performed without delay. In a hemodynamically stable patient, contrast-enhanced CT is systematically performed to obtain a comprehensive assessment of the lesions prior to surgery. At surgery, damage control principles should be applied to all involved systems (digestive, vascular, urinary and bone), with exteriorization of digestive and urinary channels, arterial revascularization, and wide drainage of peri-rectal and pelvic soft tissues. When immediate definitive surgery is performed, management must address the frequent associated lesions in order to reduce the risk of postoperative sepsis and fistula.

The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition

“…Nine patients had to undergo pelvic packing for persistent bleeding after embolisation. If haemodynamic instability persists, a laparotomy for haemostasis according to damage-control principles to all potentially involved systems (digestive, vascular, urinary and bone) should be performed [80].…”

“…The advantages of MSCT, including WBCT, among severely injured patients in time savings, diagnostic accuracy and potentially also survival have been documented [151, 176–184]. The integration of modern MSCT scanners in the emergency department area prompts immediate assessment of any trauma victim likely to survive the assessment following admission [177, 184], thereby allowing timely diagnosis, differentiation between various types of major vascular injury, identification of associated findings, specific localisation of the source of bleeding and planning for bleeding control [80, 185, 186]. A 1-year review of early management of pelvic fracture patients documented a significant delay in the recognition of (major) pelvic fractures, including those associated with hip dislocations and (potential) pelvic bleeding with selective pelvic X-ray versus CT scanning [187].…”

Resuscitative endovascular balloon occlusion of the aorta (REBOA): indications: advantages and challenges of implementation in traumatic non-compressible torso hemorrhage

“…After subsequent duplication removal, primary and secondary screening analysis based on inclusion and exclusion criteria, 105 articles were included in the study (figure 1). 3 11–70 A large proportion of articles were retrospective. 13 studies were case reports, and 10 were prospective observational studies (figure 2).…”

Wooden Penetrating Pelvic Trauma Passing the Foramen Ischiadicum

“…While we largely agree with this chart, we would like to add a few points. First, when a hemodynamically unstable patient is delivered to the emergency department, the procedure according to the principles of damage control is without alternative [7]. The hemodynamically unstable patient is at a great risk of dying and all attention must be focused on preventing death by stopping the loss of blood.…”

“…(a) Vitally endangered patients: immediate surgical treatment according to damage control principles and hemodynamic stabilization [7].…”