Management of Major Pelvic Trauma

pelvic trauma fracturePelvic trauma frequently is associated with other injuries from the high force required to break the pelvis. Management is focused on stabilizing the pelvis and stopping the bleeding. Due to other injuries requiring emergent surgical stabilization, pelvic trauma is primarily managed surgically with pre-peritoneal packing and external fixation, followed by angioembolization for continued bleeding. Emergency physicians must quickly resuscitate patients while gathering vital information to direct the correct definitive bleeding control strategy. New endovascular techniques such as REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta) may change future emergency department strategies and improve mortality in severe pelvic trauma. 

How do I know the pelvis is fractured?

  • History
    • If awake, complains of pain – more sensitive then physical exam1,2
    • Pelvic, low back, groin, or hip pain
  • Physical exam
    • Gentle palpation
      • NO pelvis ROCKING – does not provide any more evidence of unstable pelvic fracture and potentially increases bleeding1,3,4
    • Perineal bruising
    • Blood at rectum or urethra
    • Lower limb asymmetry
  • Imaging
    • Hemodynamically unstable: Obtain pelvis x-ray (PXR), because not able to obtain CT5,6
    • Hemodynamically stable: Obtain CT
      • PXR has low sensitivity and high false negative rate in stable patients7,8

When to suspect significant pelvic bleeding that needs intervention?

  • Fracture patterns are NOT predictive.8–10
    • More likely predictive with at least one finding of:
      • Sacroiliac joint disruption
      • Pubic symphysis diastasis >2.5 cm
      • Displaced obturator ring fracture
  • Findings on CT obtained with IV contrast ARE predictive.5,6
    • “Blush” on CT = active contrast extravasation
    • Hematoma size ≥500 cm3
  • Other predictive findings
    • Hemodynamically unstable + pelvic fracture on PXR
    • Age >60 years: These patients have an increased risk of need for angioembolization regardless of initial hemodynamic stability11

Key ED resuscitation points for patients with major pelvic trauma

  • Check for alternative sources for significant thoracic or abdominal bleeding.
    • E-FAST
    • Chest x-ray (CXR)
    • Pelvis x-ray vs CT scan
  • Start early massive transfusion protocol if hemodynamically unstable and not expected to be stabilized after 2 units of packed red blood cells.
  • Obtain IV/IO access above the pelvis (e.g. central line access in the subclavian vein or IO access in the humerus)

Pelvic binder positioning

  • Place a temporary pelvic binder, which is also called a Pelvic Orthotic Device (POD)5,6
    • Important to position this correctly: Over greater trochanters and pubic symphysis
    • Only for 24-48 hours
    • Safe but less effective in elderly
    • Safe in pregnancy
    • Reduced transfusion requirements with few complications12–14
    • Commercial device better than sheet, but sheet is has some benefit if it is the only thing available.
  • Avoid initial foley placement if any the following (high incidence of genitourinary and anorectal injuries):5,6
    • Unable to urinate
    • Blood at meatus
    • Gross hematuria
    • Perineal bruising

How to treat significant pelvic bleeding?

  • Best current options to stop significant pelvic bleeding are with either or both:
    • Angioembolization (AE)
      • A pelvic binder or POD should be adequate stabilization in the first 24 hours.
      • Fewer transfusion requirements in first 24 hours when AE directly compared to pelvic external fixation likely due to delay in definitive control of bleeding.12
      • Very effective for ARTERIAL bleeding (85-100%) and unlikely to control VENOUS bleeding. 15–20
      • CT findings (active IV contrast extravasation, hematoma size ≥500 cm3) are good indicators for AE.15

Preperitoneal pelvic packing diagram

    • Pre-peritoneal pelvic packing (PPP)
      • Pelvic External (EF) fixation should be done in conjunction with PPP.5
      • PPP + EF can effectively control venous bleeding and may stabilize arterial bleeding until subsequent AE.15

How do I decide which first: Surgical (PPP+EF) or endovascular (AE)?

  • Most patients (up to 90%) will have significant associated intrathoracic, intrabdominal, and/or extremity injuries that will require surgical treatment. This will direct the primary course of treatment for pelvic bleeding towards a surgical approach — that is PPP + EF.
  • For HEMODYNAMICALLY STABLE or stabilized patients, a CT scan should be done first.
    • If a therapeutic thoracotomy or laparotomy is needed based on the CT scan, then PPP + EF should be done to control active pelvic bleeding, followed by AE if needed for continued pelvic bleeding.
    • If isolated pelvic bleeding, CT findings are used to guide the decision for AE or PPP + EP.
      • AE is indicated if CT findings demonstrate active IV contrast extravasation or hematoma size ≥500 cm3.
  • For HEMODYNAMICALLY UNSTABLE patients, a FAST exam should be performed early.21–33
    • FAST positive: PPP + EF should be performed first, because of the need to address concurrent intraabdominal injuries.
    • FAST negative: Either AE or PPP + EF can be performed first, assuming AE is readily available
      • Traditionally, these patients have been directed to AE first, but delays to bleeding control have raised concerns.
        • Because PPP + EF can be completed within 30 minutes, some algorithms recommend AE as the first-line approach, if available in <30 minutes.
      • 2011 study: PPP + EF is a reasonable first-line approach for pelvic fractures with hemodynamic instability. 31
        • Overall mortality rate: 21% (Past reports have reported higher mortality rates ranging 29-35% but with varied treatment strategies so it is difficult to interpret.)
        • Secondary AE needed for continued bleeding: 13%
        • Pelvic infections after packing: 15%
      • 2016 study: PPP or AE are equally effective with similar mortality rates as the first-line approach for hemodynamically unstable patients with a negative FAST.33
        • Patient were randomized to either (PPP then AE) or (AE then PPP, with AE being readily available).
        • This study did not answer the question about whether hemorrhage control could be obtained using solely PPP or AE.
    • General rule of thumb: Continued hemodynamic instability from pelvic bleeding despite a first-line approach (AE or PPP + EF) warrants performing the alternative approach.

What are new techniques being used with severe pelvic trauma?

  • Endovascular strategies to control bleeding in pelvic trauma are being developed and currently being utilized in emergency department management.34–44

Resuscitative Endovascular Balloon Occlusion of the Aorta

  • Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA)
    • Alternative to resuscitative thoracotomy (cross clamping the aorta as a bridge to definitive surgical management)5
    • 2015 study: Patients who were hemodynamically unstable with below-diaphragm trauma showed an overall improved survival rate with ED REBOA.38
      • Resuscitative thoracotomy survival rate: 9.7%
      • REBOA survival rate: 37.5%
    • Requires common femoral artery access
    • Concern for ischemia-reperfusion organ injury
    • Intermittent or partial REBOA may improve outcomes5

Take Home Points

  1. In patients with major pelvic trauma, pelvis CT imaging is extremely valuable to help determine need for intervention (CT contrast extravasation or pelvic hematoma size ≥500 cm3)
  2. Angioembolization is primarily effective for arterial bleeding control in the pelvis.
  3. There are 2 general approaches to hemorrhage control in major pelvic trauma: angioembolization (interventional radiology) and preperitoneal pelvic packing with external fixation (operating room). Deciding on the first-line approach relies on multifactorial variables including:
    • Hemodynamic stability of the patient
    • Availability of the angiography/interventional radiology suite within 30 minutes
    • Capabilities of the angiography suite
    • Concurrent injuries which require emergent operative stabilization
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Rossaint R, Duranteau J, Stahel P, Spahn D. Nonsurgical treatment of major bleeding. Anesthesiol Clin. 2007;25(1):35-48, viii. [PubMed]
19.
Metsemakers W, Vanderschot P, Jennes E, Nijs S, Heye S, Maleux G. Transcatheter embolotherapy after external surgical stabilization is a valuable treatment algorithm for patients with persistent haemorrhage from unstable pelvic fractures: outcomes of a single centre experience. Injury. 2013;44(7):964-968. [PubMed]
20.
Panetta T, Sclafani S, Goldstein A, Phillips T, Shaftan G. Percutaneous transcatheter embolization for massive bleeding from pelvic fractures. J Trauma. 1985;25(11):1021-1029. [PubMed]
21.
Verbeek D, Zijlstra I, van der, Ponsen K, van D, Goslings J. Predicting the need for abdominal hemorrhage control in major pelvic fracture patients: the importance of quantifying the amount of free fluid. J Trauma Acute Care Surg. 2014;76(5):1259-1263. [PubMed]
22.
Gänsslen A, Hildebrand F, Pohlemann T. Management of hemodynamic unstable patients “in extremis” with pelvic ring fractures. Acta Chir Orthop Traumatol Cech. 2012;79(3):193-202. [PubMed]
23.
Costantini T, Coimbra R, Holcomb J, et al. Current management of hemorrhage from severe pelvic fractures: Results of an American Association for the Surgery of Trauma multi-institutional trial. J Trauma Acute Care Surg. 2016;80(5):717-23; discussion 723-5. [PubMed]
24.
Verbeek D, Sugrue M, Balogh Z, et al. Acute management of hemodynamically unstable pelvic trauma patients: time for a change? Multicenter review of recent practice. World J Surg. 2008;32(8):1874-1882. [PubMed]
25.
Abrassart S, Stern R, Peter R. Unstable pelvic ring injury with hemodynamic instability: what seems the best procedure choice and sequence in the initial management? Orthop Traumatol Surg Res. 2013;99(2):175-182. [PubMed]
26.
Suzuki T, Smith W, Moore E. Pelvic packing or angiography: competitive or complementary? Injury. 2009;40(4):343-353. [PubMed]
27.
Agnew S. Hemodynamically unstable pelvic fractures. Orthop Clin North Am. 1994;25(4):715-721. [PubMed]
28.
Hou Z, Smith W, Strohecker K, et al. Hemodynamically unstable pelvic fracture management by advanced trauma life support guidelines results in high mortality. Orthopedics. 2012;35(3):e319-24. [PubMed]
29.
Perkins Z, Maytham G, Koers L, Bates P, Brohi K, Tai N. Impact on outcome of a targeted performance improvement programme in haemodynamically unstable patients with a pelvic fracture. Bone Joint J. 2014;96-B(8):1090-1097. [PubMed]
30.
Osborn P, Smith W, Moore E, et al. Direct retroperitoneal pelvic packing versus pelvic angiography: A comparison of two management protocols for haemodynamically unstable pelvic fractures. Injury. 2009;40(1):54-60. [PubMed]
31.
Burlew C, Moore E, Smith W, et al. Preperitoneal pelvic packing/external fixation with secondary angioembolization: optimal care for life-threatening hemorrhage from unstable pelvic fractures. J Am Coll Surg. 2011;212(4):628-35; discussion 635-7. [PubMed]
32.
Cothren C, Osborn P, Moore E, Morgan S, Johnson J, Smith W. Preperitonal pelvic packing for hemodynamically unstable pelvic fractures: a paradigm shift. J Trauma. 2007;62(4):834-9; discussion 839-42. [PubMed]
33.
Li Q, Dong J, Yang Y, et al. Retroperitoneal packing or angioembolization for haemorrhage control of pelvic fractures–Quasi-randomized clinical trial of 56 haemodynamically unstable patients with Injury Severity Score ≥33. Injury. 2016;47(2):395-401. [PubMed]
34.
Stannard A, Eliason J, Rasmussen T. Resuscitative endovascular balloon occlusion of the aorta (REBOA) as an adjunct for hemorrhagic shock. J Trauma. 2011;71(6):1869-1872. [PubMed]
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Morrison J, Galgon R, Jansen J, Cannon J, Rasmussen T, Eliason J. A systematic review of the use of resuscitative endovascular balloon occlusion of the aorta in the management of hemorrhagic shock. J Trauma Acute Care Surg. 2016;80(2):324-334. [PubMed]
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Biffl W, Fox C, Moore E. The role of REBOA in the control of exsanguinating torso hemorrhage. J Trauma Acute Care Surg. 2015;78(5):1054-1058. [PubMed]
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Delamare L, Crognier L, Conil J, Rousseau H, Georges B, Ruiz S. Treatment of intra-abdominal haemorrhagic shock by Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA). Anaesth Crit Care Pain Med. 2015;34(1):53-55. [PubMed]
38.
Moore L, Brenner M, Kozar R, et al. Implementation of resuscitative endovascular balloon occlusion of the aorta as an alternative to resuscitative thoracotomy for noncompressible truncal hemorrhage. J Trauma Acute Care Surg. 2015;79(4):523-30; discussion 530-2. [PubMed]
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Moore L, Martin C, Harvin J, Wade C, Holcomb J. Resuscitative endovascular balloon occlusion of the aorta for control of noncompressible truncal hemorrhage in the abdomen and pelvis. Am J Surg. 2016;212(6):1222-1230. [PubMed]
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DuBose J, Scalea T, Brenner M, et al. The AAST prospective Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) registry: Data on contemporary utilization and outcomes of aortic occlusion and resuscitative balloon occlusion of the aorta (REBOA). J Trauma Acute Care Surg. 2016;81(3):409-419. [PubMed]
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Author information

Heather Mahoney, MD MA

Heather Mahoney, MD MA

Associate Clinical Professor
Department of Emergency Medicine
University of California, San Francisco
Zuckerberg San Francisco General Hospital

The post Management of Major Pelvic Trauma appeared first on ALiEM.

ED Charting and Coding: Critical Care Time

After a STEMI activation from the field on Monday morning, the cardiac catheterization team scoops the patient away shortly after the paramedics arrive in the Emergency Department (ED). “Well that was a smooth and seamless resuscitation. The patient was barely in the ED for more than 15 minutes,” you think to yourself. You diligently complete your critical care documentation, noting 20 minutes of critical care time, before seeing your next patient. A few weeks later the chart is bounced back and noted as an erroneous documentation of critical care time. The coding department notifies you that the case will be billed as a Level 3 visit (E/M code #99283). Why is that the case?

CMS Definition of Critical Care

Critical care billing can be justified if the patient has a medical condition that “impairs one or more vital organ systems” and “there is a high probability of imminent or life-threatening deterioration in the patient’s condition.” The physician should also provide “frequent personal assessment and manipulation” of the patient’s condition. Many conditions that qualify for critical care billing are obvious, such as cardiac arrest, life-threatening traumatic injuries, and most conditions that result in intensive care unit admission. However, emergency physicians take care of many other conditions and provide many interventions that may also justify critical care billing (see Table 1 from ACEP’s guidelines [Critical Care FAQ]).

Table 1: Conditions and interventions that often qualify/are associated with critical care billing

CONDITIONS that frequently qualify for critical care billing INTERVENTIONS often associated with critical care billing
Acute coronary syndrome with active chest pain Arterial line placement
Acute hepatic failure Burn care, major
Acute renal failure Cardiopulmonary resuscitation
Acute respiratory failure Chest tube insertion
Adrenal crisis Cricothyrotomy
Aortic dissection Defibrillation/ Cardioversion
Bleeding diatheses – aplastic anemia, DIC, hemophilia, ITP, leukemia, TTP Delivery of baby
Burns threatening to life or limb Emergent blood transfusions
Cardiac dysrhythmia requiring emergent treatment Endotracheal intubation
Cardiac tamponade Hemorrhage control, major
Coma (most etiologies, except simple hypoglycemic) Intravenous pacemaker insertion
Diabetic ketoacidosis or non-ketotic hyperosmolar syndrome Invasive rewarming
Drug overdose Non-invasive positive pressure ventilation (i.e. BiPAP or CPAP)
Ectopic pregnancy with hemorrhage Pericardiocentesis
Embolus of fat or amniotic fluid Therapeutic hypothermia
Envenomation Trauma care requiring multiple surgical interventions or consultants
Gastrointestinal bleeding Ventilator management
Head injury with loss of consciousness Parenteral medications necessitating continuous monitoring, such as:

  • ACLS medications administered during cardiac arrest
  • Insulin infusions
  • Medications for heart rate/rhythm control
  • Naloxone infusions
  • Vasoactive medications
Hyperkalemia
Hyper- or hypothermia
Hypertensive emergency
Ischemia of limb, bowel, or retina
Lactic acidosis
Multiple trauma
Paralysis (new onset)
Perforated abdominal viscous
Pulmonary embolism
Ruptured aneurysm
Shock, all etiologies (septic, cardiogenic, spinal, hypovolemic, anaphylactic)
Stroke, hemorrhagic (all etiologies) or ischemia
Status epilepticus
Tension pneumothorax
Thyroid storm

© 2011-2016, American College of Emergency Physicians. Reprinted and modified with permission.

Time Spent on Critical Patient Care

The amount of time spent providing critical care time must be clearly recorded and is billed by unique codes. This is a distinct difference from E/M code billing that is performed on most other patients. To bill critical care time, emergency physicians must spend 30 minutes or longer on patient care.

 

Table 2: Three Current Procedural Terminology (CPT) codes used for critical patient care

CODE SERVICE
99291 Used to report the additive total of the first 30-74 minutes of critical care performed on a given date. Critical care time totaling less than 30 minutes is reported using the appropriate E/M code.
99292 Added to 99291 to report each additional 30 minutes beyond the first 74 minutes
G0390 Added to 99291 for Trauma Team Activation when appropriate activation criteria are met at designated trauma centers

Both direct and indirect patient care time can be included in critical care billing. Therefore, time spent evaluating the patient, speaking with EMS prehospital personnel and family, interpreting studies, discussing the case with consultants or admitting teams, retrieving data and reviewing charts, documenting the visit, and performing bundled procedures should all be included in the critical care time recorded. One important exception is that the time spent on any separately-billed procedures should not be included in the critical care time.

 

Table 3: Procedures which are commonly bundled versus billed separately from critical care time

Common Procedures BUNDLED into Critical Care Time Billing

Common Procedures Billed SEPARATELY

Interpretation of cardiac output, chest x-rays, pulse oximetry, blood gases, information/data stored in computers Endotracheal intubation
Gastric intubation (e.g. nasogastric tubes) Central vascular access
Temporary transcutaneous pacing Intraosseous line placement
Ventilatory management Transvenous pacing
Blood draws for specimen Chest tubes
Peripheral vascular access CPR
Wound repair
ECG interpretation
Electrical cardioversion

 

While you do not need to carry a stopwatch to time yourself on every direct and indirect patient care task, you should accurately track and document the total time you spend providing critical care services to a given patient. It is important to remember a few things about critical care time:

  1. It is additive.
  2. It may only be billed once per day.
  3. It does need not be continuous.
  4. Critical care time does require the direct involvement and documentation by an attending physician. (Sorry residents! Your efforts are appreciated but if your attending leaves you alone with a critical patient that time is not reimbursable.)

Example of an Attending Attestation Note

I have discussed the case with the resident/mid level provider. I have personally performed a history, physical exam, and my own medical decision making. I have reviewed the note and agree with the findings and plan with the following exceptions: ____ (insert exceptions) ___.

Upon my evaluation, this patient had a high probability of imminent or life-threatening deterioration due to ___(condition)__, which required my direct attention, intervention, and personal management.

I have personally provided ___ minutes of critical care time exclusive of time spent on separately billable procedures. Time includes review of laboratory data, radiology results, discussion with consultants, and monitoring for potential decompensation. Interventions were performed as documented above.

– Your initials with time stamp

Documenting Critical Care Time

The chart must provide adequate justification for why a patient meets CMS criteria for critical care billing. To do this, explain all of the following:

  1. How the patient was critically ill
  2. What you did for the patient
  3. The cumulative critical care time spent on direct and indirect patient care

Try to document the following points, when applicable:

  1. Severity of illness and potential for decompensation
  2. Vital signs (hypotension, hypoxia, etc) and how these changed through the case
  3. Tests performed and your interpretation of the results
  4. Treatments provided, including: supplemental oxygen, IV fluids, medications, blood transfusions, burn/wound care
  5. Procedures performed
  6. Re-assessments of the patient’s status and response to interventions
  7. Conversations with EMS, the patient, the patient’s family or surrogate decision makers, nursing home personnel, consultants, and admitting teams
  8. Information retrieved by chart review and how this impacted patient care

You may notice that these documentation guidelines differ from the E/M coding guidelines that are applied for non-critical care patients. That is because a chart associated with critical care time will not have an E/M level associated with it as these codes are mutually exclusive. However, if the documentation of a critical care case does not meet CMS standards, or if the total critical care time is less than 30 minutes, the chart will be billed according to E/M codes. If there is any concern that the chart will not meet critical care criteria, providers should also document according to the appropriate E/M coding coding guidelines.

Revising the Case

Let’s get back to our case of the patient presenting with a STEMI and a subsequent rapid disposition to the cardiac catheterization lab. Although that patient met the CMS critical care organ system dysfunction and high-risk for decompensation criteria, the provider spent less than 30 minutes of cumulative time on direct and indirect patient care. It is fairly rare that you are able to evaluate a patient, interpret all studies, and complete all documentation on a critical care patient within 30 minutes but it does happen. The patient’s chart was thus billed at a Level 3 visit (E/M code #99283). Thus if there is a possibility that a patient’s chart may not qualify for at least 30 minutes of critical care time, as was the case above, be sure to chart appropriately based on E/M coding levels.

Work Smarter, Not Harder

  • Emergency physicians frequently provide critical care (by billing standards) to patients but do not even recognize that they are doing so. Reflect on your practice and consider if you are missing critical care billing opportunities.
  • A chart that qualifies for critical care time does not require the detailed history and physical exam points required for E/M level billing on non-critical care patients. Use this to your advantage by focusing more on the medical decision making portion of the chart. You do need to document how the patient was critically ill, what you did for the patient, and the number of minutes you spent caring for the patient.
  • Using a macro or template can help you provide adequate critical care documentation in a timely manner.

Additional Reading

ED Charting and Coding Series

Author information

Kenneth Dodd, MD

Kenneth Dodd, MD

Emergency Medicine-Internal Medicine Chief Resident
Critical Care Fellow
Hennepin County Medical Center

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MEdIC Series: Case of the Competency Conundrum – Expert Review and Curated Community Commentary

Our final case of this season, The Case of the Competency Conundrum, outlined a scenario of residency competency committee members who are divided in their approach to a superstar R4 resident, Josh, who has already completed the requirements of his training program. They struggle with competing opinions surrounding competency based medical education (CBME) early advancement principles and the importance of continued exposure/service.

This month, the MEdIC team (Drs. Tamara McColl, Teresa Chan, Sarah Luckett-Gatopoulos, Eve Purdy, John Eicken, Alkarim Velji, and Brent Thoma), hosted an online discussion around this case with insights from the ALiEM community. We are proud to present to you the curated community commentary and our expert opinions. Thank-you to all participants for contributing to the very rich discussions surrounding this case!

This follow-up post includes

  • Responses from our solicited experts:
    • Dr. Brent Thoma (@Brent_Thoma) is an emergency physician and trauma team leader in Saskatoon, Saskatchewan. He is the interim Director of Simulation and Program Director of the Royal College emergency medicine residency program. Brent investigates technological innovations that enhance learning with the goal of helping good people to provide exceptional healthcare. His work is online at CanadiEM.org, Debrief2Learn.org, and METRIQstudy.org.
    • Dr. Teresa Chan (@TChanMD) is an emergency physician, clinician educator and assistant professor at McMaster University, where she is also the Competence Committee chair for the Royal College Emergency Medicine training program. She is the assistant program director of the Clinician Educator Area of Focused Competence program. In her spare time she volunteers with a number of influential FOAM outlets including: ALiEM.com, CanadiEM.org, EMSimcases.com, FemInEM.org, International Clinician Educator blog, Emergency Medicine Cases
  • A summary of insights from the ALiEM community derived from the Twitter and blog discussions
  • Freely downloadable PDF versions of the case and expert responses for use in continuing medical education activities
Expert Response 1: The Stellar Resident: A Good Problem to Have (Dr. Brent Thoma)
Expert Response 2: The Complexities of Clinical Competency Committees (Dr. Teresa Chan)
Curated from the Community (Dr. Alkarim Velji)

Case and Responses for Download

Click here (or on the picture below) to download the case and responses as a PDF (321 kb).

Author information

Tamara McColl, MD FRCPC MEd(c)

Tamara McColl, MD FRCPC MEd(c)

Associate Editor, ALiEM MEdIC Series
Emergency Physician, St. Boniface Hospital, WRHA
Academic Lead, Educational Scholarship
Department of Emergency Medicine
University of Manitoba

The post MEdIC Series: Case of the Competency Conundrum – Expert Review and Curated Community Commentary appeared first on ALiEM.