EXPERIENCE IN USING THE FAST PROTOCOL IN A PATIENT WITH POLYTRAUMA ACCOMPANIED BY FRACTURES OF THE PELVIC AND HIP BONES

Grin A.A.1,2, Danilova A.V.1, Sergeev K.S.1

Tyumen State Medical University1,
Regional Clinical Hospital No.22, Tyumen, Russia

 EXPERIENCE IN USING THE FAST PROTOCOL IN A PATIENT WITH POLYTRAUMA ACCOMPANIED BY FRACTURES OF THE PELVIC AND HIP BONES

The management of patients with multiple and associated injuries is actual and discussed in traumatology societies of the world [1]. Fixation of the pelvic ring in unstable injuries is one of the basic elements of Advanced Trauma Life Support (ATLS) [2]. Owing to development of evident hemodynamic disorders, pelvic and hip fractures are assigned to life threatening conditions, with mortality rate up to 50 % [3-6].
Various devices, such as external fixing tools for the hip and the pelvis, have been currently implemented into the clinical practice. They are used for stabilization of unstable pelvic and hip injuries as a part of emergency aid for this category of patients [7, 8].
Bone pathology and abdominal pathology in associated injuries are closely related. Therefore, Focused Assessment with Sonography for Trauma (FAST-protocol) is included into ATLS-recommendations as an obligatory initial diagnostic tool for patients with polytrauma or abdominal injury for identification of hemoperitoneum, hemopericardium, hemothorax and pneumothorax. Such examination allows rapid (within 3-3.5 minutes) choice of surgical management with simultaneous realization of critical care procedures [9].
Objective – to evaluate the effectiveness of FAST in the treatment of a patient with polytrauma on the basis of Regional Clinical Hospital No.2 (RCH No.2) of Tyumen city.
The informed consent was received before beginning of the study. The study protocol was approved by local ethical committee of Tyumen State University (the protocol No. 76, September 16, 2017).

CLINICAL CASE

The patient K., age of 32, was admitted to Tyumen RCH No.2 after a road traffic accident (he was a driver). The patient was transported from the accident site within 30 minutes. At the admission department, he was examined by traumatologist, surgeon, urologist, neurosurgeon, therapeutists and intensivist. At the moment of admission: AP 40/0 mm Hg, Hb – 85 g/l, anuria. The examination showed some clinical signs of an opened fracture of the right hip in the lower one-third, dislocation of the left hip and a fracture of the pelvis.
The ultrasonic and radiologic examination showed the following injuries: a symphysis rupture (more than 2.5 cm), a rupture in the anterior part of the sacroiliac joint, a fracture of the pubic bone branches to the right. A transverse supratectal fracture of the roof, a fracture of posterior border of the left acetabulum (Fig. 1a). Retroperitoneal hematoma limited by the small pelvis cavity. An iliac dislocation of the left hip. An opened transcondylar, comminuted fracture of the lower one-third of the right hip diaphysis (Fig. 1b). Multiple scratches of the body surface. A blunt chest injury with lung damage. Left-sided pneumothorax. Traumatic shock of degree 3. Reactive urine retention.

Figure 1. The X-ray images of the patient K., age of 32, at the moment of arrival to the admission department: a) the X-ray image of pelvic bones; b) the X-ray image of the right hip

   

The patient’s condition was estimated as severe. Estimation of AIS showed 4 points in one region, 3 points in 2 regions. ISS was 34. The treatment was conducted in compliance with Damage control orthopedics [10]. Infusion-transfusion therapy was conducted simultaneously with the diagnostic procedures. The urgent operations were conducted: thoracocentesis, wound toilet (an opened fracture), stabilization of fractures of the pelvis and the hip with the external fixing device. The duration of the procedures was 30 minutes. The values on the surgical table were AP 80/60 mm Hg, Hb – 89 g/l, peritoneal symptoms. On the basis of FAST-protocol, the ultrasonic examination was conducted without removing the patient from the surgical table. It showed some free fluid in the abdominal cavity. Laparotomy was conducted. It identified a rupture of mesoileum, a rupture of serous-muscular layer of the transverse colon, intraabdominal bleeding. The lacerations were sutured. The sanitation was carried out.
The postsurgical period showed the improvement in the hemodynamic values. The general condition was estimated as severe. AP was 100/60 mm Hg, Hb – 93 g/l. Infusion-transfusion procedures were conducted.
The patient’s condition worsened 4 hours after the last surgical intervention. AP was 80/40 mm Hg, Hb – 74 g/l. The control ultrasonic examination showed the increase in the retroperitoneal hematoma. Its level reached the upper pole of the kidney. AIS showed the fourth region of the injuries, with worsening degrees of the injuries (4 points). ISS was 50. Intrapelvic space was opened through the inferior medial approach. A right-sided venous bleeding was suspected. Intrapelvic tamponade was conducted. Hemodynamics stabilization was noted. The surgery was carried out on the next day after stabilizing the patient’s condition: removal of tampons, symphysis fixation, wound suture.

Figure 2. The control X-ray images of the patient K., age of 32, after primary fixation (2nd day after admission): a) the X-ray image of pelvic bones; b) the X-ray image of the right hip

  


The patient received the elastic compression of the lower extremities with antiembolic stockings. Passive remedial gymnastics was carried out. The surgery was conducted on the 12th day after stabilizing condition: right hip osteosynthesis. Acetabular osteosynthesis was conducted on the 21st day (Fig. 3).

Figure 3. The control X-ray images of the patient K., age of 32, after final osteosynthesis (21st day after admission): a) the frontal X-ray image of pelvis; b) the frontal X-ray image of the right hip; c) the lateral X-ray image of the right hip

     

Subsequently, symptomatic, infusion, transfusion, antiplatelet, anticoagulant and antibacterial therapy was conducted. Active rehabilitation of the patient was conducted. Respiratory gymnastics and remedial exercises for development of motions in the joints and for muscle strengthening in the lower and upper extremities were carried out. The patient could take the vertical position on the 5th day after the last surgery. The sutures were removed on the 12th day. The wounds healed with primary adhesion. Subsequently, the planned examinations and estimation of motion activity were at 3, 6, 9 and 12 months after the surgery. The long term outcome was 89 according to Harris score, i.e. good (Fig. 4).

Figure 4. The functional images of the patient K. age of 32, 1 year after trauma

 

DISCUSSION

The combination of locomotor injuries and pelvic trauma consists 40 % of cases of high energy trauma [11]. Most patients are admitted with shock condition and unstable hemodynamics [3]. Mean ISS is 28.7 ± 11 [12]. Currently, the whole volume of care is rendered with Damage control principle [10]. Bone injuries present 10-20 % of cases [13] and are combined with abdominal injury causing the abdominal bleeding [1]. Therefore, FAST-protocol algorithms are efficient for diagnostic procedures and selection of management techniques. We used the ATLS recommendations for treatment of the above-mentioned patient [2]: fixation of shock-producing segments “hip-pelvis”, arresting intraabdominal bleeding. On the basis of regular ultrasonic examination we identified the increasing retroperitoneal hematoma (about 2 liters) [9].
With use of FAST-protocol we could diagnose the bleeding and save the patient’s life. 

CONCLUSION

Despite of absence of clinical and diagnostic data at the first stages of the treatment, the implemented FAST-protocol identified the injuries to the cavitary organs which had worsened the patient’s condition, with timely active surgical management and arresting bleeding.
The use of FAST-protocol for timely realization of care for patients with associated injuries allows increasing the quality of diagnostic procedures and accelerates the process of a surgical intervention for injured organs and saves the patient’s life.

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