THE ASSESSMENT AND TREATMENT OF UNSTABLE PELVIC INJURIES

Despite advances in diagnostic and operative techniques, pelvic injuries still account for 39% of al blunt trauma deaths

Pelvic injuries have a 9% mortality rate overall, but unstable fractures have a 30+% death rate

90% of patients have a second injury

Anterior View Posterior View Ligaments and anterior structure provides for 40% of pelvic stability Ligaments and posterior structure provides for 60% of pelvic stability

Types of Pelvic Fractures Anteroposterior Compression Lateral Compression Vertical Shear

Causes are generally frontal impact MV crashes, especially front seat occupants Severity is governed by the abount of ligament damage and widening of symphesis pubis Higher energy transfer is required the higher up the scale you go Type III will almost always have second injury due to this transfer including pelvic and abdominal organ damage, severe bleeding and nerve damage

Caused by lateral impact, generally side impact MV crashes or pedestrian hit by a vehicle Again, there is more energy transfer the higher up the scale you go Associated organ, vessel and nerve damage The energy transfer may cause collateral fractures, i.e. one the opposite side of impact

Caused by a fall from a height Damage dependant upon fall distance and area of impact Displacement of iliac may cause severe vessel and nerve damage

Prehospital Assessment MOI—most common is a motor vehicle or pedestrian collision MOI—second most common are high level falls or low-level involving geriatric patients Most common complaint is pelvic pain. Secondary pain in back, hip or groin are also prevalent Leg-length discrepancy present? Bruising over flank, bony prominences of pelvis, pubis, perineum or scrotum Don’t forget a full assessment—remember there is a 90% chance of other injuries! “rocking” or “springing” the pelvis is very unreliable Only 37 – 67% reliable (Gonzalez, 2002) Maryland Protocols state that palpation shall be attempted only once May dislodge clots or promote further blood loss

Associated Injuries Thorax 30-50% Abdomen 30-50% Extremity 50 – 70% Head 40-50% Thorax 30-50% Abdomen 30-50% Extremity 50 – 70%

Hemorrhage Control & Treatment Internal hemorrhage is a major cause of death within the first 24 hours Traditional treatments were internal rotation of the lower limbs followed by wrapping with a bedsheet or PASG/MAST Studies show that these had inconsistent results, questionable effectiveness and the possibility of overcompression—no mortality benefit or reduction in hospital stay

2. If Local Jurisdiction permits, a pelvic binder should be applied 1. Head-to-toe Survey 2. If Local Jurisdiction permits, a pelvic binder should be applied This is a treatment intervention-not a packaging intervention— APPLY EARLY This is an Optional Supplemental Program under MIEMSS Protocols as of July 2019 applicable to all EMS proviedrs trained in proper use of the devices 3. Patient should be moved to a long board via scoop stretcher Do not log roll—remember minimal movement 4. ALS interventions may include IV establishment and pain management

Maryland Medical Protocols

Maryland Medical Protocols

Practical Application

Review Identification of Mechanisms of Injury Anatomy of the pelvis Appropriate pre-hospital treatment of suspected pelvic injuries Maryland EMS Protocols governing commercial pelvic binders Proper application of pelvic binders

High energy MVA’s and falls have increased the number of pelvic injuries encountered in the pre-hospital setting. These potentially life-threatening events can be properly assessed and treated by pre-hospital providers, thereby reducing overall morbidity and mortality.