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Penetrating pelvic trauma: Initial assessment and surgical management in emergency
E Hornez1, T Monchal2, G Boddaert3
1Service de Chirurgie Viscérale, Hôpital d'Instruction des Armées Percy, 101, avenue Henri-Barbusse, 92140 Clamart, France.
Insights
Penetrating pelvic trauma (PPT) requires immediate hemostasis, especially in unstable patients. Management involves damage control principles for vascular, digestive, and urinary systems to minimize infection and fistula risks.
Area of Science:
- Trauma Surgery
- Emergency Medicine
- Surgical Critical Care
Background:
- Penetrating pelvic trauma (PPT) involves wounds within the pelvic bone, potentially damaging vital vascular, intestinal, or urinary organs.
- PPT presents significant risks of initial hemorrhage and subsequent infection.
- Urgent hemostasis is critical for hemodynamically unstable patients in hemorrhagic shock.
Purpose of the Study:
- To outline the urgent management strategies for penetrating pelvic trauma.
- To describe the diagnostic and surgical approaches based on patient hemodynamic stability.
- To emphasize the application of damage control principles in managing PPT.
Main Methods:
- For unstable patients: immediate hemostasis via intra-aortic balloon occlusion and/or pelvic packing, followed by damage control resuscitation and potential arteriography or laparotomy.
- For stable patients: systematic contrast-enhanced CT for lesion assessment before surgical intervention.
- Surgical management emphasizes damage control principles for all affected systems (digestive, vascular, urinary, bone), including exteriorization of channels, revascularization, and wide drainage.
Main Results:
- Initial management focuses on rapid hemostasis through non-operative or operative interventions.
- Hemodynamic status dictates the sequence of diagnostic and therapeutic interventions.
- Damage control surgery aims to stabilize the patient and prepare for definitive treatment, addressing associated injuries to prevent complications.
Conclusions:
- Effective management of PPT hinges on prompt hemorrhage control and adherence to damage control resuscitation and surgical principles.
- Systematic assessment and staged surgical intervention are crucial for improving outcomes.
- Addressing associated injuries during surgery is vital to reduce the incidence of postoperative sepsis and fistula formation.
Abstract:
Penetrating pelvic trauma (PPT) is defined as a wound extending within the bony confines of the pelvis to involve the vascular, intestinal or urinary pelvic organs. The gravity of PPT is related to initial hemorrhage and the high risk of late infection. If the patient is hemodynamically unstable and in hemorrhagic shock, the urgent treatment goal is rapid achievement of hemostasis. Initial strategy relies on insertion of an intra-aortic occlusion balloon and/or extraperitoneal pelvic packing, performed while damage control resuscitation is ongoing before proceeding to arteriography. If hemodynamic instability persists, a laparotomy for hemostasis is performed without delay. In a hemodynamically stable patient, contrast-enhanced CT is systematically performed to obtain a comprehensive assessment of the lesions prior to surgery. At surgery, damage control principles should be applied to all involved systems (digestive, vascular, urinary and bone), with exteriorization of digestive and urinary channels, arterial revascularization, and wide drainage of peri-rectal and pelvic soft tissues. When immediate definitive surgery is performed, management must address the frequent associated lesions in order to reduce the risk of postoperative sepsis and fistula.