Early management of severe pelvic injury: French Guidelines

French Guidelines for Early management of severe pelvic injury have been released. A consensus committee of 22 experts from various French Societies has released French guidelines for Early management of severe pelvic injury(in first 24 hours).

Pelvic fractures are observed in 10% of severe trauma patients admitted to level 1 trauma centres. Pre-hospital and hospital management of severe pelvic trauma requires clear organisational and therapeutic strategies in order to control haemorrhage as rapidly as possible.

Prehospital management is a critical link within a trauma network and the trauma centres/teams. Every step of patient management must be carefully thought out and focused on haemorrhage control. Establishing these guidelines is necessary to provide clear strategies to all healthcare professionals involved in the management of patients with severe pelvic trauma.

Following are the major recommendations:

• A spontaneous pelvic pain must be assessed in conscious trauma patients in order to diagnose a pelvic fracture. We recommend all trauma patients with shock or altered consciousness be systematically considered as having pelvic trauma. (Grade 1+) Strong agreement


• We suggest the open pelvic injury, associated major injury or major bleeding, be considered at risk of severe pelvic trauma. (Grade 2+) Strong agreement


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  We recommend external pelvic compression be applied as soon as possible in all patients with suspected severe pelvic trauma. (Grade 1+) Strong agreement

  
  


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  We suggest that pelvic binders, regardless of type (except sheet wrapping), be used to apply external pelvic compression. In order to be efficient (compared to surgical C-clamp compression), pelvic binders must be placed around the great trochanters. (Grade 2+) Strong agreement

  
  


• All patients with severe pelvic trauma could be initially transported to a referral centre fully staffed and equipped to treat any aspect of trauma (“trauma centre”). (Grade 1+) Strong agreement


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  We suggest getting a pelvic X-ray upon arrival to the trauma centre for patients who are haemodynamically unstable patients and/or require urgent intervention(s) to stabilise vital signs. (Grade 2+) Strong agreement

  
  


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  We do not suggest a pelvic X-ray upon arrival to the trauma centre for haemodynamically stable patients. A body (including pelvic) CT-scan with intravenous contrast should be performed. (GRADE 2-) Strong agreement

  
  


• We suggest an E-FAST be performed in all patients with suspected severe trauma including patients with suspected severe pelvic trauma. (Grade 2+) Strong agreement


• We recommend performing a thoraco-abdomino-pelvic CT-scan with contrast before angiographic embolization in patients with severe pelvic trauma when allowed by the patient's haemodynamic status. (Grade 1+) Strong agreement


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  We do not suggest systematically performing specific imaging workup for lower urinary tract injury (urethral and/or bladder opacification) in severe pelvic trauma patients. (Grade 2−) Strong agreement

  
  


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  We suggest performing a retrograde urethral and bladder opacification, ideally with a CT-scan in severe pelvic trauma patients with clinical symptoms of lower urinary tract injury (inability to urinate, gross haematuria, blood at the meatus, suprapubic tenderness and suprapubic penetrating wounds), particularly before attempting urinary catheterization in men. (Grade 2+) Strong agreement

  
  


• According to the Young-Burgess or Tile classifications, unstable pelvic fracture, particularly « open book » fractures and pelvic ring disruptions with posterior fractures or active extravasation of contrast agent during the arterial phase of the CT-scan or angiography, should probably be considered at radio-anatomical criteria of severe pelvic trauma. (Grade 2+) Strong agreement


• We recommend bleeding control procedures be performed as soon as possible in actively bleeding severe pelvic trauma. In the setting of severe pelvic trauma, bleeding control procedures may be angiographic embolization or surgical pelvic pre-peritoneal packing by a trained proficient team. (Grade 1+) Strong agreement


• We recommend that the time between admission to the hospital and bleeding control procedures, regardless of type, should not exceed 60 minutes. (Grade 1+) Strong agreement


• We recommend that a non-selective embolization through the common femoral artery be performed in unstable patients, stable patients who present multiple active bleeding targets on CT-scan and/or when attempted selective embolization fails. (Grade 1+) Strong agreement


• We suggest not performing a secondary systematic angiographic verification in severe pelvic trauma patients having undergone initial angiographic embolization. (Grade 2-) Strong agreement


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  We suggest performing a surgical pre-peritoneal pelvic packing in association with an external fixation in the case of haemodynamic instability when impossible to:

  
  

• Transfer the patient to the CT-scan or/and for embolization


• Perform an embolization in less than 60 minutes once the diagnosis has been made.


• (Grade 2+) Strong agreement

• We recommend performing an early external fixation of the pelvis in patients with a severe pelvic trauma with haemodynamic instability to limit the expansion of the pelvic haematoma. External fixation can be performed by a Ganz clamp or an anterior pelvic external fixator. (Grade 1+) Strong agreement


• We recommend using the Ganz clamp for Tile C fractures essentially, after a heavy traction of the ascended lower limb (15% of the patient's weight). Trained operators can set it up in the emergency room. (Grade 1+) Strong agreement


• We recommend using an external fixator for pelvic stabilisation of Tile C fractures and to reduce the ring disruption in Tile B1 and B3 fractures. It must be placed anteriorly and inferiorly in order to be able to perform a laparotomy. (Grade 1+) Strong agreement


• We suggest taking care of severe open pelvic trauma in referral centres because open pelvic lesions are rare, their management is complex and demands a multidisciplinary approach. (Grade 2+) Strong agreement


• We recommend considering the bleeding control and the perineal contamination as primary objectives in the management of severe open pelvic trauma. (Grade 1+) Strong agreement

For more details click on the link: https://doi.org/10.1016/j.accpm.2018.12.003