Martin J. Heetveld

Institutional practice guidelines on management of pelvic fracture-related hemodynamic instability : Do they make a difference?

BACKGROUND The management of patients with hemodynamic instability related to pelvic fracture is a major challenge, with high morbidity and mortality. Evidence-based institutional practice guidelines (PG) were developed as a strategy to optimize the care of these patients. The aims of this study were to evaluate the adherence to the new PG and compare the outcomes before and after their implementation. METHODS Major blunt trauma patients (Injury Severity Score [ISS] > 15) with hemodynamic instability (initial base deficit > 6 mEq/L or received > 6 units of packed red blood cells [PRBCs] during the first 12 hours) related to pelvic fracture were investigated. Patients presenting with ongoing bleeding from other regions or with severe head injury (Glasgow Coma Scale score < 9) were excluded. The pre-PG group (n = 17) were patients managed during the 18 months ending on December 31, 2001. The post-PG group (n = 14) consisted of patients managed during the subsequent 18 months. Demographics, ISS, shock severity, resuscitation, and outcome data were prospectively collected. The adherence to the key steps of PG was evaluated retrospectively in the pre-PG and prospectively in the post-PG group, including abdominal clearance (AC) with diagnostic peritoneal aspiration/lavage or ultrasound (<15 minutes), noninvasive pelvic binding (PB) (<15 minutes), pelvic angiography (PA) (<90 minutes after admission), and minimally invasive orthopedic fixation (MIOF) (<24 hours). Data are presented as mean +/- SEM or percentages. RESULTS The pre-PG and post-PG groups were similar regarding age (40 +/- 4 years vs. 42 +/- 6 years), gender (both 71% male), ISS (39 +/- 3 vs. 37 +/- 4), admission base deficit (9 +/- 1 vs. 10 +/- 1) admission systolic blood pressure (116 +/- 7 vs. 112 +/- 6 mm Hg), Glasgow Coma Scale score (12 +/- 1 vs. 12 +/- 1), and PRBC transfusion in the first 12 hours (9 +/- 2 U vs. 9 +/- 2 U). The adherence to the guidelines in the post-PG period was as follows: AC, 100%; PB, 86% (p < 0.05 based on t test or chi test); PA, 93% (p < 0.05 based on t test or chi test); and MIOF, 86%. In the pre-PG period, adherence to the guidelines was as follows: AC, 65%; PB, 0%; PA, 30%; and MIOF 52%. In the post-PG period, the 24-hour PRBC transfusion decreased from 16 +/- 2 U to 11 +/- 1 U and the mortality decreased from 35% to 7% (p < 0.05 based on t test or chi test for both). CONCLUSION The adherence to the PG as a reflection of optimal management was significantly improved. PG focusing particular on timely hemorrhage control reduced the 24-hour transfusion requirements and the mortality rate in the post-PG group.

Hemodynamically Unstable Pelvic Fractures: Recent Care and New Guidelines

Consistent care of hemodynamically unstable pelvic fracture patients is a major management issue. It was uncertain whether the introduction of newly developed clinical practice guidelines would require much change in current delivery of care at our institution. Assessment of recent care was undertaken and compared with the newly developed evidence-based best practice guidelines. A multidisciplinary project team developed clinical practice guidelines for determination of early optimum management of hemodynamically unstable patients with pelvic fractures. The guidelines recommend a definitive management plan to arrest hemorrhage within 30 minutes. Intra-abdominal hemorrhage should be assessed with diagnostic peritoneal aspiration (DPA) and/or focused assessment with sonography for trauma (FAST). Early noninvasive stabilization of the pelvis followed by angiography within 90 minutes are recommended if intra-abdominal hemorrhage is not found. Recent care was assessed in a historical cohort of patients, identified in a prospectively maintained trauma registry, between June 1999 and December 2001. Investigations, interventions, and times were then compared with the new guidelines. The delivery of care to 30 patients (mortality 37%, mean ISS 37.8 ± 20.9) was studied. Compared with the new guidelines, the abdominal assessment rate with DPA and/or FAST was 53% and early (< 90 minutes) angiography rate was 38%. A form of pelvic external stabilization was applied in 27% of cases. Noninvasive pelvic stabilization was not performed at all. The recent care of hemodynamically unstable pelvic fracture patients was not in line with newly developed guidelines. There is an opportunity to markedly improve the rates of initial assessment of the abdomen, pelvic stabilization, and early angiography.

Spontaneous expulsion of a screw during urination: an unusual complication 9 years after internal fixation of pubic symphysis diastasis

Nine years after treatment of symphysiolysis and dislocation of the left sacroiliac joint, a screw was spontaneously voided during urination. Unstable plate fixation of the symphysis pubis probably caused screw migration into the bladder, creating a fistula with abscess formation and septic complications.

Spontaneous Urinary Voiding of a Metallic Implant After Operative Fixation of the Pubic Symphysis

Displaced fractures and dislocations of the pelvic ring and acetabulum are usually treated with open reduction and internal fixation with a plate and screws. Loosening and migration of these plates can occur; however, to the best of our knowledge, we are the first to describe the migration of such implants into the urinary tract through the bladder wall. We report the case of a patient who experienced late migration of a screw and washer into the bladder with spontaneous voiding of the screw. In September 1992, a twenty-five-year-old man was brought to the emergency room of the Hospital Sao Lucas, Pontificia Universidade Catolica do Rio Grande do Sul—PUCRS, in Porto Alegre, Brazil, after being run over by an automobile. The patient underwent exploratory laparotomy for a hemoperitoneum, and a splenectomy was performed. No evidence of bladder injury was noted. Skeletal traction was applied to the right lower extremity because of a transverse fracture of the right acetabulum, which was associated with disruption of the pubic symphysis and the left sacroiliac joint ( Fig. 1 ). Two weeks later, after clinical stabilization of the patient, the right hip was explored through a Kocher-Langenbeck approach with an osteotomy of the greater trochanter. Multiple bone fragments were extracted from the joint, but the acetabular fracture could not be satisfactorily reduced. One week later, through an …