(iv) The initial assessment and early management of patients with severe pelvic ring injuries

In a simulated adult trauma patient, can pelvic binders be applied accurately by paramedics and HEMS paramedics? A pilot observational study

Background:

Pre-hospital treatment of suspected haemorrhagic pelvic fractures includes application of a purpose-made pelvic binder. Recent hospital studies identified poor accuracy of pelvic binder application, but there is little pre-hospital research to date.

Methods:

A pilot observational study was conducted in an NHS ambulance service to examine the accuracy of landmark identification and pelvic binder application. Paramedics and Helicopter Emergency Medical Service (HEMS) paramedics were recruited via an internal advert. Participants were asked to name and identify the landmarks (greater trochanters) on a simulated patient and apply the Prometheus pelvic splint. Participants read two clinical scenarios and indicated if they would apply a pelvic binder. Descriptive and inferential statistics were used in the analysis of results to compare performance between the two groups.

Results:

Twenty-six paramedics were recruited. A total of 92.3% (n = 12) paramedics and 100% (n = 13) HEMS paramedics verbalised the correct landmarks. A total of 23.1% (n = 3) paramedics and 61.5% (n = 8) HEMS paramedics identified the correct landmarks on both sides of the pelvis. A total of 15.4% (n = 2) paramedics and 61.5% (n = 8) HEMS paramedics applied the pelvic binder centrally over both greater trochanters. Clinical decision-making to apply a pelvic binder was largely in accordance with a local standard operating procedure.

Conclusion:

This study supports existing research highlighting cases of inaccurate pelvic binder placement. HEMS paramedics were more accurate than paramedics, but only 39% of all binders placed in the study were applied correctly. Frequent exposure to major trauma and familiarity with pelvic binders may have resulted in greater accuracy among HEMS paramedics. Further education and training around clinical assessment of the pelvis may improve the accuracy of pelvic binder application by all paramedics. This would subsequently improve the quality of patient care and ensure adequate haemorrhage control is maintained.

Identifying risk factors for suboptimal pelvic binder placement in major trauma

AIMS

This study aimed to identify the frequency of sub-optimal pelvic binder placement at a tertiary-level trauma centre, produce a reproducible, quantitative measure of pelvic binder fit, and identify risk factors for sub-optimal placement.

PATIENTS AND METHODS

We identified all consecutive patients who had a pelvic binder in place on arrival to the Royal Brisbane and Women's Hospital in Queensland, Australia from 2012-2016. The X-Rays were reviewed by two senior clinicians for position and measured for degree of displacement if not optimally placed between the greater and lesser trochanters. Risk factors for sub-optimal position of the binder were assessed using multiple logistic regression with inclusion of all variables that had a statistical association (to p<0.05) at the univariate analysis stage. Secondary assessment was conducted of patients who had undergone CT imaging for subcutaneous body fat distribution.

RESULTS

In total, 496 X-Rays were assessed for pelvic binder fit, finding 43.5% sub-optimally placed. 39.7% binders were superior to the greater trochanter line and 3.8% inferiorly placed below the lesser trochanter line. The majority of the sub-optimally placed binders were within 60 mm of the ideal position. Female patients had a greater risk of sub-optimal binder placement compared to males (62.5% vs 37%). Increasing intertrochanteric height was found to be protective for ideal binder placement with an aOR 0.62 for each cm in increased height. There was no association with sub-optimal placement and age, sex, mechanism of trauma, injury severity score, number of body regions injured or Glasgow Coma Scale. There was strong kappa agreement between the X-Ray assessors for binder position assessment on the plain radiological imaging.

CONCLUSION

Sub-optimal positioning of pelvic binders is common in our trauma population. This study has described the risk factors associated with higher rates of sub-optimal fit and provides a description of rapid radiological assessment for optimal fit for the bedside clinician caring for injured patients in the resuscitation room.

The value of 'binder-off' imaging to identify occult and unexpected pelvic ring injuries

AIMS

To determine the effectiveness of 'binder-off' plain pelvic radiographs in the assessment of pelvic ring injuries.

PATIENTS AND METHODS

All patients requiring operative intervention at our tertiary referral pelvic unit/major trauma centre for high-energy pelvic injuries between April 2012 and December 2014 were retrospectively identified. Pre-operative pelvic imaging with and without pelvic binder was reviewed with respect to fracture pattern and pelvic stability. The frequency with which the imaging without pelvic binder changed the opinion of the pelvic stability and need for operative intervention, when compared with the computed tomography (CT) scans and anteroposterior (AP) radiographs with the binder on, was assessed.

RESULTS

Seventy-three percent (71 of 97) of patients had initial imaging with a pelvic binder in situ. Of these, 76% (54 of 71) went on to have 'binder-off' imaging. Seven percent (4 of 54) of patients had unexpected unstable pelvic ring injuries identified on 'binder-off' imaging that were not identified on CT imaging in binder.

CONCLUSIONS

Trauma CT imaging of the pelvis with a pelvic binder in place is inadequate at excluding unstable pelvic ring injuries, and, based on the original findings in this paper, we recommend additional plain film 'binder-off' radiographs, when there is any clinical concern.