trauma scenario question

[europeman]

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I'd appreciate if someone could help me out with the thought process and what should be done in cases of blunt trauma patients who are hemodynamically unstable with, negative fast, with and without obvious pelvic fracture (either from physical exam or x-ray).

Do they 1) go for x-lap? 2) go to angio?

Let me tell u where I'm coming from. We had a guy who fell about 15 feet, had nothing but a pretty whimpy pelvic fracture on x-ray, a soft belly, and negative fast. He was pretty questionable stability wise, but somehow we got him to cat scan (dunno if this was the right thing to do in retrospect) which showed a grade 4 left kidney injury w/contrast blush. He went for emergent nephrectomy, but died on the table from exsanguination before ortho could get their external fixation finished (we were working sorta concurrently). On autopsy, he died from kidney exsanguination.... he had no bleeding related to his pelvic fracture.

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There are some that report retroperitoneal packing for pelvic bleeding. anyone have experience w/this? I know the Denver guys have published on it a lot.

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My *MAIN* question, though, is the patient who is unstable, blunt trauma, WITHOUT pelvic fracture.... what do you do? and with? thanks!

 

[Kuba]

Just about to start PGY1, but since no one else said anything yet I thought I'd try to contribute to the forum..

From everything I've learned thus far, hemodynamically unstable -> Ex-Lap. What do you mean by questionable stability wise though? Was SBP ~80? Also, you said he died from Kidney Lac but you're asking about Pelvic Packing? Are you referring to Pre-peritoneal pelvic packing or packing all four quadrants in a damage control type situation?

It might be error on my part, but this scenario is a little unclear, so I'll generalize what Ive learned so far..again, just graduating:

Pre-peritoneal pelvic packing is mostly for venous injuries from unstable pelvic fractures. Would not help with Kidney lac.

Unstable blunt trauma with suspicion of abd injury ->skip FAST->ExLap.

EDIT: Just saw you specified retroperitoneal - not familiar with this, I'll let the big guns take over.

 

[omarsaleh66]

at our institution, either IR or vascular surgery ( we share trauma call) will do the angio, embolize the active bleed. Then the patient goes to ortho for fixation or general surgery for lap (for other types of related injury such as bowel perf, etc..)

 

[europeman]

lets simplify.

what do you do w/unstable blunt trauma patient with no evidence of pelvic fracture and clearly a negative fast?

Appreciate previous posts, but I'd like some more senior answers thanks!

 

[Winged Scapula]

europeman - you might get more responses if you changed your status to accurately reflect being a resident instead of medical student.

FWIW, I find this an interesting phenomenon. Most SDN members are quick to jump up to the next level - you find Pre Meds cannot wait until they can put medical student there and they will list themselves as MS -0.5. Medical students will list themselves as PGY-0 and there is always much debate about when after the match you can list yourself as a resident.

Then you have other users who stick with the status they listed years ago and never change it. You have people claiming to be attendings but listed as medical students who then wonder why no one takes them seriously. People *do* look at the status and make snap judgements (not that's necessarily the case here europeman, but you're self-described as "senior surgery resident" so why not change it).

 

[LucidSplash]

Lowly intern here but I feel like if the blunt trauma patient is a non-responder to resus remaining hemodynamically unstable and has no other injuries (pelvis stable, no long bone fracture) I'm not that concerned with a negative FAST or even a negative CT. If the patient looks bad clinically and if their EXAM gives concern, they need exploration based on mechanism and clinical status.

Three weeks ago we had a patient who hit a semi on a motorcycle (surprisingly semi didn't move, motorcyclist was found under the semi) who was initially hypotensive but responded to resus. His FAST and CT weren't impressive for anything. But on exam he had early peritonitis. We went back to look at the scan again and talked with the radiologist and still didn't see anything. But based on his mechanism, history, and exam, he went to the OR. He had an ileal injury requiring resection and had basically degloved his sigmoid requiring a sigmoid resection. If the decision was made based on FAST and CT he would not have gone to the OR.

 

[europeman]

hi kuba.

thanks for the story. yes, peritonitis is a hard indictation for x-lap. the patient you describe, however, was stable enough to go to CT, which, even with peritonitis isn't the wrong thing to do because even though you will be taking the patient to the OR no matter what, it can sometimes help you localize what's going on and make your x-lap quicker/easier (for example, pancreatic injury), and prepare.

Anyway, the scenario I'm talking about is the UNSTABLE, blunt trauma (say MVA, that's all the info you have). patient with benign chest/belly/pelvis exam (maybe I didn't say this before?), *negative* fast, but too unstable to move to CT. Pt so hemodynamically unstable that they aren't mentating well and is getting tubed.

What do you do?

The only situation, other than obese patient or another patiet whereby a FAST is unreliable (i.e. dialysis patient, etc) where I can think of hemodynamic instability like this is from a tension pneumo or really bad renal bleeding (not seen often on FAST). Others please feel free to add in more (assuming heart looks good on fast)? I guess you could have a ruptured ventricle AND pericardium, which could be missedon fast too? anyway, say it's not a tension (good breath sounds/x-ray, whatever).... you have this patient here, sick as ****, with benign belly/pelvis exam and unstable. Are you therefore taking them to OR to explore region 1 of their retroperitoneam? What about angio instead?

If you have a GOOD negative fast, it's very unlikely they are bleeding INTRA-peritoneally to make them that unstable. I would think.

Thanks!

changing status now... 🙂

Winged Scapula, thanks... I forgo

 

[kirurg]

Sounds hemodynamically unstable to me, so I'd say ex-lap and 4-quadrant packing. If the pelvis is unstable, external compression and ex lap. I'd bypass CT and angio for now. I haven't done much trauma yet, so please correct me if I'm wrong.

I'd appreciate if someone could help me out with the thought process and what should be done in cases of blunt trauma patients who are hemodynamically unstable with, negative fast, with and without obvious pelvic fracture (either from physical exam or x-ray).

Do they 1) go for x-lap? 2) go to angio?

Let me tell u where I'm coming from. We had a guy who fell about 15 feet, had nothing but a pretty whimpy pelvic fracture on x-ray, a soft belly, and negative fast. He was pretty questionable stability wise, but somehow we got him to cat scan (dunno if this was the right thing to do in retrospect) which showed a grade 4 left kidney injury w/contrast blush. He went for emergent nephrectomy, but died on the table from exsanguination before ortho could get their external fixation finished (we were working sorta concurrently). On autopsy, he died from kidney exsanguination.... he had no bleeding related to his pelvic fracture.

---

There are some that report retroperitoneal packing for pelvic bleeding. anyone have experience w/this? I know the Denver guys have published on it a lot.

--

My *MAIN* question, though, is the patient who is unstable, blunt trauma, WITHOUT pelvic fracture.... what do you do? and with? thanks!

 

[europeman]

thanks for thought! 🙂 makes sense if pelvis stable. if patient had benign belly and negative fast WITH an unstable pelvis though, I don't see the utility of an x-lap. Rather their bleeding is presumably fromthe pelvis and therefore their pelvis should get stablized and either 1) go to angio or 2) get retro-peritoneal packing... i would think

now... in GOOD pelvis scenario, anyone else agree? xlap?

 

[SLUser11]

My *MAIN* question, though, is the patient who is unstable, blunt trauma, WITHOUT pelvic fracture.... what do you do? and with? thanks!

If the patient is unstable, and the chest/mediastinum/pelvis have been effectively ruled out as sources, then an emergent ex lap is definitely indicated. FASTs are great, but have a real false negative rate. There could always be another source: head, multiple bleeding fractures, cardiac contusion, etc...but you don't have time to wait.

There really isn't much room in the algorithm of an unstable patient for primary angiography. Really, the only unstable patient that should go to angio is someone with an unstable pelvic fracture...maybe a high grade liver lac after the OR....

For your patient, it sounds like you guys ended up in the right place, but wasted some time by going to the scanner. I am unclear why ortho was simultaneously trying to slap an ex fix on the patient's "wimpy" pelvic fracture....I hope their presence didn't contribute to your team's inability to control the kidney bleed in this unstable exsanguinating patient.

I've been lucky to never have to explore a blunt kidney injury (vast majority can be left alone), but I've always been warned of the perils of exploring the hematoma without good vascular control. How exactly did this patient exsanguinate on the table from a kidney injury? Was the renal vein avulsed?

As far as preperitoneal packing, I've read the Denver data, and it's quite compelling....they describe it for pelvic fractures (zone 3), and not for zone 2 injuries. I think their approach is still pretty unique, though, and most experts place angio higher on their algorithm.

....patient who hit a semi on a motorcycle .....initially hypotensive but responded to resus....FAST and CT weren't impressive....on exam he had early peritonitis. If the decision was made based on FAST and CT he would not have gone to the OR.

I'm not sure why you went to CT with that situation. If the patient has peritonitis, you go to the operating room. A negative CT wouldn't change that.

 

[Kuba]

As far as preperitoneal packing, I've read the Denver data, and it's quite compelling....they describe it for pelvic fractures (zone 3), and not for zone 2 injuries. I think their approach is still pretty unique, though, and most experts place angio higher on their algorithm.

Can you clear this up for me a bit. I was under the impression that PPP was mainly used for venous injuries, whereas angio was for arterial injuries. I realize that you may not be able to discern one from the other without imaging, so wouldn't the order be angio first to rule out arterial bleed, then PPP?

 

[LucidSplash]

I'm not sure why you went to CT with that situation. If the patient has peritonitis, you go to the operating room. A negative CT wouldn't change that.

I specified early peritonitis - initially, his abdominal exam was not consistent and was not, uh, free of recreational substances.

 

[SLUser11]

Can you clear this up for me a bit. I was under the impression that PPP was mainly used for venous injuries, whereas angio was for arterial injuries. I realize that you may not be able to discern one from the other without imaging, so wouldn't the order be angio first to rule out arterial bleed, then PPP?

I think the classification of the pelvic fracture can give you an educated guess as to what's bleeding, but my point was that the Denver group has an unconventional approach but great outcomes.

I'm at home, so I can't pull it up, but they just had an article in JACS from the Southern Surgical Association meeting. The article is definitely worth a look, as is the invited commentary that follows.

I specified early peritonitis - initially, his abdominal exam was not consistent and was not, uh, free of recreational substances.

Is there any other kind when you're seeing a patient in the trauma bay immediately after the injury? So did the patient's exam (or level of sobriety) change significantly in the 30 minutes between your primary survey and your decision to operate? Did the CT findings change your decision at all?

Anyway, I'm just giving you a hard time and playing a little Devil's Advocate...I order CTs all the time that I don't necessarily need.

 

[europeman]

SLUser11: Yes I *totally* agree we wasted time going to the scanner. Was *TOTALLY in appropriate. let me tell you what *REALLY* happened. The guy had a negative fast, an, on exam actually an IMPRESSIVE (not whimpy) pelvis fracture.... however, IR was not in house and the scanner is right next door (literally) to their angio suite so they begged us for a scan while they were on their way in. Fine. Unstable guy... minus will scan him while we are waiting for IR anyway, right? well... CT showed impressive blush from left kidney and extensive hematoma from that, though intra-peritoneally he was fine. So, decision at that point was to just take him to OR 'cuz IR still wasn't there (maybe they could have embolized it, I dunno). In the OR, after opening up retroperitoneum to get to kindey, he just continued to bleed so much that by the time vascular control was obtained it was too late. Blood was everywhere. We didn't know for sure, however, if this was his only bleeding source as it appeared the pelvis had its own independent oozing. THat said, on autopsy, his pelvis didn't have any vascular compromise and ultimately was not any source of his bleeding (which is why I said "whimpy pelvic fracture" looking back w/20-20 vision). In fact, it wasn't a whimpy fracture at all). I just said so for the purpose of my question. Thanks for being so detail oriented though.


I'm off in a third world country right now w/o access to my normal material, but, my recollection is that the Denver guys/gals retroperitoneal pack the pelvis BEFORE angio, the thought being that MOST people that die from pelvic exsanguination die from VENOUS and NOT arterial bleeding - hence to them, it doesn't make sense to go to angio first. Rather, they go to angio second IF packing doesn't work.

Regarding the patient with peritonitis, yeah, I agree, CT not *needed*, but if the patient stable, and you can get it done expeditiously, I've it is often helpful in planning your operation, equipment, etc (especially in middle of night). but, eh, that's the weak argument of someone being trained in NYC in the 21st century... I know the old guys would roll in their graves if they heard that! 🙂

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So I guess consensus is that blunt trauma patient WIT NEGATIVE FAST and NO source of hemodynamic instability goes to OR for x-lap, whereas the same patient with a pelvic fracture which thought clinically could be the etiology of his bleeding would INSTEAD (at most institutions) go to angio first? right? everyone else agree?

 

[LucidSplash]

Anyway, I'm just giving you a hard time and playing a little Devil's Advocate...I order CTs all the time that I don't necessarily need.

I know, I see it. Its reminiscent of discussing cases with one of my senior residents - appropriate as you are a chief and I am an intern. I'm not shy about engaging in such situations IRL either.

Is there any other kind when you're seeing a patient in the trauma bay immediately after the injury? So did the patient's exam (or level of sobriety) change significantly in the 30 minutes between your primary survey and your decision to operate? Did the CT findings change your decision at all?

Well you're assuming that the patient was in our bay immediately after an injury. But no, there isn't - but of course I'd be interested to know if I'm the only one who's evaluated a trauma patient (or any patient) who's initial exam isn't a binary choice between "peritonitis" and "not peritonitis." On serial exam, we became convinced his pain out of proportion was real despite no real involuntary guarding and his requests for "the medicine that starts with a D."

I'm curious though. Where I am, based on our trauma protocols, someone with his mechanism gets a CT of the head, neck, and TAP if he's hemodynamically stable, if the exam is benign or equivocal. It was the same where I was as a student. Rather than considering this a CT that we "didn't need," I think this is appropriate in a trauma population patient based on mechanism (high speed MCC) and unreliable exam due to sobriety. Sincerely, is this different from what other Level I centers are doing? I know out west one of the big centers is going back to more serial exams without scanning (experimentally with basically a room with patients needing serial exams manned by a junior resident) but at MOST places, you would have considered not scanning such a patient?

 

[europeman]

sounds like the decision to take your guy to the OR was AFTER the negative CT and not before, based on an evolving exam - which is fine.

Now, if the exam was such that the decision to take him to the OR from the get-go, then the CT would not be necessary, and certainly no one would fault you for NOT doing it. However, realistically, if it doesn't significantly delay your OR, no one would fault you for getting a pre-op CT anyway for the reasons I described earlier.

If it was me, personally, I would get the CT.

 

[Buzz Me]

FASTs are great, but have a real false negative rate.

Remember they're just supposed to look for intraperitoneal bleeding - not great for retroperitoneal blood. And of course a positive FAST doesn't always mean "head to the OR" unless the patient is unstable.

 

[dpmd]

In a patient with blunt trauma who is "unstable" but have a negative fast and a benign belly exam I would probably try a little harder to stabilize them rather than just rushing to the OR just because I would be worried about retroperitoneal stuff which might have other viable treatments if you can get them stabilized. Add in multiple extremitiy fractures (open or closed) which can be contributing to the blood loss which made them unstable in the first place, and it can get tricky.

I put unstable in quotes because I think that there are varying degrees of instability. Someone with 160 HR and SBP of 40 is different than someone with a HR 120 and SBP 80. Then you have to consider whether they are responding appropriately to your resuscitation (although beware the transient responder).

It would be nice to get the patient tubed, get some products in them and get them stabilized so they can get angio-embo of their renal lac. Remember though, angio takes time (especially for less skilled IR folks). A truly unstable patient needs something more rapid. That will usually mean the OR, but the important thing is that you help the patient instead of hurt them. Opening up the hematoma without a good plan for rapid proximal and distal control is a sure way to kill a patient. If the guy was ok enough to get a CT scan (even if only marginal), perhaps massive transfusion plus or minus things like tranexamic acid or factor VIIa would have kept him ok enough to get angioembolized.

Not sure why ortho was fiddling with an ex fix while you are trying to lap the guy since you knew from the scan that the pelvis wasn't the problem. Even if the fracture was gnarly, with the CT not showing extravasation down there I would have made them wait until later. Also if the guy dies before they even had it on it makes me wonder if he was ever salvageable. An ex fix should take less than 15 min. If the guy died 15 min into his operation maybe he was too far gone to begin with (you can debate whether the delay for the scan also contributed, although how much time did that actually take-10 min?)