18 CRITICALCARENURSE Vol 24, No. 2, APRIL 2004 Michael Frakes is a senior flight nurse with LIFE STAR at Hartford Hospital in Hartford, Conn. Tracy Evans is the trauma program manager and director of emergency medical services at Norwalk Hospital in Norwalk, Conn. T he spectrum of patients with pelvic fractures ranges from patients with isolated, simple fractures to critically injured patients with multi- ple other life-threatening injuries. Critical care nurses care for patients with major pelvic fractures in many settings, including transport, trauma resuscitation bays, perioperative areas, and intensive care units. Accordingly, they need to understand the issues involved in providing that care. In this article, we survey the current information on pelvic fractures, including epidemiology, anatomy, assessment of patients, hemorrhage, management, and associated injuries. Epidemiology Motor vehicle crashes, including motor vehicles crashing into pedes- trians, cause about 60% of pelvic fractures. Most of the remainder result from falls. 1-8 Frequency of frac- ture is highest for occupants of sub- compact or compact automobiles and for occupants of any vehicle struck on the side. 9 Pelvic fracture generally con- tributes to traumatic death but is not the primary cause. 2 For patients with pelvic fractures who die, hypotension at the time of admission is associated with increased mortality (42% vs 3.4% for patients with stable vital signs), as are head injuries requiring neuro- surgery (50% mortality); abdominal injuries requiring laparotomy (52% mortality); and concomitant thoracic, urological, or skeletal injuries (22% mortality). 5,7,10-13 Survival is worse for patients with open pelvic fractures and for pedestrians struck by cars. 5,7,12,13 Pelvic fractures are less common and less lethal in children than in adults. 14 Anatomy The pelvis protects the viscera, transmits weight from the trunk to the lower limbs, and has attachment points for muscles. The abilities to stand and to bear weight require sta- bility of the pelvic ring, made of the sacrum and aspects of the paired innominate bones. The innominate bones are formed bilaterally by the ilium, the ischium, and the pubis 7,8 (Figures 1 and 2). These bones are inherently unstable and gain stabil- ity only with ligamentous support, CoverArticle Authors Michael A. Frakes, RN, BSN, CFRN, CCRN, EMTP Tracy Evans, RN, MSN, MPH, ACNP, CEN, CCRN, EMTP To purchase reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 809-2273 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, [email protected]. CE Continuing Education CE This article has been designated for CE credit. A closed-book, multiple-choice examination follows this article, which tests your knowledge of the following objectives: 1. Discuss factors related to the anatomy of the pelvis that impact injuries in major pelvic fractures 2. Identify important aspects of the physical assessment examination for fracture and associated injuries 3. Distinguish fracture types and classifications 4. Describe nursing care considerations in the management of patients with major pelvic fractures Major Pelvic Fractures by AACN on March 7, 2019 http://ccn.aacnjournals.org/ Downloaded from
Transcript
18 CRITICALCARENURSE Vol 24, No. 2, APRIL 2004
Michael Frakes is a senior flight nursewith LIFE STAR at Hartford Hospitalin Hartford, Conn.
Tracy Evans is the trauma programmanager and director of emergencymedical services at Norwalk Hospital inNorwalk, Conn.
The spectrum of patients withpelvic fractures ranges from patientswith isolated, simple fractures tocritically injured patients with multi-ple other life-threatening injuries.Critical care nurses care for patientswith major pelvic fractures in manysettings, including transport, traumaresuscitation bays, perioperative areas,and intensive care units. Accordingly,they need to understand the issuesinvolved in providing that care. Inthis article, we survey the currentinformation on pelvic fractures,including epidemiology, anatomy,assessment of patients, hemorrhage,management, and associated injuries.
EpidemiologyMotor vehicle crashes, including
motor vehicles crashing into pedes-trians, cause about 60% of pelvicfractures. Most of the remainderresult from falls.1-8 Frequency of frac-ture is highest for occupants of sub-compact or compact automobilesand for occupants of any vehiclestruck on the side.9
Pelvic fracture generally con-tributes to traumatic death but is not
the primary cause.2 For patients withpelvic fractures who die, hypotensionat the time of admission is associatedwith increased mortality (42% vs 3.4%for patients with stable vital signs), asare head injuries requiring neuro-surgery (50% mortality); abdominalinjuries requiring laparotomy (52%mortality); and concomitant thoracic,urological, or skeletal injuries (22%mortality).5,7,10-13 Survival is worse forpatients with open pelvic fractures andfor pedestrians struck by cars.5,7,12,13
Pelvic fractures are less common andless lethal in children than in adults.14
AnatomyThe pelvis protects the viscera,
transmits weight from the trunk tothe lower limbs, and has attachmentpoints for muscles. The abilities tostand and to bear weight require sta-bility of the pelvic ring, made of thesacrum and aspects of the pairedinnominate bones. The innominatebones are formed bilaterally by theilium, the ischium, and the pubis7,8
(Figures 1 and 2). These bones areinherently unstable and gain stabil-ity only with ligamentous support,
CoverArticle
Authors
Michael A. Frakes, RN, BSN, CFRN, CCRN, EMTPTracy Evans, RN, MSN, MPH, ACNP, CEN, CCRN, EMTP
To purchase reprints, contact The InnoVision Group,101 Columbia, Aliso Viejo, CA 92656. Phone, (800)809-2273 or (949) 362-2050 (ext 532); fax, (949)362-2049; e-mail, [email protected].
CEContinuing Education
CE This article has been designated for CEcredit. A closed-book, multiple-choice examinationfollows this article, which tests your knowledge ofthe following objectives:
1. Discuss factors related to the anatomy of the pelvis that impact injuries in major pelvic fractures
2. Identify important aspects of the physical assessment examination for fracture and associated injuries
3. Distinguish fracture types and classifications
4. Describe nursing care considerations in the management of patients with major pelvic fractures
Major Pelvic Fractures
by AACN on March 7, 2019http://ccn.aacnjournals.org/Downloaded from
especially around the sacroil-iac joint posteriorly. Figure 3depicts the ligamentous net-work. The junction of theilium, ischium, and pubisforms the acetabulum, theconcave socket for the femoralhead, and the anterior aspectsof the innominate bones joinwith a cartilaginous disk toform the pubic symphysis.The pubic symphysis isimportant for pelvic support,but disruption of the symph-ysis by itself does not makethe pelvis unstable.7,15,16
A stable pelvis can withstandnormal vertical and rotational physi-ological forces, but either fractures orligamentous injuries can disruptpelvic stability. Disruption of theanterior pelvic ligaments createsrotational instability, whereas poste-rior ligamentous injury creates bothrotational and vertical instability.17
Pelvic blood supply comes prima-rily from the iliac and hypogastricarteries, which run at the level of thesacroiliac joints. Those arteries are
CRITICALCARENURSE Vol 24, No. 2, APRIL 2004 19
Figure 1 Bony anatomy of the pelvis.Copyright-protected material used with the permission of the authors and theUniversity of Iowa’s Virtual Hospital, www.vh.org.
Sacro-Iliac jointSacrum
Coccyx
Acetabulum
Ischial tuberosity
Pubic Symphysis
Inferior PubicRamus
Superior PubicRamus
Ilium
Figure 2 Radiographic anatomy of the pelvis.Copyright-protected material used with the permission of the authors and theUniversity of Iowa’s Virtual Hospital, www.vh.org.
supplemented by a rich associatednetwork, including the superiorgluteal artery, which is susceptible toinjury in posterior fractures, and theobturator and internal pudendalarteries, which can be injured infractures of the ramus8 (Figure 4).
Assessment for Fracture and Associated Injuries Physical Examination
Pelvic fractures can be accuratelydiagnosed through physical exami-
nation, but a high index ofsuspicion for a fracture basedon the mechanism of injury isessential.18 Examinationbegins with inspection forabrasions and contusions,symmetry, isolated rotation ofa lower extremity, and dis-crepancy in limb length. Dis-crepancy in limb length maybe due to a hip injury, afemoral injury, or a verticallyunstable pelvic injury.7 Arotated iliac crest indicates aserious fracture.8 Rotationalstability is evaluated by palpat-
ing for tenderness and crepitus withinward and posterior compressionof the iliac crests and with posteriorcompression of the pubic symph-ysis.17 Rocking the pelvis is inappro-priate, and care must be taken toavoid displacing a fracture or dis-rupting a pelvic hematoma duringthe examination. If no fracture of alower extremity has occurred, verti-cal stability is assessed by longitudi-nal manual traction on the lowerextremities.7 Tenderness over the
Figure 3 Ligamentous anatomy of the pelvis.Copyrighted image courtesy of Wesley Norman, MD, GeorgetownUniversity, Washington, DC. Reprinted with permission.
Iliolumbar ligament
Obturatorforamen
Sacrotuberousligament
Sacrospinousligament
Posteriorsacral
ligiment
Greatersciatic
foramen
Lessersciatic
formane
by AACN on March 7, 2019http://ccn.aacnjournals.org/Downloaded from
trochanter indicates acetabular orfemoral head injury. Any skin defectover the pelvis should be investi-gated as a possible open fracture.7,8
Genitourinary injuries compli-cate up to one quarter of pelvic frac-tures, particularly those fractureswith genitourinary injury at or nearthe pubic symphysis.19 Up to 6% ofwomen and 11% of men who havepelvic fractures have urethralinjuries; the frequency is lower ininfants and children.20,21 Blood at theurinary meatus or a “high riding”prostate suggests a urethral injuryand is a relative contraindication forplacement of a Foley catheter.7,8
If urethral injury is suspected, aretrograde urethrogram should beobtained before placement of acatheter in the bladder. For retro-grade urethrograms, an abdominalplain radiograph is obtained, andthen 60 mL of contrast material isinjected directly into the urethra via
a snugly placedsyringe. Anotherradiograph isobtained duringinjection of the last10 mL of contrastmaterial. Extravasa-tion of the contrastmaterial indicatesurethral injury.16
Other genitouri-nary injury is alsopossible, so a urinesample should be col-lected. Microscopichematuria is rarelyassociated with sig-nificant injury, butgross hematuriashould prompt fur-ther evaluation.22 Ifurethral injury is
excluded, gross hematuria suggestsbladder or renal injury. Transmittedforces can rupture a full bladder, butonly a bony fragment will injure anempty one. The bladder can be eval-uated by using cystography; a Foleycatheter is inserted, and radiographsare obtained when the bladder isfilled with up to 400 mL of contrastmaterial and again after the contrastmaterial is drained.16 In patients withstable hemodynamic status, both thebladder and thekidneys can beevaluated byusing computedtomography (CT).
Male sexualdysfunction isassociated withpelvic trauma,and the frequencyof impotenceboth with andwithout urethral
rupture is significant.8 Gynecologicand vaginal injuries are rare withpelvic fracture, and most gyneco-logic injuries occur in women whoare pregnant.7
Gastrointestinal injury associatedwith pelvic fracture can occur eitheras a separate traumatic injury or as alaceration by the sharp edge of a frac-tured bone. Both rectal and vaginalexaminations are necessary to rule outcommunication through a laceration.Especially in obtunded patients, it isimportant to keep from creating sucha communication during the exami-nation.7,16 Gastrointestinal injury canbe difficult to detect, because evenguaiac testing for occult blood is nota completely reliable indicator.23
The proximity of neurologicalstructures to the sacrum and acetab-ulum creates the possibility for nerveinjury.16 Spinal cord injury is mostoften associated with pelvic fracturewhen patients have vertical sacralfractures at or above the level of L5or any transverse sacral fracture.16
Injuries at specific levels cause specificdeficit patterns, so the dermatomesat and below L5 should be assessedcarefully. Particular attention shouldbe paid to plantar flexion and dorsi-flexion of the great toe, sensation inthe foot, and the Achilles deep tendon
20 CRITICALCARENURSE Vol 24, No. 2, APRIL 2004
Figure 4 Pelvic vasculature.Copyrighted image courtesy of Wesley Norman, MD, Georgetown University,Washington, DC. Reprinted with permission.
Obturatorartery
Urinarybladder
Rectum
Superiorvesicalartery
Inferiorvesicalartery
Middlerectalartery
Superiorrectalartery
Lateralsacralartery
Sigmoidbranches
Mediansacralartery
Vasdeferens
Externaliliac
artery & vein
Internalpudendal
artery
Inferiorglutealartery
Superiorglutealartery
Internaliliac
artery andvein
Iliolumbarartery
Commoniliac
artery
Inferior mesentericartery
Aorta
Table 1 Nerve assessment in pelvic fractures8
Nerve level
L5
S1-S2
S2-S5
Dorsiflexion of the footSensation in dorsal part of foot and
lateral part of calf
Hip extensionKnee flexionPlantar flexion
Sensation in posterior part of leg, lateral part of foot, and genitalia
Sensation in perineumBowel and bladder function
Normal function
by AACN on March 7, 2019http://ccn.aacnjournals.org/Downloaded from
reflex.8,16 Table 1 describes expectednerve function. The cauda equina syn-drome, a saddle-shaped area of defectwith leg weakness and plantar flexionweakness, also sometimes occurs.7,8
Radiological StudiesAdvanced Trauma Life Support
guidelines24 recommend an antero-posterior pelvic radiograph for allpatients with multiple trauma. Thatradiograph alone is adequate forclassification and management ofmost pelvic fractures, but it doesnot reveal some sacral fractures orsacroiliac injuries, and it does notreliably indicate the amount of bonydisplacement.8 Some patients withmultiple trauma may not need rou-tine anteroposterior pelvic radi-ographs. In patients who are awakeand alert and have no clinical evi-dence of pelvic fracture, anteropos-terior radiographs reveal unexpectedinjuries less than 1% of the time.The radiographs are essential forsome patients, however, becausephysical examination by itself isinadequate in adults who are notalert and is only 69% to 90% sensi-
and multiple views with CT scanningare especially useful for evaluatingsacral, sacroiliac, posterior arch, andacetabular injuries, and CT scans alsoallow visualization of retroperitonealhematomas.7,8
Fracture Types and ClassificationsWhen injury is found, a number
of classification systems to describepelvic fractures are available. Two ofthe most prominent are the Tile clas-sification10 and the Young and Burgessclassification,29 which are based onthe direction of the injury, pelvic sta-bility, and forces involved (Table 2).Classification helps in identifyingassociated injuries, correlates with thedegree of pelvic injury, and is usefulin preparing for definitive orthopedicrepair.10,29-31 Fracture classification,however, is not essential for develop-ing early strategies for managementof patients with pelvic fractures.
Fractures of the Ramus and Acetabulum
Patients with low-force injuriesgenerally have stable fractures andstable vital signs. One third of all
tive for detection of pelvic fracturesin infants and children.25-28
On radiographs, a normal pubicsymphysis is less than 5 mm wideand has less than 3 mm of verticaloffset. Overlap is abnormal. Gener-ally, the pelvic structures should besymmetrical about the midline, andedges and curves should be gener-ally smooth (Figure 2). Positioningand technique can cause pelvic rota-tion on plain radiographs, and thedegree of rotation should be evalu-ated by looking at the size and shapeof the iliac wings.7
Other radiological views can pro-vide additional information. An inletprojection, in which the x-ray beamis angled from the head toward thefeet, offers improved views of superi-orly and posteriorly displaced poste-rior fractures, posteriorly displacedanterior arch injuries, and sacroiliacwidening. The outlet view, with thex-ray beam angled toward the head,gives better views of sacral fracturesand sacroiliac joint injuries.8 Theseviews are less commonly used now,because CT scans and reconstructionsare widely available. The greater detail
CRITICALCARENURSE Vol 24, No. 2, APRIL 2004 21
Table 2 Classification schemes for pelvic fractures
Tile’s classification10
Type A, StableA1, Without involvement of pelvic ringA2, With involvement of pelvic ring
Type B, Rotationally unstableB1, Open bookB2, Ipsilateral lateral compressionB3, Contralateral lateral compression
Type C, Rotationally and vertically unstableC1, Rotationally and vertically unstableC2, BilateralC3, With associated acetabular fracture
Lateral compression (LC)I, Sacral compression on side of impactII, Iliac wing fracture on side of impactIII, LCI or LCII injury on side of impact with contralteral open-book injury
Anterior posterior compression (APC)I, Slight widening of pubic symphysis or anterior part of sacroiliac joint with intact
anterior and posterior sacroiliac ligamentsII, Widened anterior part of sacroiliac joint with disrupted anterior and intact posterior
sacroiliac ligamentsIII, Complete disruption of sacroiliac joint
Vertical shear (VS)Vertical displacement anteriorly and posteriorly
Combined mechanism (CM)Combination of other injury patterns
Young and Burgess classification29
by AACN on March 7, 2019http://ccn.aacnjournals.org/Downloaded from
pelvic fractures are individual bonefractures without involvement of thepelvic ring.10 An isolated, nondis-placed fracture of the pubic ramus isthe most common pelvic fracture; itoften occurs in elderly patients whofall. It should be considered in thedifferential diagnosis of any patientwith hip pain. Fractures of both thesuperior and inferior pubic rami onthe same side are also common andare also typically stable.8,18
A special type of ramus fracture isthe straddle fracture, caused by directinjury of the pubic arch or by lateralcompression forces. The injury pro-duces either a fracture of all 4 rami oripsilateral rami fractures with disrup-tion of the pubic symphysis. Geni-tourinary injury is common withstraddle fractures, and clinical mani-festations often include anuria,hematuria, or perineal ecchymosis.16
The acetabulum is involved inabout 20% of pelvic fractures in adultsand may involve injury of the femoralhead or fracture of the pelvic ring.18 Acomplex classification scheme foracetabular injuries essentiallydescribes the anatomical locations offractures across or within the acetabu-lum, as well as fractures of the poste-rior hip. A posterior hip dislocation iscommon with a posterior fracture ofthe acetabular hip, and displacementof the femoral head is highly sugges-tive of some acetabular injury.8,10 Hippain aggravated by percussion of thegreater trochanter or the talus is alsosuggestive of acetabular injury.8
Injuries to the sciatic nerve complicatemore than 10% of acetabular fractures.15
High-Energy and Pelvic Ring Fractures
Higher energy injuries producegreater structural and hemodynamic
damage to both the pelvis and otherorgans. Compared with patientswith low-energy fractures, patientswith high-energy fractures of thepelvic ring have higher transfusionrequirements, between 3.6 and 14.8units, and more than three quartershave associated head injury, hemo-thorax, pneumothorax, splenic lac-eration, or gastrointestinal orgenitourinary injuries.29
Because the pelvis has a ringshape and because the sacroiliacjoints are relatively immobile, dis-placement of the pelvic ring requiresa break in 2 places. Even if plainradiographs appear to show only anisolated displaced anterior fracture,bone scans and autopsy studies indi-cate that all patients who have ante-rior pelvic ring displacement have aposterior pelvic ring injury aswell.32,33 Patients with double breaksin the pelvic ring are severelyinjured. These fractures, from eitheranteroposterior or lateral compres-sion, always create rotational insta-bility and may or may not bevertically unstable. Ifthe compressionforce is sufficient tocause both rotationaland vertical instabil-ity, the significant lig-amentous and bonyinjuries are typicallycomplicated by dam-age to both vascularand nerve structures.The direction ofinjury helps definecommon patterns ofinjury.8
The so-calledopen-book fracture iscaused by a severeanteroposterior com-
pression force, such as a head-onmotor vehicle crash, that causes dis-ruption at the pubic symphysis (Fig-ure 5). The sacroiliac joint remainssupported by the posterior liga-ments and opens like a hinge, creat-ing a pelvis that is vertically stablebut rotationally unstable.10 Associ-ated injuries to the neurological andvascular structures in the posteriorarch are common, and increasedpelvic volume allows the collectionof a large amount of blood. Patientswith severe anteroposterior injurieshave the highest crystalloid andblood requirements of all patientswith pelvic fractures.8,29
High-energy lateral forces suchas a side-impact motor vehicle crashor a car striking a pedestrian causeinward rotation of the hemipelvis androtational instability.8,10 Pelvic volumeis decreased with these injuries, andalthough critically injured, thesepatients generally have much lowerfluid resuscitation requirements thando other patients with pelvic injuriescaused by high-energy forces.8,29
22 CRITICALCARENURSE Vol 24, No. 2, APRIL 2004
Figure 5 Plain radiograph of open-book pelvic fracture.Note widening of the pubic symphysis and disruption atthe right sacroiliac joint, creating a fracture with verticaland rotational instability.Image courtesy of Adam Starr, MD, University of Texas SouthwesternMedical Center, Dallas, Tex. Reprinted with permission.
by AACN on March 7, 2019http://ccn.aacnjournals.org/Downloaded from
High-energy vertical forces trans-mitted to the pelvis via extendedfemurs can produce unique injurypatterns. Malgaigne fractures areanterior fractures through the ramiand/or pubic symphysis coupledwith posterior fracture of the ipsilat-eral ilium, sacrum, or sacroiliac joint.
The combination of anterior andposterior injury creates both rota-tional and vertical instability, andmortality and morbidity in patientswith Malgaigne fractures are high.The bucket-handle fracture is simi-lar, with the posterior injury on thecontralateral side.16 These injuriescould be caused by motor vehiclecrashes in which the force of a frontalimpact is transmitted throughextended legs or by a long fall with afoot-first landing.
Acute Injury and Management Pelvic Bleeding
The most common cause ofdeath in patients with lateral com-pression pelvic fractures is an associ-ated closed-head injury; death inpatients with anteroposterior pelvicinjuries is related to pelvic bleedingand visceral injuries.29 Amongpatients in whom death is due solelyto pelvic fracture, 65% die because ofexsanguination.8
About 90% of hemorrhaging asso-ciated with pelvic fractures is venousbleeding from fractured bone surfaces.The fracture site itself is the primarybleeding source in about 86% of
and intraperitoneal injury has beenruled out or by a blood requirementgreater than 6 units in 24 hours.12,36
Current trauma managementguidelines36,37 recommend that earlyexternal pelvic stabilization be con-sidered in hypotensive patients withunstable pelvic fractures and thatexternal fixation precede laparotomyincision if that operation is to be per-formed. Anterior external fixationprovides adequate rotational stabil-ity and reduces bleeding by reap-proximating bleeding bony surfacesand preventing clot disruption. It mayprovide an advantageous reductionin pelvic volume.1,7,36 Placement of anexternal fixator at the time of admis-sion to the hospital can reduce themortality of patients with unstablepelvic injuries to the level of patientswith stable injuries and can decreasethe mortality of patients who are ini-tially hypotensive.38 External fixationdoes not restore vertical stability,which requires posterior stabilization,and it probably does not provideadequate posterior control.1,7,16,17,39-41
Other assessment and care should beprovided simultaneously with appli-cation of an external fixator.8,16
Anterior external fixation isaccomplished with a simple framethat has 2 or 3 pins in each iliaccrest.17,41,42 Pins can be placed eitherabove the anterior superior iliac spineor between the anterior iliac spinesand can be placed either through anincision or percutaneously. Lowerplacement may allow better abdomi-nal access, and the strength of bothapproaches is comparable.4,41,43 Theexternal fixator can be applied in thetrauma bay in as few as 15 minutesby skilled operators, but the skill ofthe trauma team and institutionalrequirements affect that time.8,16
injuries. An arterial source amenableto embolization occurs in only about10% of patients.7,12 Large venous injuryis even less common; it occurs in 1%or less of patients.34 Patients withinjury to large vessels have very highmortality rates, up to 85%, and aretypically hypotensive at the time of
admission. Pedestrians struck by carshave the highest incidence of largevessel injury.7
Blood from pelvic fractures typi-cally goes into the retroperitoneum,which can hold up to 4 L.7,8 An intactperitoneum is important in control-ling retroperitoneal bleeding, andmovement during examination,resuscitation, or transport can pre-vent hemostasis.7 Similarly, the tam-ponade provided by the peritoneummakes abdominal surgery inpatients with pelvic fractures particu-larly challenging, because simplyopening the abdomen increasespelvic volume by 15%.30,35 Intrapelvicbleeding can also track into the tho-rax or abdomen, and retroperitonealbleeding can dissect anteriorlythrough the peritoneum.7,8,16
Fracture Stabilization andBleeding Management
Several therapeutic options areavailable for the management of pelvicfracture and associated bleeding.Care usually begins with some formof pelvic stabilization, with someform of invasive management indi-cated by continued hemodynamicinstability that persists after chest
CRITICALCARENURSE Vol 24, No. 2, APRIL 2004 23
About 90% of hemorrhaging associatedwith pelvic fractures is venous bleedingfrom fractured bone surfaces.
by AACN on March 7, 2019http://ccn.aacnjournals.org/Downloaded from
Another version of the externalfixator is the C-clamp, developed tocreate greater compression of theposterior part of the pelvis at the pointof greatest bleeding and to increasethe speed of application.1,12 The clamphas 2 pins placed on the posteriorpart of the ilium, near the sacroiliacjoints. The clamp allows continuedaccess to the abdomen, pelvis, andlower extremities.7 In an evaluation1
of the use of clamps in patients withhypotension, the need for bloodproducts was decreased and bloodpressure was increased. The clampcan be placed in as few as 10 minutes.8
Pneumatic antishock garmentsappear to be useful in pelvic fractures,presumably because the garmentsprovide tamponade of injuries tosmall vessels and immobilize frac-tures. The garments may be particu-larly useful in a community hospitalsetting where patients must betransferred to trauma centers fordefinitive management. In a follow-upstudy of 92 patients with pelvic frac-tures who required more than 6 unitsof blood, Moreno et al44 found thatpneumatic antishock garments alonecontrolled bleeding in 71% of thepatients. In another study, Flint etal45 found that mortality wasreduced when the garments wereused. Pneumatic antishock gar-ments are easy to use, can beapplied rapidly, and are noninva-sive. However, they also block accessto significant parts of patients,decrease vital capacity anddiaphragmatic excursion, and cancause compartment syndromes.7
The garments have been used for upto 48 hours and have been used suc-cessfully in children.8,44-46 An infla-tion pressure of 40 mm Hg isrecommended, and the bony promi-
nences of the hips, thighs, knees,and ankles should be padded beforethe garments are inflated.8
Other alternatives for temporarypelvic stability are available. Oftenacceptable intermediate support canbe achieved by wrapping the pelvicgirdle with a bed sheet and thensecuring the sheet tightly in place.The Trauma Pelvic Orthotic Device,a commercial stabilization corset,has been used with some success, ashave the Dallas belt and a collapsi-ble beanbag.36,47
As mentioned earlier, arterialbleeding manageable by embolizationis uncommon in patients with pelvicfractures.1,11,12,48 When such an injurydoes occur, however, embolization isdefinitive and reduces the meanblood requirement by about 85%.49
The most likely injuries are ones tothe superior gluteal artery or internalpudendal arteries.50 Although theindications vary from author toauthor, angiography is generallysuggested when hemodynamicinstability persists after nonpelvicsources of bleeding have beenexcluded, and many authors recom-mend external fixation beforeangiography. Injuries to the posteriorarch are most often associated withsevere bleeding, so earlier angiogra-phy may be appropriate for patientswith such injuries. Certainly, thetiming of angiography should beindividualized for each patient andvaries according to institutionalcapabilities and requirements.7,30,31,36,37,51
Adequate personnel and equipmentto manage the potential deteriora-tion in status of a critically injuredpatient should be available duringangiography.8
Surgery to control bleeding inpelvic fractures typically is reserved
for injuries to large vessels.39 Attemptsat surgical control of an expandingpelvic hematoma are rarely success-ful because of the loss of tamponadefrom opening the peritoneum andexploring the hematoma.35 Similarly,early internal fixation of pelvic frac-tures is rarely attempted.15
External bleeding is possible aswell. Open pelvic fractures involvemarked pelvic visceral injury and arefatal for about half of patients. Profuserectal or perineal bleeding oftenoccurs, and heavy contaminationfrom gastrointestinal and genitouri-nary disruption greatly complicatesthe recovery of patients who surviveinitial resuscitation.19
Pelvic Fracture in Multiple TraumaManagement of patients with
multiple trauma is complicated bythe presence of pelvic fractures. Whenthe pelvic fracture is discrete, man-agement proceeds as described before.The force required to fracture thepelvis, however, makes associatedinjury common, and other injuriesoccur in more than 90% of patientswith disruption of the pelvic ring.Head injury is concomitant in 27%of such patients and thoracic injuryin 26%.19 Compared with the generalpopulation of patients with blunttrauma, patients with anteroposteriorpelvic injury have an 800% increasein aortic rupture.52,53
When pelvic fracture is accom-panied by head, chest, or extremityinjury, management follows traumaguidelines in a fairly straightforwardmanner, blending specific responsesto the associated injuries with thespecific management of the pelvicfracture.24 Because a single episodeof hypotension or hypoxia dramati-cally decreases recovery from head
24 CRITICALCARENURSE Vol 24, No. 2, APRIL 2004
by AACN on March 7, 2019http://ccn.aacnjournals.org/Downloaded from
injury, the hemodynamic compromisepossible with pelvic fracture can beparticularly troublesome for patientswith head injuries.54
Up to 40% of patients with pelvicfractures also have abdominalinjuries, and trauma patients withintra-abdominal blood and pelvicfractures present a diagnostic andmanagement challenge for which noclear consensus on the preferredapproach exists.7,16 Distinguishingabdominal from retroperitonealbleeding in patients with pelvic frac-tures is difficult but important,because a laparotomy that providesno therapeutic benefit is clearlyassociated with a high mortality rateand should be avoided.7,16,18,39 Unfor-tunately, pelvic fractures limit theeffectiveness of available diagnostictools.
Both diagnostic peritoneal lavageand bedside sonography are usefulbut are complicated by the presenceof pelvic fractures. Diagnostic peri-toneal lavage has up to 98.9% overallaccuracy for detecting peritonealblood, but the false-positive rate isbetween 16% and 20% in patientswith pelvic fractures.7,8,11 An earlydiagnostic peritoneal lavage done byusing an open, supraumbilical tech-nique helps minimize false-positives,especially those associated with apelvic hematoma dissecting alongthe abdominal wall.16,35
Bedside sonography can also beused to detect intra-abdominalbleeding, but information on theuse of sonography in patients withpelvic fractures is limited.55 In onestudy,56 specificity for detectingabdominal bleeding was 100% (posi-tive predictive value 1.0, negativepredictive value 0.8), but the false-negative rate was high in patients
ResuscitationA full discussion of massive
resuscitation is beyond the scope ofthis article, but such resuscitationdoes require consideration of issues,including coagulopathy, hypother-mia, and acid-base disorders. Coagu-lopathy in patients resuscitated withpacked red blood cells and crystalloidfluids is due to dilution of clotting fac-tors. Prothombin and activated partialthromboplastin times begin to beprolonged after replacement ofroughly half of a patient’s blood vol-ume, and increases in clinically evi-dent bleeding become manifest whenthe times are more than 1.5 timesnormal. A similar dilutional effecton platelets occurs and generallybecomes critical after depletion ofclotting factors. Administration offresh-frozen plasma will help restorethe clotting factors; platelet reple-tion will be needed for the thrombo-cytopenia. The use of both productsshould be guided by specific labora-tory results. One recommendation57
is to evaluate prothrombin and acti-vated partial thromboplastin timesand levels of fibrinogen and plateletswith every replacement of 5 units ofpacked red cells.
Coagulopathy is worsened byhypothermia, because of both slowedmetabolism and temperature-relatedplatelet dysfunction. Administrationof each unit of packed red cells atstorage temperatures (1°C-6°C)reduces core body temperature byabout 0.25°C. Lowered body tem-perature also impairs tissue perfusion,increases oxygen consumption, andleads to the development of a meta-bolic acidosis. Hypothermia is asso-ciated with increased morbidity andmortality, so all fluids used in resus-citation should be warmed.57
with fractures of the pelvic ring,patients with the most seriousinjuries. The authors56 concludedthat patients with fractures of thepelvic ring and normal findings onsonography should have appropri-ately timed CT scans to avoidmissed detection of injury. The exactrole of sonography in trauma deci-sion making is still being clarified.
CT scanning accurately differen-tiates the location of bleeding, butthe procedure can be time-consumingand in areas poorly staffed andequipped for resuscitation, is associ-ated with a risk for deterioration inpatients’ clinical status.7 Little pub-lished support exists for CT evalua-tion of patients with unstablehemodynamic status.36,37
Current trauma managementguidelines36,37 recommend that exter-nal pelvic fixation precede laparo-tomy if laparotomy is performed.However, support for early externalfixation is not universal, and it maynot be used by all trauma teams.Both early laparotomy and earlyangiographic repair are also advo-cated. The care plan should bedeveloped collaboratively betweenstaff in trauma surgery, orthopedicsurgery, and interventional radiol-ogy and varies according to institu-tional capabilities.30,31,36
Management in the Critical Care Unit
Whereas some patients withpelvic fractures arrive in the criticalcare unit in stable hemodynamiccondition, others have profoundshock and require aggressive resusci-tation to restore perfusion. Manage-ment of patients both during andafter resuscitation is complex and isfraught with risks for complications.
26 CRITICALCARENURSE Vol 24, No. 2, APRIL 2004
by AACN on March 7, 2019http://ccn.aacnjournals.org/Downloaded from
Two other traits of stored bloodare also important. Banked blood isacidotic, with a pH between 6.9 and7.1. Whether administration ofbanked blood by itself leads to aci-dosis or the citrate preservativeadded to stored blood prevents it isunclear. Poorly perfused patientscertainly have acidosis, and restora-tion of tissue perfusion is probablythe best approach to resolving theacidosis. Transfusion is also compli-cated by a time-related degradationof the 2,3-diphosphoglycerate inbanked blood. This decrease resultsin less efficient oxygen delivery fromthe transfused blood, despite anappropriate hemoglobin response.57
Because hemodynamic stabilitymay not reflect adequate resuscita-tion, base excess or lactate levelsshould be evaluated. The basedeficit at the time of admission tothe hospital correlates well withdegree of shock, the need for trans-fusion, the likelihood of transfusioncomplications, and risk for death.Nurses should anticipate and pre-pare for transfusion when the basedeficit exceeds 5 mmol/L. Failure toprogressively clear lactate is alsoassociated with complications anddeath. Lactate levels greater than 2.5 mmol/L 12 hours after admis-sion correlate with the developmentof multiple organ dysfunction, andlevels of 8 mmol/L at 24 hours areassociated with nonsurvivableinjuries. Accordingly, the basedeficit or lactate levels should beevaluated at the time of admissionand followed up throughout resusci-tation. An elevated level of either,even with adequate vital signs, indicates cellular acidosis andshould be corrected by increasingoxygen delivery via volume loading,
transfusion, or pharmacologicalmeasures.57,58
Orthopedic RepairPermanent orthopedic repair
can be accomplished with externalor internal fixation and generally isdone 24 to 72 hours after injury,when the patient is warm and resus-citated, and does not have acidosisor coagulopathy.
Nondisplaced, stable pelvic frac-tures do not require surgical inter-vention and can be managed withanalgesics and early mobilization.Displaced anterior fractures, how-ever, require some kind of invasiveintervention. External fixation witheither a frame or an Ilizarov systemavoids the complications and risksof an operation and can sometimesbe done without general anesthesia.However, the reduction must be pre-cise.59,60 If a reduction to less than 1cm of displacement is not maintainedthroughout healing, about 80% ofpatients require chronic analgesia,compared with essentially none ofthose in whom reduction is main-tained. External fixa-tors remain in placefor 6 to 12 weeks andrequire meticulouscare of the pin site toprevent infection.Twice daily cleaningwith hydrogen perox-ide swabs is usuallyadequate.41 Thedressing shouldapply some compres-sion to minimize pinmotion. Loose orinfected pins needreplacement anddebridement of thepin site.60
Internal fixation works well, withlittle occurrence of chronic pain evenwith strenuous activity. This type offixation is a complex operation gen-erally performed through a long hor-izontal incision just above the pubis(the Pfannenstiel incision), and somecombination of plates and screws isused.60
Vertically unstable posteriorinjuries can also be fixed with eitherexternal or internal approaches. Anexternal repair is not accomplishedwith a frame but through placementof percutaneous screws. This approachrisks damage to neurological andvascular structures in and near thesacrum, but it is associated with goodoutcomes when used by surgeonswith experience with the procedure.Adequate reduction is sometimesdifficult to achieve with a closedapproach, necessitating open reduc-tion before placement of the screws.The alternative is to proceed directlyto open reduction and internal fixa-tion60 (Figure 6).
After invasive repair, patientsgenerally are given antibiotics for 2
CRITICALCARENURSE Vol 24, No. 2, APRIL 2004 27
Figure 6 Plain radiograph of pelvic fracture repairedwith internal fixation by anterior plates and posteriorscrew.Image courtesy of Adam Starr, MD, University of Texas SouthwesternMedical Center, Dallas, Tex. Reprinted with permission.
by AACN on March 7, 2019http://ccn.aacnjournals.org/Downloaded from
to 3 days and have suction drains inplace for 2 days.60 Whatever repair ischosen, early mobilization in impor-tant in facilitating recovery and mini-mizing complications.59,61 Patientswith anterior injuries can beginweight bearing when comfortableand can progress as tolerated. Patientswith unilateral posterior injuriesbegin with a limit of 15 kg of weightbearing on the affected side andprogress to “as tolerated” at 6 to 8weeks. Patients with bilateral poste-rior injuries can do pivot transfersbut no other weight bearing untilafter 6 to 8 weeks.60
Potential ComplicationsPatients who have multiple
trauma may have primary lung injuryand are also at risk for the secondarycomplications of respiratory failureand respiratory distress syndromes.Careful attention to early diagnosisand relief of pneumothorax or hemo-thorax is important, as are early eval-uation of ventilation and oxygenationand ongoing observation for declinein pulmonary function. Risk for pri-mary lung injury is increased in
patients with rib fractures, and therisk for complications increases whenpositive-pressure ventilation isrequired.61 Use of lung-protective ven-tilator strategies with smaller tidal vol-umes, lower pressures, andpermissive hypercapnia may helpreduce morbidity and mortality.62
chest pain, wheezing, hypotension,or right ventricular electrocardio-graphic abnormalities develop.64
Pain management is importantindependently and also as an adjunctin preventing pulmonary andthromboembolic complications dueto reduced mobility. Continuousinfusion and patient-controlledadministration of analgesics are bothgenerally more effective than nurse-delivered intermittent bolus strate-gies.61 The Society of Critical CareMedicine standards for analgesiarecommend morphine as the drug ofchoice, with fentanyl available forpatients who are allergic to morphineor in whom hemodynamic instabilitymakes the histamine release associ-ated with use of morphine undesir-able.68 Use of narcotic analgesicsdramatically increases the risk forgastrointestinal complications, so anaggressive gastrointestinal protectionstrategy should be followed whenthese drugs are used.61
Patients with pelvic fractures, likeall other trauma patients, requireprompt and effective nutritionalsupport to optimize their potentialfor recovery. Enteral feeding is asso-ciated with fewer septic complica-tions than is parenteral feeding, andtotal parenteral nutrition is recom-mended only if patients cannot meetmore than 50% of their nutritionalneeds by hospital day 7. A specialistshould evaluate nutritional needs,and feeding should begin within 24hours after resuscitation is completed.Patients who have had a laparotomyshould probably have small-bowelfeedings via either a nasojejunal or afeeding jejunostomy tube. Patientswho have not had a laparotomy maydo well with gastric feedings, and atrial of gastric feeding is suggested.
Immobility also increases the riskfor ventilatory and infections com-plications, so positioning is impor-tant, and early mobilization or earlyuse of a therapeutic bed should beconsidered.61
Thromboembolic disease is asso-ciated with pulmonary disorders andis a known complication of pelvicfracture because of venous stasis,immobility, endothelial damage,and direct venous injury. Deep veinthrombosis occurs in up to 80% ofpatients with multiple trauma, andclinical pulmonary embolism devel-ops in about 10% of those patients.An equal number may have subclini-cal emboli. Mortality from pulmonaryembolism in patients with pelvicfractures may be as high as 4%.63-65
Because of the high risk, patients withpelvic fractures need prophylaxis fordeep vein thrombosis, probably withlow molecular weight heparin unlesscontraindicated by uncontrolledbleeding or associated intracranialbleeding. Pneumatic compressiondevices are useful, unless massiveorthopedic injury precludes theiruse, and the placement of a venacaval
filter may be useful if other means ofprevention are impossible or unsuc-cessful. Early mobilization out of bedis also helpful.61,64,66,67 Critical carenurses should maintain a high indexof suspicion for pulmonary embolismin patients with a history of pelvicfracture in whom dyspnea, tachypnea,
28 CRITICALCARENURSE Vol 24, No. 2, APRIL 2004
Deep vein thrombosis occurs in up to 80% of patients with multiple trauma, and clinical pulmonary embolism develops in about 10% of those patients.
by AACN on March 7, 2019http://ccn.aacnjournals.org/Downloaded from
Serial measurements of prealbuminlevels appear to be the most usefulway to monitor ongoing nutritionalstatus.69
Wound care is a concern forpatients with pelvic fractures. Thepatients may have other externaltraumatic injuries and may have sur-gical sites from internal fixation ofthe pelvic fractures or repair of otherinjuries. As described earlier, externalfixation requires careful skin care.Open fractures generally requiredebridement and irrigation in theoperating room for at least 4 daysand frequent dressing changes.59,61
Colostomy is a common part ofthe management of visceral injuryand is often, but not always, neces-sary for patients with open pelvicfractures. If the laceration is in therectal, perineal, buttock, or midlineareas, a colostomy is always indicated.As the location of the lacerationmoves laterally from those areas, theneed for colostomy is progressivelylower.60,70,71 A colostomy is not withoutrisks. As described earlier, openingthe abdomen can disrupt retroperi-toneal tamponade. Additionally,operating on the colon can introducecontamination that may not havepreviously existed and also necessi-tates subsequent procedures forrepair. Careful attention must be paidto the health of the new ostomy site,to the nearby skin, and to prevent-ing contamination of nearbywounds and incisions.70
Immobility increases the risk foriatrogenic skin breakdown, andinadequate nutrition impairs woundhealing and the ability to maintainskin integrity. Early feeding, goodpain management, adequate resusci-tation, and mobility or use of thera-peutic beds with repositioning of
patients are all key tools in decreas-ing and preventing integumentarycomplications.61
Infection can come from surgicalsites, open fractures, skin break-down, pulmonary infection, invasivecatheters, and a myriad of othersources. Infection may cause up to50% of late deaths in patients withpelvic fractures.70 Again, preventionwith good nursing care, resuscita-tion, and feeding is preferred, andantibiotic therapy based on theresults of microbial cultures is alsoimportant.61
Rehabilitation is also an essen-tial part of the care of patients withpelvic fractures. The physical ther-apy department should be consultedearly in the case and should followup the patients closely. Critical carenurses have an important role ascase managers in helping to ensurethat these consultations are orderedand therapies are implemented.Early and expert involvement ofphysical therapy, occupational ther-apy, and rehabilitation services isone of the benefits of care at a veri-fied trauma center.
ConclusionPelvic fractures can range from
simple, stable injuries to a componentof injury in severe multisystemtrauma. Critical care nurses shouldhave a high index of suspicion forpelvic injury, should conduct a care-ful examination for fractures andassociated injuries, and should beprepared for diverse needs of patientsand diverse interventions. Recoveryfrom pelvic fracture is a long-termprocess and can include multisystemcomplications. Good basic, criticalcare, and trauma nursing skills andan understanding of the nature of
pelvic injuries are important to criti-cal care nursing practice.
References1. Buckle R, Browner BD, Morandi M. Emer-
gency reduction for pelvic ring disruptionand control of associated hemorrhage usingthe pelvic stabilizer. Tech Orthop.1995;9:258-266.
2. Pohlemann T, Bosch U, Gansslen A,Tscheme H. The Hannover experience inmanagement of pelvic fractures. ClinOrthop. August 1994:69-80.
3. Simonian PT, Routt ML Jr, Harrington RM,Tencer AF. Anterior versus posterior provi-sional fixation in the unstable pelvis: a bio-mechanical comparison. Clin Orthop.January 1995:245-251.
4. Tile M. Pelvic ring fractures: should they befixed? J Bone Joint Surg Br. 1988;70:1-12.
5. Rothenberger DA, Fischer RP, Strate RG,Velasco R, Perry JF Jr. The mortality associ-ated with pelvic fractures. Surgery.1978;84:356-361.
6. Davidson BS, Simmons GT, Williamson PR,Buerk CA. Pelvic fractures associated withopen perineal wounds: a survivable injury. JTrauma. 1993;35:36-39.
7. Wolinsky PR. Assessment and managementof pelvic fracture in the hemodynamicallyunstable patient. Orthop Clin North Am.1997;28:321-329.
8. Cwinn AA. Pelvis. In: Marx JA, ed. Rosen’sEmergency Medicine: Concepts and ClinicalPractice. 5th ed. St Louis, Mo: Mosby;2002:625-642.
10. Tile M, ed. Fractures of the Pelvis and Acetab-ulum. 2nd ed. Baltimore, Md: Williams &Wilkins: 1995:41-52.
11. Gilliland MD, Ward RE, Barton RM, MillerPW, Duke JH. Factors affecting mortality inpelvic fractures. J Trauma. 1982;22:691-693.
12. Agnew SG. Hemodynamically unstablepelvic fractures. Orthop Clin North Am.1994;25:715-21.
13. Patterson FP, Morton KS. The cause ofdeath in fractures of the pelvis: with a noteon treatment by ligation of the hypogastric(internal iliac) artery. J Trauma.1973;13:849-856.
14. Ismail N, Bellemare JF, Mollitt DL, DiScalaC, Koeppel B, Tepas JJ III. Death from pelvicfracture: children are different. J PediatrSurg. 1996;31:82-85.
15. Failinger MS, McGanity PLJ. Unstable frac-tures of the pelvic ring. J Bone Joint Surg Am.1992;745:781-791.
16. Coppola PT, Coppola M. Emergencydepartment evaluation and treatment ofpelvic fractures. Emerg Med Clin North Am.2000;18:1-27.
agement: An Emergency Medicine Approach.St Louis, Mo: Mosby; 1998:330-333.
20. Taffet R. Management of pelvic fractureswith concomitant urologic injuries. OrthopClin North Am. 1997;28:389-396.
21. Tarman GJ, Kaplan GW, Lerman SL,McAleer IM, Losasso BE. Lower genitouri-nary injury and pelvic fractures in pediatricpatients. Urology. 2002;59:123-126.
22. Hochberg E, Stone NN. Bladder ruptureassociated with pelvic fracture due to blunttrauma. Urology. 1993;41:531-533.
23. Aihara R, Blansfield JS, Milham FH, LaM-orte WW, Hirsch EF. Fracture locationsinfluence the likelihood of rectal and lowerurinary tract injuries in patients sustainingpelvic fractures. J Trauma. 2002;52:205-209.
24. American College of Surgeons. AdvancedTrauma Life Support Program for Doctors:Student Course Manual. 6th ed. Chicago, Ill:American College of Surgeons; 1997.
25. Salvino CK, Esposito TJ, Smith D, et al. Rou-tine pelvic x-ray studies in awake blunttrauma patients: a sensible policy? JTrauma. 1992;33:413-416.
26. Junkins EP, Nelson DS, Carroll KL, HansenK, Furnival RA. A prospective evaluation ofthe clinical presentation of pediatric pelvicfractures. J Trauma. 2001;51:64-68.
27. Duane TM, Tan BB, Golay D, Cole FJ Jr,Weireter LJ Jr, Britt LD. Blunt trauma andthe role of routine pelvic radiographs: aprospective analysis. J Trauma.2002;53:463-468.
28. Gonzalez RP, Fried PQ, Bukhalo M. Theutility of clinical examination in screeningfor pelvic fracture in blunt trauma. J Am CollSurg. 2002;194:121-125.
29. Burgess AR, Eastridge BJ, Young JW, et al.Pelvic ring disruptions: effective classifica-tion system and treatment protocols. JTrauma. 1990;30:848-856.
30. Eastridge BJ, Starr A, Minei JP, O’Keefe GE,Scalea TM. The importance of fracture pat-tern in guiding therapeutic decision-makingin patients with hemorrhagic shock andpelvic ring disruptions. J Trauma.2002;53:446-451.
31. Miller PR, Moore PS, Mansell E, MeredithJW, Chang MC. External fixation or arteri-ogram in bleeding pelvic fracture: initialtherapy guided by markers of arterial hem-orrhage. J Trauma. 2003;54:437-443.
32. Buckle R, Browner BD, Morandi M. Emer-gency reduction for pelvic ring disruptionand control of associated hemorrhage usingthe pelvic stabilizer. Tech Orthop.1995;9:258-266.
65. Kelsey LJ, Fry DM, VanderKolk WE. Throm-bosis risk in the trauma patient: preventionand treatment. Hematol Oncol Clin NorthAm. 2000;14:417-430.
66. Montgomery KD, Geerts WH, Potter HG,Helfet DL. Thromboembolic complicationsin patients with pelvic trauma. Clin Orthop.August 1996:68-85.
67. Rogers FB, Cipolle MD, Velmahos G, Rozy-cki G. Practice management guidelines forthe management of venous thromboem-bolism in trauma patients. Winston-Salem,NC: Eastern Association for the Surgery ofTrauma; 2001. Available at: http://www.east.org/tpg/dvt.pdf. Accessed May 12,2003.
68. Shapiro BA, Warren J, Egol AB, et al. Prac-tice parameters for intravenous analgesiaand sedation for adult patients in the inten-sive care unit: an executive summary. Soci-ety of Critical Care Medicine. Crit Care Med.1995;23:1596-1600. Also available at:http://www.sccm.org/pdf/analgesia.pdf.Accessed May 27, 2002.
69. Jacobs DO, Jacobs DG, Kudsk KA, et al.Practice management guidelines for nutri-tional support of the trauma patient. Win-ston-Salem, NC: Eastern Association for theSurgery of Trauma; 2003. Available at:http://www.east.org/tpg/nutrition.pdf.Accessed January 16, 2003.
70. Woods RK, O’Keefe G, Rhee P, Routt ML Jr,Maier RV. Open pelvic fracture and fecaldiversion. Arch Surg. 1998;133:281-286.
71. Pell M, Flynn WJ Jr, Seibel RW. Is colostomyalways necessary in the treatment of openpelvic fractures? J Trauma. 1998;45:371-373.
rhage in pelvic fracture. Winston-Salem,NC: Eastern Association for the Surgery ofTrauma; 2001. Available at: http://www.east.org/tpg/pelvis.pdf. Accessed May 27,2002.
38. Riemer BL, Butterfield SL, Diamond DL, etal. Acute mortality associated with injuriesto the pelvic ring: the role of early patientmobilization and external fixation. JTrauma. 1993;35:671-677.
39. Jerrard DA. Pelvic fractures. Emerg Med ClinNorth Am. 1993;11:147-163.
40. Tucker MC, Nork SE, Simonian PT, RouttML Jr. Simple anterior pelvic external fixa-tion. J Trauma. 2000;29:989-994.
41. Yang AP, Iannacone WM. External fixationfor pelvic ring disruptions. Orthop ClinNorth Am. 1997;28:331-344.
43. Noordeen MH, Taylor BA, Briggs TW, LavyCB. Pin placement in external fixation.Injury. 1993;24:581-584.
44. Moreno C, Moore EE, Rosenberger A,Cleveland HC. Hemorrhage associated withmajor pelvic trauma: a multispecialty chal-lenge. J Trauma. 1986;26:987-994.
45. Flint LM Jr, Brown A, Richardson JD, PolkHC. Definitive control of bleeding fromsevere pelvic fractures. Ann Surg.1979;189:709-716.
46. Flint L, Babikian G, Anders M, Rodriguez J,Steinberg S. Definitive control of mortalityfrom severe pelvic fracture. Ann Surg.1990;211:703-706.
47. FitzPatrick MK. A new tool for initial stabi-lization of pelvic fractures. J Trauma Nurs.2002;9:20-21.
48. Ghanayem AJ, Wilber JH, Lieberman JM,Motta AO. The effect of laparotomy andexternal fixator stabilization on pelvic vol-ume in an unstable pelvic injury. J Trauma.1995;38:396-400.
49. Matalon TS, Athanasoulis CA, MargoliesMN, et al. Hemorrhage with pelvic frac-tures: efficacy of transcatheter embolization.AJR Am J Roentgenol. 1979;133:859-864.
50. Kam J, Jackson H, Ben-Menachem Y. Vascu-lar injuries in blunt pelvic trauma. RadiolClin North Am. 1981;19:171-186.
51. Ben-Menachem Y. Exploratory angiographyand transcatheter embolization for controlof arterial hemorrhage in patients withpelvic ring disruption. Tech Orthop.1995;9:271-274.
52. Ochsner MG Jr, Champion HR, ChambersRJ, Harviel JD. Pelvic fracture as an indica-tor of increased risk of thoracic aortic rup-ture. J Trauma. 1989;29:1376-1379.
53. Oschner MG Jr, Hoffman AP, DiPasquale D,et al. Associated aortic rupture-pelvic frac-ture: an alert for orthopedic and generalsurgeons. J Trauma. 1992;33:429-434.
54. Brain Trauma Foundation, American Associ-ation of Neurological Surgeons, Joint Sectionon Neurotrauma and Critical Care. Guide-lines for the management of severe headinjury. J Neurotrauma. 1996;13:641-734.
55. Rozycki GS. Abdominal ultrasonography intrauma. Surg Clin North Am. 1995;75:175-191.
56. Ballard RB, Rozycki GS, Newman PG, et al.An algorithm to reduce the incidence offalse-negative FAST examinations inpatients at high risk for occult injury.Focused Assessment for the SonographicExamination of the Trauma Patient. J AmColl Surg. 1999;189:145-151.
30 CRITICALCARENURSE Vol 24, No. 2, APRIL 2004
by AACN on March 7, 2019http://ccn.aacnjournals.org/Downloaded from
