The prehospital management of pelvic fractures: initial consensus statement

Pelvic Binder Radiography Is Safe and Feasible for Quantifying Fracture Instability in LC1 Pelvis Fractures: A Clinical Trial

OBJECTIVES

To demonstrate fracture displacement, patient tolerance, and in-hospital safety quantifying lateral compression type 1 (LC1) pelvis fracture stability with awake stress radiography using a pelvic binder (PBR).

METHODS

DESIGN

Prospective clinical trial of PBR diagnostic intervention.

SETTING

Two centers, Level I trauma center and academic hospital.

PATIENT SELECTION CRITERIA

Alert adults with LC1 (OTA/AO B1.1/2.1) pelvic fractures from blunt mechanism presenting within 3 weeks of injury between February and December 2023 without hypotension or injury precluding pelvic binder application.

OUTCOME MEASURES AND COMPARISONS

The primary outcome was fracture displacement on PBR. Secondary outcomes included feasibility (≥85% patient tolerance) and safety (no major adverse events). Exploratory outcomes included pain during examination, opioid medication consumption within 96 hours, length of hospital stay, discharge destination, and correlation between fracture displacement on PBR and examination under anesthetic.

RESULTS

One hundred sixty-nine patients with pelvis fractures were screened, 58 were eligible, and 31 were enrolled. The mean age of enrolled patients was 58.7 ± 23 years, 54.8% were female, 22.6% were White, and 67.7% Hispanic. Fracture displacement was 4.3 ± 4.7 mm on PBR at 5 kg and 8.4 ± 9.0 mm at 10 kg. All patients tolerated PBR. Sixteen patients (52%) reported pain during PBR but completed the test. No patient experienced an adverse event. Patients received 40.4 ± 56.4 mg oral morphine equivalents within 96 hours of PBR. Ten patients (32.2%) received internal fixation. The median hospital stay was 6 days (interquartile range 5.5 days) with no inpatient mortality. Fourteen patients (45.2%) discharged home.

CONCLUSIONS

PBR is feasible and safe as a point-of-care test for LC1 pelvis fracture instability.

LEVEL OF EVIDENCE

Level II Diagnostic.

Identification and Management of Pelvic Fractures in Prehospital and Emergency Department Settings

INTRODUCTION

This study aims to describe the characteristics of patients with a pelvic fracture treated at a level 1 trauma center, the proportion of prehospital undertriage and the use of pelvic circumferential compression device (PCCD).

METHODS

This is a retrospective cohort study. Prehospital and inhospital medical records of adults (≥16 y old) with a pelvic fracture who were treated at Hopital de l'Enfant-Jesus-CHU de Québec (Quebec City, Canada), a university-affiliated level 1 trauma center, between September 01, 2017 and September 01, 2021 were reviewed. Isolated hip or pubic ramus fracture were excluded. Data are presented using proportions and means with standard deviations.

RESULTS

A total of 228 patients were included (males: 62.3%; mean age: 54.6 [standard deviation 21.1]). Motor vehicle collision (47.4%) was the main mechanism of injury followed by high-level fall (21.5%). Approximately a third (34.2%) needed at least one blood transfusion. Compared to those admitted directly, transferred patients were more likely to be male (73.0% versus 51.3%, P < 0.001) and to have a surgical procedure performed at the trauma center (71.3% versus 46.9%, P < 0.001). The proportion of prehospital undertriage was 22.6%. Overall, 17.1% had an open-book fracture and would have potentially benefited from a prehospital PCCD. Forty-six transferred patients had a PCCD applied at the referral hospital of which 26.1% needed adjustment.

CONCLUSIONS

Pelvic fractures are challenging to identify in the prehospital environment and are associated with a high undertriage of 22.6%. Reducing undertriage and optimizing the use of PCCD are key opportunities to improve care of patients with a pelvic fracture.

Effective approaches to address noncompressible torso hemorrhage

PURPOSE OF REVIEW

Noncompressible torso hemorrhage (NCTH) is now considered as the major cause of preventable death after both severe military and civilian trauma. Around 20% of all trauma patients still die from uncontrolled exsanguination along with rapidly evolving hemostatic failure. This review highlights the most recent advances in the field and provides an outline for future research directions.

RECENT FINDINGS

The updated definition of NCTH includes a combination of high-grade anatomical torso injury, hemodynamic instability, urgent need for hemorrhage control and aggressive hemostatic resuscitation. Therapeutic concepts consider the following three aspects: control the bleeding source (close the tap), resuscitate to maintain organ perfusion and restore hemostasis (fill the tank), and increase the body's resistance against ischemia (upgrade the armor).

SUMMARY

The concepts for the early management of NCTH have substantially evolved over the last decade. The development of new devices and techniques combined with early intervention of hemostatic failure have contributed to more successful resuscitations. Future research needs to refine and validate their potential clinical application.

Pelvic binder radiography detects occult instability in cadaveric simulated lateral compression type I (LC1) pelvic fractures

OBJECTIVES

Occult instability in minimally displaced lateral compression (LC) pelvic ring injuries may have clinical relevance for treatment. We describe two novel LC pelvis fracture stress examinations - pelvic binder stress radiography (PBR) and pelvic binder stress bladder manometry (PBM) - which do not require sedation, anesthesia, patient transport, or radiation of personnel.

METHODS

A biomechanical study was performed with five fresh elderly cadavers. Sequential osteotomies of the pelvis simulated increasingly unstable LC pelvis fracture patterns (OTA/AO 61A2.2, 61B1.1a, 61B1.1b, 61B2.1). Compressive force was quantitatively applied using a pelvic binder and scale. Pelvis fracture displacement was measured on AP and inlet fluoroscopic views. Pelvic bladder pressure (PBM) was measured using a Foley catheter as a water column.

RESULTS

Fracture displacement strongly correlated with force applied (R2=0.600-0.963). PBR discriminated between simulated LC injuries. Mean displacement of 61B1.1b injuries >1cm was observed at 3.8kg on AP view and 5kg on inlet view. Mean displacement of 61B1.1a injuries >1cm was observed at 8.2kg on AP view and 9.3kg on inlet view. 61A2.2 injuries did not displace >1cm at forces up to 10kg. >95% of 61B1.1a and 61B1.1b injuries displaced >1cm at 10kg. PBM moderately correlated with force applied (R2=0.517-0.842) but did not discriminate between LC injuries.

CONCLUSIONS

PBR is feasible, precisely quantified occult mechanical instability in simulated LC pelvis fractures in response to reproducible applied force, and discriminated between simulated LC pelvis fractures. PBM did not discriminate between simulated LC fractures. A clinical trial to validate the safety and efficacy of PBR for assessing occult instability in LC pelvis fracture is warranted.

Predictive Factors for the Application of Pelvic Binders in the Prehospital Setting

OBJECTIVES

Early pelvic binder placement in the field stabilizes pelvic fractures and tamponades potential hemorrhage within the pelvis. Despite known risk factors for pelvic fracture, it remains challenging to quickly triage and correctly apply a pelvic binder. We aim to develop a prediction model that exclusively uses prehospital criteria to inform the decision to place a pelvic binder.

METHODS

The trauma registry was used to identify all trauma patients admitted to an urban Level I trauma center between January 2013 and December 2017. Variables collected included patient demographics, mechanism of injury, prehospital vital signs, and the presence of a pelvic fracture. Participants were randomly assigned to a training group (70%) or a validation group (30%). Univariate analyses were used to identify significant predictors for use in multivariate predictive models.

RESULTS

A total of 8,480 (65% male; median age 49; median ISS 9) and 3,676 (65% male; median age 48; median ISS 9) trauma patients were randomly assigned to the training and validation groups, respectively. Univariate analysis showed significant likelihood of pelvic fracture associated with female sex, hemodynamic instability (initial systolic blood pressure < 90 mmHg), blunt injury type, specific mechanisms of injury (motor vehicle collision, motorcycle collision, pedestrian struck by motor vehicle, crushing injury, and riding an animal), impact location, and position in vehicle. Multivariate models adjusting for blunt type injury, hemodynamic instability, impact location, and position in vehicle showed that presence of two or more of these risk factors is significantly associated with presence of pelvic fracture.

CONCLUSION

Establishing select prehospital criteria for the empiric application of pelvic binders for patients in the field with blunt injuries, hemodynamic instability, frontal or side motor vehicle collision impact, and non-front seat passenger may improve outcomes among patients with pelvic fractures.

Sex-disaggregated analysis of the injury patterns, outcome data and trapped status of major trauma patients injured in motor vehicle collisions: a prespecified analysis of the UK trauma registry (TARN)

OBJECTIVES

To identify the differences between women and men in the probability of entrapment, frequency of injury and outcomes following a motor vehicle collision. Publishing sex-disaggregated data, understanding differential patterns and exploring the reasons for these will assist with ensuring equity of outcomes especially in respect to triage, rescue and treatment of all patients.

DESIGN

We examined data from the Trauma Audit and Research Network (TARN) registry to explore sex differences in entrapment, injuries and outcomes. We explored the relationship between age, sex and trapped status using multivariate logistical regression.

SETTING

TARN is a UK-based trauma registry covering England and Wales.

PARTICIPANTS

We examined data for 450 357 patients submitted to TARN during the study period (2012-2019), of which 70 027 met the inclusion criteria. There were 18 175 (26%) female and 51 852 (74%) male patients.

PRIMARY AND SECONDARY OUTCOME MEASURES

We report difference in entrapment status, injury and outcome between female and male patients. For trapped patients, we examined the effect of sex and age on death from any cause.

RESULTS

Female patients were more frequently trapped than male patients (female patients (F) 15.8%, male patients (M) 9.4%; p<0.0001). Trapped male patients more frequently suffered head (M 1318 (27.0%), F 578 (20.1%)), face, (M 46 (0.9%), F 6 (0.2%)), thoracic (M 2721 (55.8%), F 1438 (49.9%)) and limb injuries (M 1744 (35.8%), F 778 (27.0%); all p<0.0001). Female patients had more injuries to the pelvis (F 420 (14.6%), M 475 (9.7%); p<0.0001) and spine (F 359 (12.5%), M 485 (9.9%); p=0.001). Following adjustment for the interaction between age and sex, injury severity score, Glasgow Coma Scale and the Charlson Comorbidity Index, no difference in mortality was found between female and male patients.

CONCLUSIONS

There are significant differences between female and male patients in the frequency at which patients are trapped and the injuries these patients sustain. This sex-disaggregated data may help vehicle manufacturers, road safety organisations and emergency services to tailor responses with the aim of equitable outcomes by targeting equal performance of safety measures and reducing excessive risk to one sex or gender.

Do entrapment, injuries, outcomes and potential for self-extrication vary with age? A pre-specified analysis of the UK trauma registry (TARN)

Background

Motor vehicle collisions (MVCs), particularly those associated with entrapment, are a common cause of major trauma. Current extrication methods are focused on spinal movement minimisation and mitigation, but for many patients self-extrication may be an appropriate alternative. Older drivers and passengers are increasingly injured in MVCs and may be at an increased risk of entrapment and its deleterious effects. The aim of this study is to describe the injuries, trapped status, outcomes, and potential for self-extrication for patients following an MVC across a range of age groups.

Methods

This is a retrospective study using the Trauma Audit and Research Network (TARN) database. Patients were included if they were admitted to an English hospital following an MVC from 2012 to 2019. Patients were excluded when their outcomes were not known or if they were secondary transfers. Simple descriptive analysis was used across the age groups: 16–59, 60–69, 70–79 and 80+  years. Logistic regression was performed to develop a model with known confounders, considering the odds of death by age group, and examining any interaction between age and trapped status with mortality.

Results

70,027 patients met the inclusion criteria. Older patients were more likely to be trapped and to die following an MVC (p < 0.0001). Head, abdominal and limb injuries were more common in the young with thoracic and spinal injuries being more common in older patients (all p < 0.0001). No statistical difference was found between the age groups in relation to ability to self-extricate. After adjustment for confounders, the 80 + age group were more likely to die if they were trapped; adjusted OR trapped 30.2 (19.8–46), not trapped 24.2 (20.1–29.2).

Conclusions

Patients over the age of 80 are more likely to die when trapped following an MVC. Self-extrication should be considered the primary route of egress for patients of all ages unless it is clearly impracticable or unachievable. For those patients who cannot self-extricate, a minimally invasive extrication approach should be employed to minimise entrapment time.

Epidemiologic, Postmortem Computed Tomography-Morphologic and Biomechanical Analysis of the Effects of Non-Invasive External Pelvic Stabilizers in Genuine Unstable Pelvic Injuries

Unstable pelvic injuries are rare (3–8% of all fractures) but are associated with a mortality of up to 30%. An effective way to treat venous and cancellous sources of bleeding prehospital is to reduce intrapelvic volume with external noninvasive pelvic stabilizers. Scientifically reliable data regarding pelvic volume reduction and applicable pressure are lacking. Epidemiologic data were collected, and multiple post-mortem CT scans and biomechanical measurements were performed on real, unstable pelvic injuries. Unstable pelvic injury was shown to be the leading source of bleeding in only 19%. All external non-invasive pelvic stabilizers achieved intrapelvic volume reduction; the T-POD^® succeeded best on average (333 ± 234 cm³), but with higher average peak traction (110 N). The reduction results of the VBM^® pneumatic pelvic sling consistently showed significantly better results at a pressure of 200 mmHg than at 100 mmHg at similar peak traction forces. All pelvic stabilizers exhibited the highest peak tensile force shortly after application. Unstable pelvic injuries must be considered as an indicator of serious concomitant injuries. Stabilization should be performed prehospital with specific pelvic stabilizers, such as the T-POD^® or the VBM^® pneumatic pelvic sling. We recommend adjusting the pressure recommendation of the VBM^® pneumatic pelvic sling to 200 mmHg.

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.

[Prehospital Strategies to Stop the Bleeding]

Seriously injured patients represent only a small group of patients in the emergency medical service with 0.5% (ground based) to 5% (HEMS), but they are associated with a high mortality rate. Among people younger than 45, trauma is the most common cause of death, mostly as a result of severe traumatic brain injury (TBI) and/or extreme hemorrhage. As the outcome of severe TBI prehospitally can only be influenced to a very limited extent, a majority of preventable deaths in prehospital setting are caused by "critical" bleeding. The "critical" bleeding is defined by its life-threatening dimension. Anticoagulation medication can have a reinforcing effect. Adequate prehospital therapy strategies exist for external bleeding. In contrast, internal bleeding regularly evades a causal prehospital care, so that in such cases, transport prioritization and rapid definitive surgical intervention remain the only option. In the civilian environment the tested and evaluated "ABCDE" scheme must be preceded by the <C> (for "critical bleeding") in order to react time-critically to compressible external bleeding, possibly even prior to airway management. These findings have found their way into the current version of the S3 guideline on treatment of multi system trauma by the German Society for Trauma Surgery (DGU). According to this "severely bleeding injuries that can impair vital functions should be treated with priority". Thus, this publication focuses on prehospital bleeding control.

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.

Pelvic Ring Fracture During a Professional Surfing Event at the Banzai Pipeline

We present a case of a 32-y-old male professional surfer who sustained an isolated pelvic ring fracture after wiping out on a large wave and striking the ocean floor during a world championship tour surfing competition in Hawaii. The surfer was rescued by the water patrol lifeguards, evaluated by onsite medical staff, and stabilized for transfer and subsequent surgical management. As surfing and surfing competitions become increasingly popular, medical staff and event organizers must be aware of the possibility for severe, life-threatening injuries during surfing events. Although infrequent, staff must be prepared to manage these injuries, including immediate resuscitation, stabilization, analgesia, and transfer to definitive care. We hope this case encourages not only surf event organizers and medical staff, but also staff of all professional and recreational water sports, to increase their preparedness to stabilize and treat both life-threatening and minor injuries. Expeditious and appropriate treatment of an injured athlete has the potential to decrease morbidity and mortality while maximizing the athletes' functional outcome after injury.

Haemodynamics as a determinant of need for pre-hospital application of a pelvic circumferential compression device in adult trauma patients

INTRODUCTION

Pelvic ring fractures are common following high-energy blunt trauma and can lead to substantial haemorrhage, morbidity and mortality. Pelvic circumferential compression devices (PCCDs) improve position and stability of open-book type pelvic fracture, and can improve haemodynamics in patients with hypovolaemic shock. However, PCCDs may cause adverse outcomes including worsening of lateral compression fracture patterns and routine use is associated with high costs. Controversy regarding indication of PCCDs exists with some centres recommending PCCD in the setting of hypovolaemic shock compared to placement for any suspected pelvic injury.

OBJECTIVE

To assess the need for PCCD application based on pre-hospital vital signs and mechanism of injury.

METHODS

A retrospective cohort study was conducted in a single adult major trauma centre examining a 2-year period. Patients were sub-grouped based on initial pre-hospital and emergency department observations as haemodynamically normal (heart rate <100 bpm, systolic blood pressure ≥100 mmHg and Glasgow Coma Scale ≥13) or abnormal. Diagnostic accuracy of pre-hospital haemodynamics as a predictor of pelvic fracture requiring intervention within 24 h was assessed.

RESULTS

There were 376 patients with PCCD in-situ on hospital arrival. Pelvic fractures were diagnosed in 137 patients (36.4%). Of these, 39 (28.5%) were haemodynamically normal and 98 (71.5%) were haemodynamically abnormal. The most common mechanisms of injury were motor vehicle collision (57.7%) and motorcycle collision (13.8%). Of those with fractures, 40 patients (29.2%) required pelvic intervention within 24 h of admission; of these, 8 (20%) were haemodynamically normal and 32 (80%) were haemodynamically abnormal. As a test for pelvic fracture requiring intervention within 24 h, abnormal pre-hospital haemodynamics had a sensitivity of 0.80 (95% CI 0.64-0.91), specificity of 0.32 (95% CI 0.27-0.38) and negative predictive value (NPV) of 0.93 (95% CI 0.88-0.96). Combined with absence of a major mechanism of injury, normal haemodynamics had a sensitivity 1.00, specificity 0.51 (95% CI 0.36-0.66) and NPV of 1.00 for pelvic intervention within 24 h.

CONCLUSION

Normal haemodynamic status, combined with absence of major mechanism of injury can rule out requirement for urgent pelvic intervention. Ongoing surveillance is recommended to monitor for any adverse effects of this change in practice.

Timely completion of multiple life-saving interventions for traumatic haemorrhagic shock: a retrospective cohort study

Background

Early control of haemorrhage and optimisation of physiology are guiding principles of resuscitation after injury. Improved outcomes have been previously associated with single, timely interventions. The aim of this study was to assess the association between multiple timely life-saving interventions (LSIs) and outcomes of traumatic haemorrhagic shock patients.

Methods

A retrospective cohort study was undertaken of injured patients with haemorrhagic shock who presented to Alfered Emergency & Trauma Centre between July 01, 2010 and July 31, 2014. LSIs studied included chest decompression, control of external haemorrhage, pelvic binder application, transfusion of red cells and coagulation products and surgical control of bleeding through angio-embolisation or operative intervention. The primary exposure variable was timely initiation of ≥ 50% of the indicated interventions. The association between the primary exposure variable and outcome of death at hospital discharge was adjusted for potential confounders using multivariable logistic regression analysis. The association between total pre-hospital times and pre-hospital care times (time from ambulance at scene to trauma centre), in-hospital mortality and timely initiation of ≥ 50% of the indicated interventions were assessed.

Results

Of the 168 patients, 54 (32.1%) patients had ≥ 50% of indicated LSI completed within the specified time period. Timely delivery of LSI was independently associated with improved survival to hospital discharge (adjusted odds ratio (OR) for in-hospital death 0.17; 95% confidence interval (CI) 0.03–0.83; p = 0.028). This association was independent of patient age, pre-hospital care time, injury severity score, initial serum lactate levels and coagulopathy. Among patients with pre-hospital time of ≥ 2 h, 2 (3.6%) received timely LSIs. Pre-hospital care times of ≥ 2 h were associated with delayed LSIs and with in-hospital death (unadjusted OR 4.3; 95% CI 1.4–13.0).

Conclusions

Timely completion of LSI when indicated was completed in a small proportion of patients and reflects previous research demonstrating delayed processes and errors even in advanced trauma systems. Timely delivery of a high proportion of LSIs was associated with improved outcomes among patients presenting with haemorrhagic shock after injury. Provision of LSIs in the pre-hospital phase of trauma care has the potential to improve outcomes.

Mountain Rescue Casualty Care and the Undergraduate Medical Elective

Many UK medical curricula lack dedicated prehospital education other than first aid courses and basic life support training. In contrast, nonmedical mountain rescue team members receive advanced prehospital training addressing scene management and various clinical interventions. This article reports a condensed mountain rescue casualty care course designed for medical students by a mountain rescue team. The course was offered as part of a student-selected module during phase 3A at the University of Sheffield Medical School. Within the module, students also learned the relevant biomedical sciences and clinical skills to construct their knowledge of mountain rescue casualty care.

Chinese expert consensus on echelons treatment of pelvic fractures in modern war

The characteristics and treatment of pelvic fractures vary between general conditions and modern war. An expert consensus has been reached based on pelvic injury epidemiology and the concepts of battlefield treatment combined with the existing levels of military medical care in modern warfare. According to this consensus, first aid, emergency treatment and early treatment of pelvic fractures are introduced in three separate levels. In Level I facilities, simple triage and rapid treatment following the principles of advanced trauma life support are recommended to evaluate combat casualties during the first-aid stage. Re-evaluation, further immobilization and fixation, and hemostasis are recommended at Level II facilities. At Level III facilities, the main components of damage control surgery are recommended, including comprehensive hemostasis, a proper resuscitation strategy, the treatment of concurrent visceral and blood vessel damage, and battlefield intensive care. The grading standard for evidence evaluation and recommendation was used to reach this expert consensus.

Improvised first aid techniques for terrorist attacks

Terrorist acts occur every day around the world. Healthcare professionals are often present as bystander survivors in these situations, with none of the equipment or infrastructure they rely on in their day-to-day practice. Within several countries there has been a move to disseminate the actions to take in the event of such attacks: in the UK, Run, Hide, Tell, and in the USA, Fight Back. This paper outlines how a very basic medical knowledge combined with everyday high-street items can render highly effective first aid and save lives. We discuss and summarise modern improvised techniques. These include the <C> ABCDE approach of treating catastrophic haemorrhage before airway management, bringing together improvised techniques from the military and wilderness medicine. We explain how improvised tourniquets, wound dressings, splinting and traction devices can be fabricated using items from the high street: nappies, tampons, cling film, duct tape and tablecloths. Cervical spine immobilisation is a labour-intensive protocol that is often practised defensively. With little evidence to support the routine use of triple immobilisation, this should be replaced with a common sense dynamic approach such as the Montana neck brace. Acid or alkali attacks are also examined with simple pragmatic advice. Analgesia is discussed in the context of a prehospital setting. Pharmacy-obtained oral morphine and diclofenac suppositories can be used to treat moderate pain without relying on equipment for intravenous/intraosseous infusion in prolonged hold situations. The differentiation between concealment and cover is summarised: scene safety remains paramount.

Effects of the establishment of a trauma center and a new protocol on patients with hemodynamically unstable pelvic fractures at a single institution in Korea

PURPOSE

The aim of this study was to determine whether the outcomes of patients with hemodynamically unstable pelvic bone fractures changed after the introduction of a protocol including extraperitoneal pelvic packing (EPP) and the establishment of a trauma center.

METHODS

We analyzed data of adult patients (≥ 18 years old) with hemodynamically unstable pelvic bone fractures who visited a single trauma center from February 2009 to October 2016. In July 2014, a new protocol for pelvic fractures was implemented, and a trauma center was established. Therefore, patient outcomes were compared by period (period I: pre-protocol vs. period II: post-protocol).

RESULTS

Seventy-nine patients with hemodynamically unstable pelvic bone fractures were recruited. The time to angiographic embolization after arrival at the emergency room decreased significantly in period II when compared to period I (182.9 vs. 268.9 min, respectively, p < 0.001). The time required to intervention, including EPP, also decreased, from 268.9 ± 132.4 min in period I to 141.9 ± 79.9 min in period II (p < 0.001). The overall mortality rate decreased from 47.2% in period I to 23.3% in period II (p = 0.033), and mortality related to hemorrhagic shock in particular, was significantly lowered, from 27.8% in period I to 4.7% in period II (p = 0.009).

CONCLUSIONS

The establishment of a trauma center and the implementation of a new protocol that included EPP were effective in the treatment of patients with hemodynamically unstable pelvic fractures.

An assessment of pelvic binder placement at a UK major trauma centre

Introduction Pelvic binders are used to reduce the haemorrhage associated with pelvic ring injuries. Application at the level of the greater trochanters is required. We assessed the frequency of their use in patients with pelvic ring injuries and their positioning in patients presenting to a single major trauma centre. Methods A retrospective review of our trauma database was performed to randomly select 1000 patients for study from April 2012 to December 2016. Patients with a pelvic binder or a pelvic ring injury defined by the Young and Burgess classification were included. Computed tomography was used to identify and measure pelvic binder placement. Results 140 patients were identified: 110/140 had a binder placed. Of the total, 54 (49.1%) patients had satisfactory placement and 56 (50.9%) had unsatisfactory placement; 30/67 (44.8%) patients with a pelvic ring injury had no binder applied, of whom 6 (20%) had an unstable injury; 9/67 patients died. Discussion This is the first study assessing pelvic binder placement in patients at a UK major trauma centre. Unsatisfactory positioning of the pelvic binder is a common problem and it was not used in a large proportion of patients with pelvic ring injuries. This demonstrates that there is a need for continuing education for teams dealing with major trauma.

Intra-pelvic pressure changes after pelvic fracture: A cadaveric study quantifying the effect of a pelvic binder and limb bandaging over a bolster

INTRODUCTION

Unstable pelvic fractures can be life-threatening due to catastrophic haemorrhage. Non-invasive methods of reducing and stabilising these injuries include pelvic binder application and also lower limb bandaging over a knee-flexion bolster. Both of these methods help close the pelvic ring and should tamponade bleeding. This study aimed to quantify the intra-pelvic pressure changes that occurred with 3 different manoeuvres: lower limb bandaging over a bolster; a Trauma Pelvic Orthotic Device (T-POD) pelvic binder, and a combination of both.

METHODS

Following a pilot study with 2 soft embalmed cadavers, a formal study with 6 unembalmed cadavers was performed. For each specimen an unstable pelvic injury was created (OA/OTA 61-C1) by dividing the pelvic ring anteriorly and posteriorly. A 3-4cm manometric water-filled balloon was placed in the retropubic space and connected to a 50ml syringe and water manometer via a 3-way tap. A baseline pressure of 8cmH₂O (equating to the average central venous pressure) was used for each cadaver. Steady intra-pelvic pressures (more reliably reflecting the pressures achieved following an intervention) were used in the subsequent statistical analysis, using R statistical language and Rstudio. Paired t-test or Wilcoxon's rank sum test were used (depending on the normality of the dataset) to determine the impact of each intervention on the intra-pelvic pressure.

RESULTS

The mean steady intra-pelvic pressures were significantly greater than the baseline pressure for each intervention. The binder and limb bandaging over a bolster alone increased the mean steady pelvic pressures significantly to 24 (SE=5) (p<0.036) and 15.5 (SE=2) (p<0.02)cmH₂O respectively. Combining these interventions further increased the mean steady pressure to 31 (SE=7)cmH₂O. However, this was not significantly greater than pressures for each of the individual interventions.

DISCUSSION

Both lower limb bandaging over a bolster and pelvic binder application significantly increased intra-pelvic pressure above the baseline pressure. This was further increased through combining these interventions, which could be useful clinically to augment haemorrhage control in these fractures.

CONCLUSION

Lower-limb bandaging over a bolster, and pelvic binder application, both significantly increased intra-pelvic pressures, and were greatest in combination. These findings support the use of these techniques to facilitate non-surgical haemorrhage control.

Potentially preventable prehospital deaths from motor vehicle collisions

BACKGROUND

In 2011, about 30,000 people died in motor vehicle collisions (MVCs) in the United States. We sought to evaluate the causes of prehospital deaths related to MVCs and to assess whether these deaths were potentially preventable.

METHODS

Miami-Dade Medical Examiner records for 2011 were reviewed for all prehospital deaths of occupants of 4-wheeled motor vehicle collisions. Injuries were categorized by affected organ and anatomic location of the body. Cases were reviewed by a panel of 2 trauma surgeons to determine cause of death and whether the death was potentially preventable. Time to death and hospital arrival times were determined using the Fatality Analysis Reporting System (FARS) data from 2002 to 2012, which allowed comparison of our local data to national prevalence estimates.

RESULTS

Local data revealed that 39% of the 98 deaths reviewed were potentially preventable (PPD). Significantly more patients with PPD had neurotrauma as a cause of death compared to those with a nonpreventable death (NPD) (44.7% vs. 25.0%, P =.049). NPDs were significantly more likely to have combined neurotrauma and hemorrhage as cause of death compared to PPDs (45.0% vs. 10.5%, P <.001). NPDs were significantly more likely to have injuries to the chest, pelvis, or spine. NPDs also had significantly more injuries to the following organ systems: lung, cardiac, and vascular chest (all P <.05). In the nationally representative FARS data from 2002 to 2012, 30% of deaths occurred on scene and another 32% occurred within 1 h of injury. When comparing the 2011 FARS data for Miami-Dade to the remainder of the United States in that year, percentage of deaths when reported on scene (25 vs. 23%, respectively) and within 1 h of injury (35 vs. 32%, respectively) were similar.

CONCLUSIONS

Nationally, FARS data demonstrated that two thirds of all MVC deaths occurred within 1 h of injury. Over a third of prehospital MVC deaths were potentially preventable in our local sample. By examining injury patterns in PPDs, targeted intervention may be initiated.

Prehospital control of life-threatening truncal and junctional haemorrhage is the ultimate challenge in optimizing trauma care; a review of treatment options and their applicability in the civilian trauma setting

Introduction

Exsanguination following trauma is potentially preventable. Extremity tourniquets have been successfully implemented in military and civilian prehospital care. Prehospital control of bleeding from the torso and junctional area’s remains challenging but offers a great potential to improve survival rates. This review aims to provide an overview of potential treatment options in both clinical as preclinical state of research on truncal and junctional bleeding. Since many options have been developed for application in the military primarily, translation to the civilian situation is discussed.

Methods

Medline (via Pubmed) and Embase were searched to identify known and potential prehospital treatment options. Search terms were|: haemorrhage/hemorrhage, exsanguination, junctional, truncal, intra-abdominal, intrathoracic, intervention, haemostasis/hemostasis, prehospital, en route, junctional tourniquet, REBOA, resuscitative thoracotomy, emergency thoracotomy, pelvic binder, pelvic sheet, circumferential. Treatment options were listed per anatomical site: axilla, groin, thorax, abdomen and pelvis Also, the available evidence was graded in (pre) clinical stadia of research.

Results

Identified treatment options were wound clamps, injectable haemostatic sponges, pelvic circumferential stabilizers, resuscitative thoracotomy, resuscitative endovascular balloon occlusion of the aorta (REBOA), intra-abdominal gas insufflation, intra-abdominal self-expanding foam, junctional and truncal tourniquets. A total of 70 papers on these aforementioned options was retrieved. No clinical reports on injectable haemostatic sponges, intra-abdominal insufflation or self-expanding foam injections and one type of junctional tourniquets were available.

Conclusion

Options to stop truncal and junctional traumatic haemorrhage in the prehospital arena are evolving and may offer a potentially great survival advantage. Because of differences in injury pattern, time to definitive care, different prehospital scenario’s and level of proficiency of care providers; successful translation of various military applications to the civilian situation has to be awaited. Overall, the level of evidence on the retrieved adjuncts is extremely low.

Damage control: The modern paradigm

It is more than 20 years since the term ‘Damage control’ was introduced to describe an emerging surgical strategy of abbreviated laparotomy for exsanguinating trauma patients. This strategy of temporisation and prioritisation of physiological recovery over completeness of anatomical repair was associated with improved survival in a subset of patients with combined major vascular and multiple visceral injuries. The ensuing years saw the rapid adoption of these principles as standard of care for massively injured and physiologically exhausted patients. Resuscitation of severely injured patients has changed significantly in the last decade with the emergence of a new resuscitation paradigm termed ‘damage control resuscitation’. Originating in combat support hospitals, damage control resuscitation emphasises the primacy of haemorrhage control while directly targeting the ‘lethal triad’ of coagulopathy, acidosis, and hypothermia. Integral to damage control resuscitation is the appropriate application of damage control surgery and together they constitute the modern damage control paradigm. This review aims to discuss the modern application of damage control resuscitation and damage control surgery and to review the evidence supporting its constituent components, as well as considering deficiencies in current knowledge and areas for future research.

Pelvic fracture in multiple trauma: are we still up-to-date with massive fluid resuscitation?

Until today the mortality of complex pelvic trauma remains unacceptably high. On the one hand this could be attributed to a biological limit of the survivable trauma load, on the other hand side an ongoing inadequate treatment might be conceivable too. For the management of multiple trauma patients with life-threatening pelvic fractures, there is ongoing international debate on the adequate therapeutic strategy, e.g. arterial embolization or pelvic packing, as well as aggressive or restrained volume therapy. Whereas traditional pelvis-specific trauma algorithms still recommend massive fluid resuscitation, there is upcoming evidence that a restrained volume therapy in the preclinical setting may improve trauma outcomes. Less intravenous fluid administration may also reduce haemodilution and concomitant trauma-associated coagulopathy. After linking the data of the TraumaRegister DGU(®) and the German Pelvic Injury Register, for the first time, the initial fluid management for complex pelvic traumas as well as for different Tile/OTA types of pelvic ring fractures could be addressed. Unfortunately, the results could not answer the question of the adequate fluid resuscitation but confirmed the actuality of massive fluid resuscitation in the prehospital and emergency room setting. Low-volume resuscitation seems not yet accepted in practice in managing multiple trauma patients with pelvic fractures at least in Germany. Nevertheless, prevention of exsanguination and of complications like multiple organ dysfunction syndrome still poses a major challenge in the management of complex pelvic ring injuries. Even nowadays, fluid management for trauma, not only for pelvic fractures, remains a controversial area and further research is mandatory.