Hemodinamik Olarak İnstabil Pelvis Kırıkları: Acil Ortopedik Yaklaşım
Özet
Hemodinamik olarak instabil pelvis kırıkları, özellikle genç popülasyonda yüksek enerjili travmalar sonrası gelişen ve %30-60 gibi yüksek mortalite oranlarına sahip acil ortopedik durumlardır. ATLS kılavuzuna göre bu durum; sistolik kan basıncının 90 mmHg’nın altında olması, nabzın 120’nin üzerinde seyretmesi, vazokonstrüksiyon bulguları, bilinç bulanıklığı veya masif transfüzyon ihtiyacı ile tanımlanır. İlk müdahale olay yerinde hava yolu, solunum ve dolaşım desteğiyle başlar; pelvik hacmi küçülterek kanamayı sınırlandırmak adına pelvik bandaj uygulaması hayatidir. Klinik değerlendirmede, hematom hacmini korumak için pelvisin mekanik stabilite muayenesinin tekrarlanmasından kaçınılmalıdır. Tanı ve planlamada radyografi, FAST ultrasonografi ve bilgisayarlı tomografiden yararlanılırken, hastanın fizyolojik durumunu izlemek için ATLS hemorajik şok ve ISS-AIS skorlama sistemleri kullanılır. Tedavide hasar kontrol ilkeleri benimsenerek, yüksek kanamalı definitif cerrahiler yerine metabolik stresi düşük tutacak geçici fiksasyonlar tercih edilir. Genellikle arteriyel kaynaklı olan bu ölümcül kanamaların durdurulmasında en çok anjiyografi eşliğinde embolizasyon önerilirken, pelvis içi hacmi azaltarak mekanik stabilite sağlayan eksternal fiksatörler ve Ganz tipi C klempler yaygın olarak kullanılır. Pelvik açık cerrahi ve paketleme yöntemi ise venöz kanamaları bası yoluyla sınırlandırmak amacıyla anjiyografi ile tamamlayıcı olarak son seçenek şeklinde uygulanır.
Hemodynamically unstable pelvic fractures are emergency orthopedic conditions with high mortality rates of 30-60%, usually resulting from high-energy traumas in young populations. According to ATLS guidelines, this condition is defined by a systolic blood pressure below 90 mmHg, a heart rate above 120, signs of vasoconstriction, altered mental status, or massive transfusion requirements. Initial management begins at the scene with airway, breathing, and circulatory support, where pelvic binder application is vital to limit bleeding by reducing pelvic volume. During clinical assessment, repeating the mechanical stability examination must be avoided to preserve hematoma volume. Radiography, FAST ultrasonography, and computed tomography are utilized for diagnosis, while ATLS hemorrhagic shock and ISS-AIS scoring systems help monitor physiological status. In treatment, damage control principles are adopted, prioritizing temporary fixations with low metabolic stress over high-bleeding definitive surgeries. Angiography-guided embolization is highly recommended to control these arterial hemorrhages, while external fixators and Ganz-type C-clamps are widely used to stabilize the pelvis mechanically and decrease its volume. Pelvic open surgery and packing are applied as a last resort, complementing angiography to restrict venous bleeding through compression.
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