Trauma Surgeons Gone Wild: Pelvic Fracture, PPP, REBOA, 4 Factor PCCs

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Sid W -

Wanted to ask a question concerning external fixation of pelvic fractures.

I had a case years ago in which a rodeo rider went up and down on a saddle horn on his perineum. He presented with abdominal and testicular pain. His plain film showed a pubic symphysis diastasis, a bit beyond 2cm. He had pretty significant lower abdominal pain on exam. Short story is CT showed blush on exam, and the general surgeon wanted the orthopedist to do an ex fix on the patient and THEN get an angio. Pt.'s pelvis was sheeted but he was dropping his pressure and needing blood.

Does an ex-fix of the pelvis really add anything beyond sheeting the pelvis or using another device in terms of stabilizing a patient? (More to the point, if your sheeted patient is still crashing, is an ex-fix likely to help?)

Second question, when presented with a blush on CT, shouldn't the priority be angio first?

I work in a semi-rural area but we have an interventional radiologist. The patient went to the OR, got ex-fixed by a flustered orthopedist who hadn't done the procedure in probably a decade. He then went to angio and his bleeder was stopped there. It was very touch and go in the OR and at angio but the patient lived and was then transferred by air to a major university.

I was trying to push for angio back then but was meeting resistance. Probably will never have another case like it but it would be nice to know your thoughts.

Sid W -

Perhaps another way to phrase my questions is does ex-fixing the pelvis do anything to control hemorrhage beyond what could be accomplished with sheeting?

B. -

Love the REBOA song...where the heck did you get the symphony accompanying you? Haha!

Nilesh P. -

Kenji, Mel:

Great podcast as usual! I wanted to comment on the discussion on 4 factor PCCs.
I do agree that the literature is not high quality regarding reversal in general. However, there is a decent amount of literature, mostly prospective observational/cohort literature that there may be incomplete reversal with 3 factor PCCs. To me, this makes 4 factor PCCs a better option.
The podcast mentions a lack of prospective, randomized control trials. While I agree that this literature is important, we cannot base all of our practice on such studies b/c they simply don't exist. Also, by convention, most reversal trials look at things such as hemostatic efficacy and INR reduction. And my read on that is 4 factor PCC gives you more sustained and rapid INR reduction without the occurrence of incomplete reversal with similar hemostatic efficacy to its 3 factor counterpart. So in most outcomes, 4 factor PCC similar to 3 factor PCC but in INR reduction, seems to be better.
As far as mortality--similar. As far as safety--pretty similar.
I do agree more data required and would be nice to see.

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