Editing Pelvic trauma (section)

=== '''Surgery (pelvic packing)''' ===

* Indications
** Retroperitoneal haemorrhage as source of hypotension and patient not responsive to other measures
** Especially suspected venous small vessel bleeding
* Steps
** Ideally takes place after external fixation of pelvic fractures
** Low vertical midline laparotomy and check and pack abdomen
** Artery clips on cut edge of peritoneum and retract cephalad
** Develop plane between rectus and peritoneum, just lateral to bladder, down obliquely towards the true pelvis (can develop plane bluntly with hands if haematoma has already dissected for you), posteriorly as far as SIJ
** Evacuate pelvic haematoma, then pack the extraperitoneal space (it's not a big space, usually only 1-2 packs each side, as posterior and deep as possible)
*** One pack posteriorly at SIJ
*** One just anterior at the middle of the pelvic brim
*** Last just posterior and lateral to the pubis
*** Intra-peritoneal packing may also be helpful
** Finish by suturing the peritoneal reflection to the ipsilateral posterior sheath to prevent the packs migrating
** Leave abdomen open (high risk ACS)
** Packs out 48 hours later, which usually deals with the bleeding
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