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.
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!
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.
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?
–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.