Category Archives: Procedures

Efficacy Of Preperitoneal Packing For Pelvic Fractures

September 2, 2016 The Trauma Pro Leave a comment

A multi-center trial published in 2015 showed an astounding 32% mortality rate for patients with shock from pelvic fracture. And as I continue to preach, going any place but the OR is dangerous for the patient. Unfortunately, it’s generally not feasible to operatively fix the pelvis acutely, and external fixation has limited impact on ongoing hemorrhage.

If the patient can be stabilized to some degree, interventional radiology can be very helpful. Unfortunately, access after hours involves some degree of time delay. Ideally, the team arrives in 30 minutes or less. But the patient may not be ready, so time to procedure may increase significantly.

So preperitoneal packing of the pelvis (PPP) has now become popular. Years ago, we tried to pack the pelvis from the inside (peritoneal cavity), but it never worked very well. You can push sponges deep into the pelvis as firmly as you want, but the intestines will not keep them from expanding back out of the pelvis.

PPP entails making a lower midline incision, but not entering the peritoneal cavity. A hand is then slid along the anterior surface of the peritoneum around the inside of the iliac wing. Sponges can then be pushed around toward the sacrum, applying direct pressure over bleeding fracture sites and the overlying tissues.

preperitoneal-packing

Image courtesy of ACSSurgery.com

But does it work? Denver Health performed an 11 year retrospective review of their experience with 2293 patients with pelvic fractures. They looked at time to intervention, blood product usage, and mortality.

Here are the factoids:

A total of 128 patients underwent PPP
Most were younger (mean age 43) and badly injured (mean ISS 48)
Median time from door to OR was 44 minutes
Patients received an average of 8 units of RBCs intraop, and an additional 3 units in the ensuing 24 hours
Overall mortality was 21% (27 of 128), but 9 (7%) were due to severe head injury

Bottom line: Compared to other published studies, time to “definitive management” with PPP was very short. Blood usage also dropped quickly after the procedure. Mortality seems to be much better than expected at about 13%. These results suggest that if you have to wait for angio, or your patient is too unstable to go there, run to the OR first to do some PPP.

And don’t forget these other important management tips:

If you see any posterior pelvic fracture on the initial pelvic x-ray, call for blood
If the blood pressure softens at any point activate your massive transfusion protocol
Apply a binder, especially for open book type fractures
Always get a CT in stable patients to help your orthopedic surgeons plan, and to identify contrast blushes
If the patient has to go to OR first to stabilize them, consider angio afterwards. You’ll probably find something they can fix.
Think about using your hybrid OR!

Reference: Preperitoneal pelvic packing reduces mortality in patients with life-threatening hemorrhage due to unstable pelvic fractures. AAST 2016, Paper 32.

Procedures

Once Again: Leg Fasciotomy With Less Than Two Incisions

June 24, 2016 The Trauma Pro Leave a comment

It seems like this topic keeps on coming up! This is the second article I’ve seen this year that describes a variation on the single-incision leg fasciotomy. In the classic two-incision approach, the lateral incision gives access to the anterior and lateral compartments, and the medial incision to the posterior and deep posterior. See below.

The more “standard” single-incision approaches either go through (i.e. removes part of) or around, the fibula. In the diagram below, the arrows point to the access points into the anterior, lateral, posterior and deep posterior from top to bottom.

In the “new” variation described, the authors slide along the lateral edge of the tibia to get to the deep posterior compartment.

This approach requires stripping the tibialis

anterior muscle away from the tibia, which some orthopods may argue interferes with healing. And, as with the other single-incision technique, the procedure may take additional time.

Bottom line: I’m still not a big fan of single-incision fasciotomy. My main reason is that most surgeons are not as familiar with the technique. And patients who have a potentially limb threatening process are not the best to learn on. I have seen too many incomplete fasciotomies with persistent compartment syndrome in my career.

So unless you are being mentored by someone who is well versed in the technique, use the two incision technique and use a cadaver to practice your single incision operation.

Reference: A Single-Incision Fasciotomy for Compartment Syndrome
of the Lower Leg. J Ortho Surg 30(7):e252-e255, 2016.

Procedures

REBOA: The References

June 10, 2016 The Trauma Pro Leave a comment

Here are a few references for some of the significant work on REBOA. Be aware that new research is now being published every month! Good luck keeping up!

References:

1. Resuscitative endovascular balloon occlusion of the aorta (REBOA) as an adjunct for hemorrhagic shock. J Trauma 71(6):1869-1872, 2011.

2. A novel fluoroscopy-free, resuscitative endovascular aortic balloon occlusion system in a model of hemorrhagic shock. J Trauma 75(1):122-128, 2013.

3. Survival of severe blunt trauma patients treated with resuscitative endovascular balloon occlusion of the aorta compared with propensity score-adjusted untreated patients. J Trauma 78(4):721-728, 2015.

4. Evaluation of the safety and feasibility of resuscitative endovascular balloon occlusion of the aorta. J Trauma 78(5):897-023, 2015.

5. The role of REBOA in the control of exsanguinating torso hemorrhage. J Trauma 78(5):1054-1058, 2015.

6. Resuscitative endovascular balloon occlusion of the aorta. Resuscitation 96:275-279, 2015.

Direct links to the REBOA series:

Procedures

REBOA Part 5: The Real Bottom Line

June 9, 2016 The Trauma Pro Leave a comment

We are now entering the “golden age” of REBOA. A number of small, single-institution studies are beginning to appear, most of which tout reasonably positive results. And enough articles are now available to even support a few authors seeking to publish review articles.

Yes, REBOA shows a great deal of promise. But there are a lot of details yet to be worked out. Here are some of the items on the REBOA “questions to answer” list:

What are the best indications (and contraindications) when considering this highly invasive technique? You will notice that I only listed general indications here. There is some agreement at the major REBOA centers in the US, but there are a lot of differences of opinion as well.
What kind of training is required to assure competence with this technique?
What kind of experience, supervision, performance standards should be required for credentialing?
What about the anatomic, physiologic, and metabolic complications of this technique?
How long can the catheter be left in place?
What kind of monitoring is required to assure limb and overall patient safety?
What about the inevitable technical improvements that are ongoing? In only a few years we have moved from 12 Fr catheters to 7 Fr. From guidewire systems to wireless ones. Expect numerous advancements that will reduce complications and improve survival.

Bottom line: This is a very exciting new technique. But we are still very early in the REBOA life cycle. Everybody wants to be doing the next great thing, but be careful! We are still working with a huge knowledge deficit, and additional published work is essential. If you are working outside of an established REBOA center, I highly recommend you do two things. First, get some training for this complicated technique (see page 1). And don’t let your experience go to waste. Design or join a good study that will contribute to the global knowledge base on REBOA.

Tomorrow: References (if you want to look this stuff up)

Direct links to the REBOA series:

Procedures

REBOA Part 4: What Are The Results?

June 8, 2016 The Trauma Pro Leave a comment

The first modern paper published on REBOA for trauma in 2011 was really a description of the technique using the catheters available “back in the day” (only 5 years ago!). There were six papers published in 2012 through 2015 which I term the years of the pig, as we sought to figure out if this was really something we could and should do in people. The answer in all six was a resounding yes.

Next, a Japanese group published a retrospective database review of 45,153 humans, of whom 452 patients underwent REBOA placement. REBOA has been in use in Japan for a number of years. It is typically placed by emergency physicians, for whom it is a competency requirement for board certification. Raw mortality numbers were worse (76% with REBOA vs 16% without). This poor result persisted even when the patients were matched for their ISS difference (35 with REBOA vs 13 without).

This was troubling, but it was a registry study and questions also arose regarding experience levels of the clinicians. Major trauma is a less frequent event in Japan, and trauma surgeons do not typically take in-house call, which may have resulted in delays to definitive control of hemorrhage.

Another Japanese study published last year was a single center review of 24 insertions over a 7-year period. REBOA survival was 29% vs a TRISS probability of survival rate of only 13%. Better news! However, temper this with one vascular injury and two ischemic limbs, all of which required amputation.

And now, more human studies are beginning to trickle down into the journals, with promising results.

Tomorrow: The real bottom line.

Direct links to the REBOA series:

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