SESAP Critique
==============


**Category 6, Items 36 and 37**

Pelvic fractures are common after high-speed motor vehicle crashes. Successful treatment requires rapid resuscitation from hemorrhagic shock, identification of associated injuries, and bony stabilization to reduce long-term disability.

Based on the extent of injuries, celiotomy is necessary. In the case described, the laceration of the perineum is diagnostic of an open fracture and extends into the rectum. To prevent continued fecal contamination of the pelvic spaces and hematoma, a diverting colostomy with distal colon washout is indicated. Debridement, irrigation, and cleansing of the contaminated area are warranted, and packing of the area may be needed to control bleeding. External pelvic fixation closes the pelvic space and is effective in control of bleeding in most cases. Continued pelvic bleeding is a life-threatening problem, but operative ligation of the hypogastric vessels in an attempt to decrease pelvic bleeding is not useful because of extensive collateral flow, and because most bleeding originates from the fracture sites. Operative ligation of these vessels would require opening the contained pelvic hematoma, leading to further hemorrhage.

![Figure1](http://canjsurg.ca/https://www.canjsurg.ca/content/cjs/44/4/257/F1.medium.gif)

[Figure1](http://canjsurg.ca/content/44/4/257/F1)

After external pelvic fixation and in the absence of another obvious source for bleeding, continued hypotension and transfusions are indicative of pelvic vascular injury. Angiography is indicated to locate and embolize the source of the bleeding (see angiogram). This usually stabilizes the patient, assuming all other sources of bleeding have been addressed. A repeat CT scan will not localize the site of injury and celiotomy with pelvic packing is not effective in controlling arterial bleeding. Application of a pneumatic antishock garment (PASG) is not indicated because it severely limits patient access, at times results in extremity ischemia from compartment syndrome, and is not effective in controlling arterial bleeding. Diuretic therapy is not indicated for hemorrhagic shock.

## References

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2.  Flint L, Babikian G, Anders M, et al: Definitive control of mortality from severe pelvic fracture. Ann Surg 211:703–711, 1990
    
    [CrossRef](http://canjsurg.ca/lookup/external-ref?access_num=10.1097/00000658-199006000-00008&link_type=DOI) 
    
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3.  Richardson JD, Harty J, Amin M, Flint LM: Open pelvic fractures. J Trauma 22:533–538, 1982
    
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4.  Trafton PG: Pelvic ring injuries. Surg Clin North Am 70:655–669, 1990
    
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