Pelvic fracture management Guideline 2024
**Discussion between Two Professionals on Pelvic Fracture Guidelines**
**Dr. A:** "The guidelines for managing pelvic fractures are critical, especially in trauma systems with defined referral pathways. These fractures, especially those involving the pelvic ring, can lead to significant complications like hemorrhage and urological injuries, so we need to ensure these patients are handled by multidisciplinary teams at Major Trauma Centres."
**Dr. B:** "Absolutely. The complexity of pelvic fractures, especially when associated with haemodynamic instability, means time is of the essence. For instance, applying a pelvic binder in the correct position immediately—preferably in the prehospital setting—is an essential first step when active bleeding is suspected."
**Dr. A:** "Right, and it’s equally important that patients with suspected pelvic fractures and signs of haemodynamic instability be transported directly to Major Trauma Centres. If they arrive at a trauma unit, resuscitation should begin immediately, but they should be transferred as soon as possible for definitive treatment. These centres must be equipped with clear protocols for managing active pelvic bleeding, whether it's through surgical packing or interventional radiology."
**Dr. B:** "I agree. I also want to emphasize the importance of administering IV Tranexamic Acid early—ideally within an hour. It's a standard now for trauma patients, especially those with pelvic fractures. Alongside resuscitation with blood products, adhering to the Massive Transfusion Protocols can make a difference in outcomes."
**Dr. A:** "Absolutely, and the initial imaging, like a CT scan with IV contrast from head to toe, is vital. It's not just about diagnosing the pelvic injury; it also helps assess for other high-energy trauma injuries. And, for those undergoing damage control laparotomy, pelvic imaging before surgery is non-negotiable."
**Dr. B:** "True. Pelvic binders should stay in place during surgery, and only be removed once the patient is haemodynamically stable. The post-binder X-ray is a necessary step after resuscitation, even if the initial CT scan was negative. We can’t forget that a well-applied binder may mask a catastrophic injury."
**Dr. A:** "This highlights the importance of having a clear network protocol for binder removal. Ideally, it should happen within 24 hours of injury. And in cases where definitive surgery can’t happen early, temporary mechanical stabilization, like external fixation, should be considered."
**Dr. B:** "Good point. And let’s not overlook vertical shear fractures. Traction should be used as a temporary solution when early surgery isn’t possible. Similarly, potential bladder or urethral injuries must be managed carefully in line with BOAST guidelines for urological trauma."
**Dr. A:** "Indeed. For open pelvic fractures, collaboration with a consultant general or colorectal surgeon is essential, especially for wound debridement and assessing for stoma formation. The risks and timing of creating a defunctioning stoma need careful consideration."
**Dr. B:** "Yes, it’s a complex decision. The guidelines stress that each case should be evaluated individually, and a stoma should not be formed hastily during damage control laparotomy unless absolutely necessary. When performed, ensuring the stoma is placed away from potential pelvic fixation sites is key."
**Dr. A:** "Exactly. Timely reconstruction of the pelvic ring is another crucial point. Ideally, this should happen within 72 hours of the patient being physiologically stabilized, assuming no other injuries prevent it. Delay in this can affect long-term outcomes, especially in fragility fractures where early mobilization is key."
**Dr. B:** "Yes, and we also need to follow standardized protocols for thromboprophylaxis and post-discharge care. This includes thorough follow-up to manage common adverse outcomes like pain, psychological distress, and urological issues. Sexual dysfunction is often overlooked, but providing clear written advice for sexually active patients is an important part of their recovery."
**Dr. A:** "I couldn’t agree more. Finally, documenting outcomes in national databases like TARN and monitoring performance against standards is vital for improving care. Continuous auditing helps identify gaps and improve trauma care pathways."
**Dr. B:** "Exactly. Consistent follow-up and outcome tracking ensure we can improve patient outcomes and maintain best practices."
Reference
https://www.boa.ac.uk/resource/boast-3-pdf.html
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