eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics
Fracture, Pelvic: Treatment & Medication
Updated: Sep 30, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Prehospital Care
- Address acute life-threatening conditions. Be very aware that the amount of force necessary to cause a significant pelvic fracture is likely to have caused other significant injuries.
- Application of an external compression device to a grossly unstable pelvis will provide mechanical stabilization while controlling hemorrhage from the fracture site. A sheet or one of a variety of inexpensive, commercial products may be used.10
- Avoid excessive movement of the pelvis.
- Obtain large-bore intravenous (IV) access, and administer analgesia and fluids in accordance with local protocols.
- Closely monitor vital signs.
Emergency Department Care
- Treatment involves an algorithmic, multidisciplinary approach.
- Investigate associated intra-abdominal and intrapelvic injuries. A FAST examination should be performed as soon as possible, as well as a chest radiograph to look for other injuries or bleeding sources, especially in the unstable patient.
- Avoid excessive movement of the pelvis.
- If not done by prehospital providers, the pelvis should be rapidly stabilized with a sheet or commercial pelvic external stabilizer.
- This is very important prior to neuromuscular blockade because the muscles may be the only thing maintaining pelvic stability.
- In some patients, such as those with truncal obesity, internal rotation of the lower extremities and taping together the knees may be more effective than a compression binder.11
- In the case of unstable pelvic fractures, early application of an external fixation device by the appropriate surgical consultant should be considered.
- Administer fluid replacement and analgesics as needed.
- Do not place a urinary catheter until urethral injury has been ruled out or determined to be unlikely by physical examination or retrograde urethrography.
Consultations
- Consult an orthopedic surgeon when a pelvic fracture is diagnosed. Hemodynamically unstable patients with unstable pelvic fractures require emergent orthopedic consultation for possible external fixation. In addition, pelvic or retroperitoneal packing may be required for hemorrhage control.12
- Consult an interventional radiologist for embolization in the unstable patient.
- Consult a urologist for any suspected urethral injury.
Medication
Primary treatment of pelvic fracture is for pain with narcotic analgesics. Administer antibiotics whenever disruption of bowel, vagina, or urinary tract is suspected. Since bleeding is the major life-threatening complication of pelvic fractures, avoid nonsteroidal anti-inflammatory drugs in initial treatment. They may be considered later if inflammation is a concern.
Analgesics
Narcotic analgesics are the treatment of choice in the acute setting. Pain control is essential to quality patient care. It ensures patient comfort, promotes pulmonary toilet, and aids physical therapy regimens. Many analgesics have sedating properties that benefit patients who have sustained fractures. Adequate pain control helps keep the patient quiet and avoids movement of the pelvis.
Morphine sulfate (Duramorph, Astramorph, MS Contin)
DOC for narcotic analgesia because of its reliable and predictable effects, safety, and ease of reversibility with naloxone. Administered IV, may be dosed in a number of ways and commonly is titrated until desired effect obtained. Titrated doses especially useful in trauma patients to avoid oversedation or hypotension. Caution in hypotensive patients as may worsen hypotension because of histamine release. Consider fentanyl in this setting.
Adult
Starting dose: 0.1 mg/kg IV
Maintenance dose: 5-20 mg/70 kg IV/IM/SC q4h
Relatively hypovolemic patients: Start with 2 mg IV and reassess hemodynamic effects of dose
Pediatric
Neonates: 0.05-0.2 mg/kg IV/IM/SC q2-4h prn
Children: 0.1-0.2 mg/kg IV/IM/SC q2-4h prn
Phenothiazines may antagonize analgesic effects; tricyclic antidepressants, MAOIs, and other CNS depressants may potentiate adverse effects
Documented hypersensitivity; hypotension; potentially compromised airway in which establishing rapid airway control would be difficult
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Avoid in hypotension, respiratory depression, nausea, emesis, constipation, and urinary retention; caution in atrial flutter and other supraventricular tachycardias; has vagolytic action and may increase ventricular response rate
Fentanyl (Sublimaze, Duragesic)
Excellent drug for analgesia in patients with hypotension or whose cardiovascular condition is unstable. Does not release histamine. Short-acting acutely, duration becomes longer with repetitive dosing.
Adult
1-2 mcg/kg IV then titrate to pain relief
Pediatric
1-3 mcg/kg IV then titrate to pain relief
Phenothiazines may antagonize analgesic effects; tricyclic antidepressants may potentiate adverse effects
Documented hypersensitivity; hypotension; potentially compromised airway in which establishing rapid airway control would be difficult
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in hypotension, respiratory depression, constipation, nausea, emesis, and urinary retention; idiosyncratic reaction, known as chest wall rigidity syndrome (never reported in analgesic dosages, <200-mcg bolus), may require neuromuscular blockade to increase ventilation
Acetaminophen (Tylenol, Panadol, aspirin-free Anacin)
DOC for treatment of pain in patients with documented hypersensitivity to aspirin or NSAIDs or those at high risk of bleeding, with upper GI disease, or taking oral anticoagulants. DOC for pain relief in noninflammatory conditions.
Adult
325-650 mg PO q4-6h or 1000 mg tid/qid; not to exceed 4 g/d
Pediatric
<12 years: 10-15 mg/kg/dose PO q4-6h prn; not to exceed 2.6 g/d
>12 years: 325-650 mg PO q4h; not to exceed 5 doses/d
Rifampin can reduce analgesic effects; barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity
Documented hypersensitivity; known G-6-P deficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Severe or recurrent pain or high or continued fever may indicate a serious illness; acetaminophen is contained in many OTC products and combined use with these products may result in cumulative acetaminophen doses exceeding recommended maximum dose
Hydrocodone bitartrate and acetaminophen (Vicodin ES)
Drug combination indicated for relief of moderately severe to severe pain.
Adult
1-2 tab/cap PO q4-6h prn based on hydrocodone content 5-10 mg dosage
Pediatric
<12 years: 10-15 mg/kg/dose acetaminophen PO q4-6h prn; not to exceed 2.6 g/d of acetaminophen
>12 years: 750 mg acetaminophen PO q4h; single dose not to exceed 10 mg of hydrocodone bitartrate; not to exceed 5 doses/d
Phenothiazines may decrease analgesic effects; CNS depressants or tricyclic antidepressants increase toxicity
Documented hypersensitivity; high-altitude cerebral edema; elevated intracranial pressure
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Tablets contain metabisulfite, which may cause hypersensitivity; caution in patients dependent on opiates because this substitution may result in acute opiate-withdrawal symptoms; caution in severe renal or hepatic dysfunction; be careful when adding to other drugs that contain acetaminophen
Oxycodone and acetaminophen (Percocet, Tylox, Roxicet, Roxilox)
Drug combination indicated for relief of moderately severe to severe pain. DOC for aspirin-hypersensitive patients.
Adult
1-2 tab/cap PO q4-6h prn
Pediatric
0.05-0.15 mg/kg/dose oxycodone PO q4-6h prn; not to exceed 5 mg/dose of oxycodone
Phenothiazines may decrease analgesic effects; CNS depressants or tricyclic antidepressants increase toxicity
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Duration of action may increase in elderly persons; be aware of total daily dose of acetaminophen patient is receiving; do not exceed 4000 mg/24 h of acetaminophen; higher doses may cause liver toxicity
Oxycodone and aspirin (Percodan, Roxiprin)
Drug combination indicated for relief of moderately severe to severe pain. Avoid in early treatment because of platelet inhibition from aspirin and increased risk of bleeding. See discussion under NSAIDs above.
Adult
1-2 tabs/caps PO q4-6h prn
Pediatric
0.05-0.15 mg/kg/dose oxycodone PO q4-6h prn; not to exceed 5 mg/dose of oxycodone
Phenothiazines may decrease analgesic effects; CNS depressants or tricyclic antidepressants increase toxicity; may potentiate anticoagulant effects of warfarin
Documented hypersensitivity; liver damage; hypoprothrombinemia; vitamin K deficiency; bleeding disorders; asthma
Because of association with Reye syndrome, not for use in children (<16 y) who have flu
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Duration of action may increase in elderly persons; caution in renal or liver impairment, peptic ulcer disease, and erosive gastritis
More on Fracture, Pelvic |
| Overview: Fracture, Pelvic |
| Differential Diagnoses & Workup: Fracture, Pelvic |
 Treatment & Medication: Fracture, Pelvic |
| Follow-up: Fracture, Pelvic |
| Multimedia: Fracture, Pelvic |
| References |
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References
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Further Reading
Keywords
pelvic fracture, fracture of the pelvis, acetabular fractures, lateral compression fractures, transverse fractures of the pubic rami, avulsion fracture, Tile classification system, Young classification system, anterior-posterior compression fractures
