Pelvic Immobilization: the new C-Collar?!

Hi Team, first blog for me on here so go easy. Apologies for the late publishing of this entry, I’ve had a few things on my plate.

I wanted to write about something topical and about an area that I wanted to know more about.

So I picked pelvic fractures; the assessment, physiology and treatments. I also wanted to open the floor for discussion about our current stance, equipment and management of these injuries. It was great last coffee and cases getting Suzi’s take on these injuries and the further treatment provided at hospital.

Consider this a summary of the points covered during our session.

So cracking on.


Pathophysiology

Pelvic fractures are a really relevant injury  to be aware of in the prehospital setting; they have a high rate of going undiagnosed in the field and are a statistically significant cause for hypovolemia in the setting of trauma.

The most common places we see them are in the setting of MVA’s, car vs pedestrian and in some falls. For the most part, there is a significant mechanism required to achieve a fracture or else an osteoporosis process occurring in the patient prior to injury.

-There is a ring or crown of bone surrounding the pelvic organs.

-The pelvic ring is intertwined with a large number of veins and arteries. See the attached picture.

-Fracture of this ring has a high likelihood of causing rupture of any number of these large blood vessels. It is a number that become ruptured too; it is almost unheard of for a single vessel injury to occur with a fracture.

-The pelvis as it is, provides a large space to bleed into and does a poor job of self tamponading due to the greater available volume.

-To give you an idea, these patient’s on average require between 2-6L of blood replacement over their time at hospital!

Patients with these injuries are an orthopedic emergency:

Pelvic Fractures bleed out!

artsandveinsofpelvis

 

 

 

Assessment

So before we can treat these patients we need to identify these injuries right?

How do we do this?

 

Looking across a number of specific physical pelvic assessments; none of them are very reliable or specific at determining fractures and some of them are even potentially harmful to the patients if these injuries exist.

-Springing the pelvis or log rolling patients may exacerbate bleeding and can dislodge clots in the setting of pelvic fracture.

 

Pain as a Diagnostic– Unreliable- often other distracting injuries as Pelvic fractures rarely occur in isolation. Pain is also only a useful diagnostic in the conscious patient.

Pain that may be indicative of pelvic fracture can be found in the hips, groin, lower back and pubic region. May or may not find bruising around hips, lower pelvic guarding, incontinence

Note that bleeding from any orifices may be indicative of an open pelvic fracture. Consider these as signs to be more aware of, since the mortality associated with open pelvic fracture is approximately 50%

In the unconscious patient there is a high rate of unrecognized pelvic fracture. Pelvic stabilization should be a routine treatment for patients in this group, with a significant mechanism and/or the presence of shock.

Accordingly, mechanism of injury and cardiovascular status remain the two most reliable indicators of pelvic fracture in the unconscious patient.

 

Treatment

A range of different devices available- Basic principles remain the same; prevent the movement of fractures, support the boney ring of the pelvis, compressing internal blood vessels and reducing the potential space for bleeding in severe fracture.

Minimal movement is also key and the binder should be prepared to apply on the extrication device or stretcher as feasible to minimize the movement of patients. Ideally we should also actually look at removing external clothes prior to placement, there is some discussion that to do otherwise can create areas of increased pressure or allow for movement of the binder. Practically it is also important for the assessment of patients.

Considering the significant amount of bleeding occurring with pelvic fractures, several treatment regimes would lend towards the idea of treating them as an uncontrolled bleed and allowing permissive hypotension. Given that the only fluids we currently have to provide are saline, evidence would suggest that conservative fluid therapy would likely be of greater benefit to these patients. In doing so it would reduce the dilution of clotting factors and the exacerbation of bleeding and hypothermia. These factors in combination with acidosis lead to coagulopathy and ultimately death, if not mitigated.

Summary of Treatment Options

Ideally a firm wrap of the pelvis should end up covering the greater trochanters of the pelvis and the pubis synthesis; it sits lower than most think.

So here are some of the options from here and abroad:

-MAST or PASG- could be used to immobilize and bind the pelvis, but also to provide circulatory support. Poor evidence to support use. Not currently in active use anymore by many places.

-Sheet wrap or binding- unreliable in the stabilization it provides, poor evidence to support practice. Not something supported under current practice though even and partly because of the many variations in how this is performed.

-SAM Sling- Specifically designed for pelvic binding. Some studies showing good results, to the point where the pelvic fractures didn’t show up in the first x-rays. Simple and easy to apply, used in hospital, several ambulance services and on the helicopters.

-Sagar strap- Firm but not possibly tight enough. Better than nothing, but should not be mistaken for true immobilization. No evidence to support specific use.

-Transfer Belt- Approximately same width with its padding as the SAM Sling. Again, still no evidence to support specific use, but potentially able to provide some benefit when the same principles are adhered too.

 

The New C-Collar?

As a comparison, I present the idea of considering pelvic immobilization as the new C-Collar; in the sense that collaring used to be one of our earliest considerations in a trauma patient, it was almost a routine treatment and an expected treatment at hospital. C-Spine immobilization has also always been seen as a two person maneuver and providing a pelvic wrap should be treated the same; with one officer providing stability to the pelvis through the selected device while the other tightens and secures it.

Because of the rate of missed diagnosis, there could be a perceived benefit from a culture change to far greater rate of pelvic immobilization. Unlike the hard collars, there is a much lower risk of harm from the application of a binder to a patient, whether they have a pelvic fracture. The literature would support the idea of providing this intervention as early as possible, ideally in the primary survey.

From an organizational perspective too, cervical immobilization is an area that we had a fair amount of training around and we were resourced appropriately with what was believed to be reasonable equipment at the time. Does this compare to the training and equipment we have received in pelvic immobilization?

 

Summary:

Pelvic fractures are a potentially deadly traumatic injury, with a significant risk of major hemorrhage.

-Consideration should be given to the idea that we need to have a lower threshold to treat for pelvic fractures, especially in unconscious patients, while understanding that the specific assessment for these injuries is difficult. Mechanism of injury, signs of shock and sometimes pain are going to be our best indicators.

-The gold standard in care for these patients would be something akin to SAM Sling or another purpose built device. However many of the same principles can apply to the use of our current equipment.

-Consider the nature of bleeding with these fractures and address them in the primary survey. At the same time, critical thought must be given to the administration of fluid.

-With our current equipment the best result we can likely achieve is through a coordinated team approach to apply a firm transfer belt, with the minimal amount of lateral movement. The understanding we now have from ED is that this binder may stay on the patient for a long time, provided it appears to be doing the job.

Check out these summarising articles.

Lee, C., & Porter, K. (2007). The prehospital management of pelvic fractures. Emergency Medicine Journal : EMJ24(2), 130–133. http://doi.org/10.1136/emj.2006.041384

I Scott, K Porter, C Laird, I Greaves, & M Bloch. (2015). The prehospital management of pelvic fractures: initial consensus statement. Trauma, 17(2), 151–154. https://doi.org/10.1177/1460408614556442

 

 

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4 Comments Add yours

  1. Tatsu Kuwasaki says:

    I believe the question “When to put the pelvic binder” is already raising some good discussions.
    As usual, please also refer our CPG (if you haven’t done so already).

    CPG recommendations for the pelvic binder application include;
    * In traumatic cardiac arrest with ? pelvic fracture
    * Hypovolaemic shock is associated with possible pelvic fracture

    In the additional information section (P157) in 4.5 Hypovolaemia from other causes, our CPG highlight the fact that determining the pelvic fracture is difficult by clinical examination, and assume fracture if pain in the area or when MOI suggests.

    Like

  2. Jared van der Hilst says:

    First off, what a great website you guys a creating.
    Just wanted to add to the excellent post on Pelvic injuries.
    I think that while binding is useful in some patients, there have been some instances reported where hemodynamic instability occurred post application of the binder.
    Like you said, pelvic fractures bleed out – Haemorrhage from a pelvic fracture is essentially bleeding into a free space. The pelvis is potentially capable of accommodating the patient’s entire blood volume without the pressure in the space increasing to a point that it causes a tamponading effect to reduce blood loss.
    True pelvic volume is about 1.5 litres. This is increased with disruption of the pelvic ring as the tamponade effect of the pelvic ring is lost with severe pelvic fractures.
    Pelvic Haemorrhage can escape into the. retroperitoneal space, peritoneum and thighs with disruption of the pelvic floor (possible in open book fractures).

    Some pre-hospital services now use pelvic binders on all patients with a suggestive mechanism regardless of clinical or physiological signs of pelvic fracture and the practice is becoming more widespread. Indeed, under section 4.5, page 153 of the Comprehensive CPGs 2016-2018 (WFA edition), the recommendation is to splint the pelvis and tie the legs together if the patient has shock from a potential pelvic fracture.

    So, how can we determine who should have a pelvic binder and who we should be wary of?
    Most classification systems rely on X- ray findings which is not much use to us in the pre-hospital environment, Unless you have X-ray glasses (If you do, I want a pair!) However, the Young and Burgess Classification system is based on the vector of force, which is a bit more useful for us pre-hospitally.
    The system classifies injuries into:

    – Antero-posterior compression (AP)
    – Lateral compression (LC)
    – Vertical shear (VS)
    (Mixed patterns are also possible.)

    AP Compression:
    This is also described as an “open book fracture” if you think about how a book opens , well that exactly replicates how this injury affects the pelvis.
    The hallmark of the AP compression injury is pubic diastasis (diastasis refers to separation of parts normally joint together) with or without disruption of the Sacro-Iliac joints. The location and degree of diastasis is related to the magnitude of force to the pelvis and the amount of instability that results. The AP compression causes the pelvis to open. (like a book – as mentioned)
    Either one or both sides of the pelvis becomes externally rotated and this increases the volume and potential space for bleeding to occur which can then lead to exsanguination.(Very bad!)
    This set of patients is likely to benefit from reduction of the increased pelvic volume by placing on a binder. Placing a binder reverses the direction of the force which caused the injury, thereby reducing the volume and also splints the fracture.
    Identifying the MOI:
    AP compression injuries are typically seen in patients crushed in industrial accidents, where a vehicle has run right over a pedestrian, and in frontal motor vehicle collisions, particularly in vans and incidents where the dash or engine has pushed on both the patients femurs with the hips flexed. It can also be associated with motor bike injuries depending on how the patient lands.(Front on with legs splayed)

    Vertical Shear Injury.
    A vertically oriented force applied to one side of the pelvis (hemipelvis, usually by the femur, results in a vertical shear injury. The affected hemipelvis is displaced in an upwards direction. Complete disruption of the posterior ligaments causes a rotationally and vertically unstable pelvis. Having said that, I know of someone who had a tree fall on their shoulder that led to a similar injury but with a downwards force.
    There are some characteristics that are similar to the AP compression fracture with widening of the pubic symphysis. (The part down the at the bottom that looks like two rings) Placing a binder may help with reduction but it also may rotate the hemipelvis inwards and increase deformity also.
    Identifying the MOI:
    Vertical shear injury is classically associated with long falls where one leg strikes an object that the other does not, with the hip extended. A clinical clue is one leg shorter than the other although this can also be due to a femur fracture.

    Lateral compression injury
    These are the ones we need to be really wary of. Lateral compression injury results in internal rotation of the affected hemipelvis. This internal rotation decreases rather than increases the pelvic volume.
    According to Toth et al (2012) Lateral compression injury comprised 57/115 (50%) cases of unstable high-energy pelvic ring injuries.
    Of this, 10/57 (18%) were haemodynamically unstable.
    The Toth study had 8 cases with lateral compression who had binders applied and in three it resulted in increased deformity. In the other 5 there was no improvement.
    Placing a binder in this group of patients can result in increased fragment displacement. This has been documented in both patients and cadavers with binders in lateral compression injury. (Source Alan Garner, CareFlight)
    Placing a binder in these patients is something we should likely avoid. When you think about it, a binder replicates the direction of the injury force. It also increases fragment displacement in many patients which may cause further laceration of blood vessels or other structures.

    Identifying the MOI:
    Lateral compression is classically seen with T-bone type MVAs or when lateral forces such as a lamp post impacting on the side of the car occur. It also occurs in falls where patients land on one side. Suspect it where you find all the injuries down one side of the patient.

    So, now having gone through this. Although I partially agree with your comment about treating everyone with a MOI that could potentially suggest a pelvic injury, with a binder, I think we need to be a bit more selective in who will receive them. My practice would be to:
    Determine the MOI – AP, VS or LC:
    Are they in shock or exhibiting signs of early shock?
    Check for:
    • Leg length discrepancy (particularly suggests vertical shear injury although may also occur with lateral compression)
    • Flank bruising
    • Pelvic abrasions or lacerations
    • Unexplained hypotension

    Best evidence is that binders are indicated in hemodyamically unstable AP compression injuries and probably vertical shear injuries.
    Binders are best avoided in lateral compression injury; they cannot help and harm has now been reported (Source Alan Garner: CareFlight)

    There is no evidence for prophylactic use in stable patient. In these instances, my practice would be to place it on, but not tighten it. If the hemodynamics worsen, then excluding other factors, I would then tighten it and hope for improvement. (as well as a rapid arrival at ED with a massive transfusion protocol)

    References
    Tan ECTH, et al. Effect of a new pelvic stabilizer (T-POD1) on reduction of pelvic volume and haemodynamic stability in unstable pelvic fractures. Injury (2010), doi:10.1016/j.injury.2010.03.013
    Toth L, King KL, McGrath B, Balogh ZJ. Efficacy and safety of emergency non-invasive pelvic ring stabilisation. Injury, Int. J. Care Injured 43 (2012) 1330–1334

    Liked by 1 person

    1. Tatsu Kuwasaki says:

      Hi Jared,
      It’s great to hear from you and thanks for your input.
      I hear you are spending some time in Australian outback???
      Please join us for more peer learning in future.
      Take care mate.

      Like

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