Resuscitation of Polytrauma Patients: The Management of Massive Skeletal Bleeding

Abstract

The term ‘severely injured patient’ is often synonymous of polytrauma patient, multiply-injured patient or, in some settings, polyfractured patient. Together with brain trauma, copious bleeding is the most severe complication of polytrauma. Consequently hypotension develop. Then, the perfusion of organs may be compromised, with the risk of organ failure. Treatment of chest bleeding after trauma is essential and is mainly addressed via surgical manoeuvres. As in the case of lesions to the pelvis, abdomen or extremities, this approach demonstrates the application of damage control (DC). The introduction of sonography has dramatically changed the diagnosis and prognosis of abdominal bleeding. In stable patients, a contrast CT-scan should be performed before any x-ray projection, because, in an emergency situation, spinal or pelvic fractures be missed by conventional radiological studies. Fractures or dislocation of the pelvis causing enlargement of the pelvic cavity, provoked by an anteroposterior trauma, and in particular cases presenting vertical instability, are the most severe types and require fast stabilisation by closing the pelvic ring diameter to normal dimensions and by stabilising the vertical shear. Controversy still exists about whether angiography or packing should be used as the first choice to address active bleeding after pelvic ring closure. Pelvic angiography plays a significant complementary role to pelvic packing for final haemorrhage control. Apart from pelvic trauma, fracture of the femur is the only fracture provoking acute life-threatening bleeding. If possible, femur fractures should be immobilised immediately, either by external fixation or by a sheet wrap around both extremities.

Damage control orthopaedics: State of the art

“…ExFix provides more stability than binders, avoiding anterior abdominal cavity compression and also the risk of skin necrosis[45]. When properly applied, ExFix facilitates laparotomy, stabilising the pelvic bones[6,7]. However, the ExFix technique is much more time-consuming and aggressive.…”

“…When there is major retroperitoneal bleeding that remains uncontained after pelvic ring closure, the indicated approach could be packing or embolisation[6,7]. However, since pelvic ring closure produces a tamponade effect, stabilises the pelvis and occludes fractures, thus enhancing cessation of the haemorrhage, pelvic stabilisation is advised before any attempts are made at packing or embolisation[6,7,37], although if necessary the latter could be performed even in the case of an unfixed, unstable pelvic fracture[61].…”

“…The concept of damage control orthopaedics (DCO)[1] originally concerned the provisional immobilisation of long bone fractures - mainly the femur - in the severely traumatised patient (STP) in order to minimise the traumatic effects of non-life saving surgical procedures, termed the “second hit” effect[2-5]. In recent years, new locations have been added to the DCO concept, such as pelvis fractures, spine fractures and upper limb injuries[6].…”

“…Although haemorrhage complicates the generalised inflammatory reaction, transfusion may also aggravate the general traumatic syndrome, as this therapy can provoke complications in a patient who already presents a pathological inflammatory response. Massive transfusion can also provoke coagulation abnormalities, ion disorders and immunosuppression with subsequent infection as well as proclivity to lung injury and hypothermia[6,7]. Therefore, blood transfusion can be a life-saving procedure, but it may also provoke a “second hit” reaction.…”

The effect of preperitoneal pelvic packing for hemodynamically unstable patients with pelvic fractures

“…Many previous studies suggested that angiography with subsequent embolization and immediate external fixation should be performed to control the bleeding of pelvic fracture. 2 , 7 , 8 But the incidence of pelvic fracture patients who need the embolization treatment is estimated to be less than 10%, 2 , 9 and the application of embolization under the guidance of angiography is only efficacious in addressing arterial haemorrhage which only presents in 15% of lethal pelvic fractures. 10 Moreover, the procedures of embolization under the guidance of angiography can be time-consuming and the treatment for other associated injuries would be delayed.…”