Airway & Respiratory, Cardiac & Resuscitation, Patient Care, Trauma

Critical Management of Deadly Pelvic Injuries

Issue 12 and Volume 39.

It’s 2 p.m. on a Saturday when you’re dispatched to the northbound lanes of Interstate 75 at mile marker 80 for reports of a motorcycle accident. En route, highway patrol notifies you there’s a single male rider involved in a high-speed crash. On arrival, you find a 22-year-old male lying on the highway 40 feet from his motorcycle, wearing a helmet and body gear. He’s conscious but confused. His breathing is fast and shallow. A radial pulse is barely palpable and his skin is cool and pale.

The responding engine company prepares for packaging as you and your partner complete your rapid trauma assessment, obtain vital signs and prepare for transport. You’re 25 minutes from the trauma center and suspect this young man has serious internal injuries.

Introduction to Pelvic Trauma
Pelvic fractures represent approximately 3% of all skeletal injuries annually in the United States1 and account for 9% of trauma patients admitted to the hospital. 2 These injuries range from benign to rapidly life-threatening, with an overall mortality of 10–16%.2 However, open pelvic fractures, which represent approximately 2–4% of pelvic injuries, have the highest mortality rate at nearly 45%.1,3 Pelvic fractures most frequently occur in patients 15–28 years old who sustain high-energy, side-impact mechanisms of injury such as high-level falls or motor vehicle collisions (MVCs),4 but serious pelvic injuries can also occur from minor mechanisms such as ground-level falls. This is especially true in elderly patients.

Pelvis Anatomy
The pelvis is a ring-shaped bony structure consisting of the sacrum, coccyx, and three innominate bones: the ilium, ischium and pubis. The innominate bones join to form the acetabulum—the socket in which the head of the femur sits to form the hip joint. The joint between the sacrum and ilium (sacroiliac joint, or SI joint) is the strongest joint in the body, and the pubic symphysis is the weakest link in the pelvic ring. (See Figure 1, p. 29). The strength and stability of the pelvis is a result of several ligaments that connect the sacrum to the other pelvic bones, and potentially dangerous pelvic instability can result when these ligaments are disrupted.

The primary organs lying within the pelvis are the bladder, rectum, anal canal and urethra, along with the prostate in males and the uterus and vagina in females. Also contained within the pelvis is a vast array of blood vessels, nerves and internal organs. When trauma causes pelvic instability or a fracture, injury to the large network of arteries and thin-walled veins that lie anterior to the sacrum can cause severe internal hemorrhage. Injury to nerve roots, which course through the pelvis, can result in bowel, bladder and sexual dysfunction.

Types of Pelvic Fractures
Injuries include fractures of the sacrum or acetabulum, avulsion injuries, and pelvic ring disruption, which tends to be the most serious. Because the pelvis is a closed ring, it commonly fractures or is disrupted in more than one location. Disruptions are most commonly described by using the Young and Burgess classification scheme, which classifies pelvic ring disruptions into three broad categories based on the direction of the causative injury force: lateral compression injuries, anteroposterior compression injuries and vertical shear injuries.5

Lateral compression injuries usually occur when a significant force is delivered to the side of the body, such as a pedestrian side struck or a T-bone MVC. In the most serious type of lateral compression, the injury force is so great that energy is transmitted through the pelvis to the opposite side, creating an open-book fracture on the side opposite of impact.6

Anteroposterior compression injuries occur when an anterior force impacts the patient, such as in a head-on MVC. The most severe injury causes complete disruption of the SI joint in addition to anterior pelvic ring injuries.

Although rare, vertical shear injuries are structurally devastating as one side of the pelvis is forced upward, separating entirely from the other half of the pelvis. These injuries may result from a head-on MVC in which the occupant’s leg is extended and braced on the brake pedal.6 As a result, the femur is driven upward and causes that side of the pelvis to be displaced superiorly.

An open-book pelvic fracture is a term used to describe any fracture that significantly disrupts the pelvic ring. These injuries combine an anterior pelvic injury causing a widening (opening) of the pubic symphysis, and a posterior pelvic fracture or ligamentous injury.6 Based on the severity of pelvic widening, lateral compression, anteroposterior compression and vertical shear injuries can be termed open-book. If the normally closed anterior pelvic ring is widened greater than 2.5 cm, there’s increased likelihood the posterior pelvis is also injured, thus increasing the volume of the pelvis and the risk of major hemorrhage.6 Though any pelvic fracture can be life-threatening, open-book pelvic injuries have the highest risk of death or disability.

Pelvic Injury Hemorrhage & Associated Injuries
The most feared complication of a pelvic injury is rapid and uncontrolled hemorrhage into the retroperitoneal space, which is capable of accommodating the patient’s entire blood volume. Any pelvic fracture pattern can be associated with significant hemorrhage that occurs from arterial laceration, venous injury, or bone fragments. However, the source of pelvic hemorrhage is found to be a venous injury in 80–90% of cases.8

Additionally, up to 20% of pelvic fractures may result in hemodynamic instability and over 1/3 of patients hospitalized with pelvic fractures will require blood transfusions.3,7

To disrupt the pelvic ring requires a significant force of injury, equivalent to instantly coming to a stop from 30 miles per hour.9 As a result of these high-energy impacts, pelvic fractures are frequently associated with potentially life-threatening, coexisting injuries to the head, chest, abdomen or spinal column. Over 80% of patients with unstable pelvic fractures will also have additional musculoskeletal injuries.9 Patients with pelvic trauma suffer damage to intra-abdominal organs in 16.5% of cases with the spleen, liver and bowel most frequently injured.3 Rectal injuries occur in approximately 5% of patients predisposing to the risk of late onset infection and sepsis.

The bladder and urethra are also frequently injured, with males being ten times more likely to sustain this injury then females.10 Lastly, in the presence of an unstable pelvic fracture, up to 50% of trauma patients may experience some degree of associated neurologic injury.6

Assessment
Pelvic pain is the most common finding in patients with pelvic fractures who are awake and alert,11 but pain in the lower back, groin or hip may also be an indication.12 In addition, patients may have a leg length discrepancy (one leg shorter than the other) or a rotational deformity. Bruising over the flank, bony prominences of the pelvis, pubis, perineum or scrotum are also suggestive of significant pelvic injury. Wounds over the pelvis or bleeding from the rectum, vagina or urethra are signs that a bone fragment may have penetrated the skin and thus an open pelvic fracture may exist. If pelvic trauma is causing an associated nerve injury, the patient may experience loss of bowel or bladder control.10

Classic teaching encourages “rocking” or “springing” the pelvis to identify pelvic tenderness or instability and thus a possible source of internal hemorrhage. However, this technique has proved to be very unreliable, detecting only the most severe pelvic disruptions.9,12,13 Furthermore, this maneuver may be dangerous to the patient by further displacing fracture fragments and dislodging formed blood clots, resulting in worsening hemorrhage.6,9 Thus, it’s strongly recommended that providers avoid rocking the pelvis. Instead, gently palpate the bony structures of the pelvis and lower spine for tenderness. Some clinicians also recommend a cautious, one-time only inward compression maneuver of the iliac crests to assess for instability.

EMS Management
Internal hemorrhage is a major cause of death during the first 24 hours after pelvic injury.9,14 Compared to causes of external hemorrhage such as extremity wounds, EMS diagnosis of pelvic fractures can be extremely difficult. Therefore, the most critical aspect of prehospital management of pelvic injuries is having a high suspicion. Early suspicion and identification by EMS allows for the timely triage and treatment required to maximize patient outcomes. (See Table 1).

In 2013, researchers from the United Kingdom published a consensus statement on the prehospital management of pelvic fractures.15 (See Table 2). Although some of the statements don’t have considerable scientific support, it’s a valuable resource for any EMS agency.

When to stabilize the patient: In general, the literature demonstrates that in the hemodynamically stable, alert and oriented trauma patient with no distracting injury and no signs of pelvic fracture, pelvic stabilization is not required.12,16

However, in trauma patients with an altered level of consciousness (Glasgow coma scale (GCS) < 13), hemodynamic instability or obvious distracting injuries, the clinical assessment for pelvic fracture is devastatingly inaccurate.17 Many experts advocate these patients should be routinely placed in pelvic stabilization as the potential risks of missing an occult pelvic injury outweigh the risks or complications associated with pelvic binding. Some advocate that in the unresponsive blunt trauma patient, the pelvis shouldn’t be palpated for instability at all because the presence of a pelvic injury should be assumed and thus a pelvic binder empirically placed.12

In general, a reasonably conservative approach is to stabilize the pelvis of any trauma patient with a moderate to severe blunt mechanism of injury who has any of the following criteria:

1. Obvious signs of pelvic injury/instability on physical exam;
2. Signs of hemorrhagic shock and reports pelvic or low back pain/tenderness even if the pelvis seems stable; or
3. Signs of hemorrhagic shock and altered mental status regardless of the presence or absence of pelvic pain or instability.

Controlling hemorrhage: The goal of pelvic stabilization is to prevent additional vascular and tissue injury from fracture fragment movement while also decreasing pelvic volume in an attempt to tamponade bleeding vessels and bones. With that said, the exact mechanism by which pelvic binding actually contributes to hemorrhage control is controversial.9 Regardless, because appropriate pelvic stabilization plays a role in stopping potentially life-threatening bleeding, it should be considered as part of a provider’s initial trauma treatment.15

Classic teaching on the management of pelvic fractures recommends circumferentially wrapping a bed sheet around the pelvis while taping the lower limbs in internal rotation to reduce the pelvic volume.18,19

Although successful reduction of open-book pelvic fractures with a circumferential sheet has been reported, this technique is often difficult to consistently reproduce, requires multiple providers to accomplish, and frequently doesn’t achieve or maintain the necessary reduction force.12,19,20

In the past 15 years, a variety of commercial external pelvic compression devices have evolved to provide fast, easy and consistent pelvic stabilization (e.g., TPOD, SAM Pelvic Sling). Cadaver and some clinical studies demonstrate the ability of these devices to improve pelvic alignment.21,22 However, research evaluating the efficacy of these pelvic binders in controlling hemorrhage from pelvic fractures has been conflicting. Case series and some clinical studies report improved hemodynamics after pelvic binding along with a decreased need for blood transfusions, but no high-quality study has demonstrated a clear, statistically significant decrease in patient mortality.23,24

Furthermore, there isn’t sufficient evidence to conclusively support one commercial device over another and there’s little evidence that commercially available products ultimately result in better patient outcomes than accurate application and utilization of a circumferential bed sheet.6,15,25

Despite this conflicting literature, in 2011 the Eastern Association for Surgery of Trauma stated in its systematic review that “because of the ease of application, relatively inexpensive cost, low potential for complications, and benefit to pelvic stability, temporary external stabilization devices should be considered for emergent application to all hemodynamically unstable patients with pelvic injuries.”24

In utilizing a pelvic compression device, it’s important to note two points. First, there’s evidence that misplacement of pelvic binders can significantly decrease the ability of the binder to reduce pelvic fractures.22 In a 2011 retrospective review, there was significantly less pelvic fracture reduction (mean difference of 22 mm) when the SAM Pelvic Sling was placed higher than the level of the greater trochanters than when placed correctly directly over the trochanters.22 The large residual gap in the pelvis when compression devices are misplaced may lead to worse patient outcomes and supports the need for adequate training for providers using these devices.

Second, when stabilizing a suspected pelvic fracture, care must be taken not to over-reduce the fracture. Excessive reduction can increase stress on pelvic ligaments, thereby leading to increased hemorrhage and further injury. Over-reduction can be assessed by examining the position of the legs, greater trochanters and knees with the patient in the supine position. The goal is to achieve normal anatomic position of the pelvis, so the lower legs should be symmetric after stabilization.6

Resuscitation: For any patient with acute, life-threatening bleeding, it’s preferable to replace hemorrhaged blood with blood products. This serves to both optimize the delivery of oxygen to vital organs as well as replenish clotting factors that will help stop continued bleeding. However, until these blood products are available, prompt resuscitation with warmed fluids should be initiated.

Except in those patients suspected of having a coexisting traumatic brain injury, prehospital providers should utilize a permissive hypotension resuscitation strategy.9

Permissive hypotension resuscitation calls for incremental fluid boluses (250 ml) to restore or maintain adequate vital organ perfusion. This is typically defined as the presence of a radial pulse or normal mental status. A systolic blood pressure of approximately 80–90 mmHg is believed to meet this objective in most patients. Providers should avoid overly aggressive IV fluid resuscitation to a normal blood pressure, which can potentially “pop the clot” and worsen hemorrhage into the pelvis. (See “Add a little salt: Permissive hypotension in trauma resuscitation,” by Jeff Beeson, DO, FACEP, EMT-P and Trenton Starnes, NREMT-P, in the April 2013 issue.)

Transport and additional management points: When clinically indicated and logistically feasible, placing a pelvic binder prior to extrication and movement is recommended. When packaging these patients, every reasonable effort should be made to avoid traditional logrolling onto the spine board. The additional weight and lateral compression of log rolling on an unstable pelvic ring injury may cause fracture fragment movement, disrupt internal blood clots, and worsen further bleeding. In support of this teaching, some clinicians describe scenarios in which patients have become hemodynamically unstable after routine logroll in the ED.12 A scoop stretcher, with its ability to separate for placement and removal, is ideal for transfer and movement of this type of patient. When using a scoop stretcher, it’s recommended to not exceed a logroll of 15 degrees.12,18

Pelvic fractures and the associated tissue damage are incredibly painful injuries. Thus, pelvic stabilization plays an important role in pain management. In addition, if a patient with a suspected pelvic fracture is awake and hemodynamically stable, providers should follow local protocols for the early administration of IV narcotic pain medication.

During transport, it’s critical providers constantly reassess these patients for new signs of a hidden injury or hemorrhage that could have also occurred during impact.

Case Conclusion
As you rapidly assess your patient lying on the highway, your partner simultaneously obtains a set of vital signs: blood pressure of 72/42, a heart rate of 110, a respiratory rate of 24 and an O2 saturation of 97% on room air. Your rapid trauma exam reveals a GCS of 12, (eye 3, verbal 4, motor 5), a patent airway, clear lungs and a soft abdomen. Upon inspection of the lower extremities, the left leg appears to be internally rotated. You immediately recognize the potential for a serious pelvic injury and associated internal hemorrhage as the cause for the patient’s hypotension and tachycardia. Your partner rapidly applies a commercially available pelvic binder prior to moving the patient. The responding engine company utilizes a scoop stretcher to avoid logrolling a patient with a potentially unstable pelvic fracture.

In the back of your preheated ambulance, your partner successfully places a 16-gauge IV and you begin to remove the young man’s protective riding gear. Other than an obviously deformed right wrist, you don’t find any other signs of significant injury. En route to the trauma center your patient continues to have an altered level of consciousness with only weak peripheral pulses and significant tachypnea. Your partner administers a 500 cc bolus of warmed normal saline in an attempt to maintain vital organ perfusion. In addition, you administer 1 gram of tranexamic acid (TXA) per protocol. Your partner notifies the receiving trauma center of your patient’s critical condition.

On arrival, your patient’s blood pressure has improved to 94/52 with a heart rate of 102. CT scans and X-rays reveal several broken ribs, a fractured right wrist and a severe open-book lateral compression pelvic fracture. As the patient is taken to the intensive care unit for additional resuscitation, the emergency physician approaches you and compliments your exceptional skill in managing this critically injured patient.

Final Thoughts
Pelvic fractures can range from benign to life-threatening depending on the mechanism of trauma, the extent of vascular injury and the severity of coexisting organ damage. Because pelvic deformities can be difficult to detect and the resulting internal hemorrhage is unseen, timely diagnosis of pelvic injuries is a challenge in the prehospital setting. It’s important for all providers to remember that in a blunt trauma patient with altered mental status or a distracting injury, the ability to assess for a pelvic injury is extremely unreliable. However, by maintaining a high, on-scene suspicion for the presence of a pelvic fracture, EMS providers are uniquely positioned to improve outcomes through rapid pelvic stabilization, calculated resuscitation and timely transport.

References
1. Grotz MR, Allami MK, Harwood P, et al. Open pelvic fractures: Epidemiology, current concepts of management and outcome. Injury. 2005;36(1):1–13.
2. Demetriades D, Karaiskakis M, Toutouzas K, et al. Pelvic fractures: Epidemiology and predictors of associated abdominal injuries and outcomes. J Am Coll Surg. 2002;195(1):1–10.
3. Dente CJ, Feliciano DV, Rozycki GS, et al. The outcome of open pelvic fractures in the modern era. Am J Surg. 2005;190(6):830–835.
4. Melton LJ, Sampson JM, Morrey BF, et al. Epidemiologic features of pelvic fractures. Clin Orthop Relat Res.1981;(155):43–47.
5. Burgess AR, Eastridge BJ, Young JW, et al. Pelvic ring disruptions: Effective classification system and treatment protocols. J Trauma. 1990;30(7):848–856.
6. Fiechti JF, Gibbs MA. An evidence-based approach to managing injuries of the pelvis and hip in the emergency department. Emergency Medicine Practice. 2010;12(12):1–24.
7. Magnussen RA, Tressler MA, Obremskey WT, et al. Predicting blood loss in isolated pelvic and acetabular high energy trauma. J Orthop Trauma. 2007;21(9):603.
8. Gansslen A, Giannoudis P, Pape HC. Hemorrhage in pelvic fracture: Who needs angiography? Curr Opin Crit Care. 2003;9(6):515–523.
9. White CE, Hsu JR, Holcomb JB. Haemodynamically unstable pelvic fractures. Injury. 2009;40(10):1023–1030.
10. Bjurlin MA, Fantus RJ, Mellett MM, et al. Genitourinary injuries in pelvic fracture morbidity and mortality using the National Trauma Bank. J Trauma. 2009;67(5):1033.
11. Gonzalez RP, Fried PQ, Bukhalo M. The utility of clinical examination in screening for pelvic fractures in blunt trauma. J Am Coll Surg. 2002;194(2):121–125.
12. Lee C, Porter K. The prehospital management of pelvic fractures. Emerg Med J. 2007;24(2):130–133.
13. Shlamovitz GZ, Mower WR, Bergman J, et al. How (un)useful is the pelvic ring stability examination in diagnosing mechanically unstable pelvic fractures in blunt trauma patients? J Trauma. 2009;66(3):815–820.
14. Papakostidis C, Giannoudis PV. Pelvic ring injuries with haemodynamic instability: Efficacy of pelvic packing, a systematic review. Injury. 2009;40(suppl 4):S54–S61.
15. Scott I, Porter K, Laird C, et al. The prehospital management of pelvic fractures: Initial consensus statement. Emerg Med J. 2013;30(12):1070–1072.
16. Civil ID, Ross SE, Botehlo G, et al. Routine pelvic radiography in severe blunt trauma: Is it necessary? Ann Emerg Med. 1988;17(5):488–490.
17. Mackersie RC, Shackford SR, Garfin SR, et al. Major skeletal injuries in the obtunded trauma patient: A case for routine radiological survey. J Trauma. 1988;28(10):1450–1454.
18. Limmer D, O’Keef MF. Emergency Care, 12th Edition. Pearson: Upper Saddle River, N.J., pp. 718–720, 2012.
19. Gardner MJ, Parada S, Routt ML. Internal rotation and taping of the lower extremities for closed pelvic reduction. J Orthop Trauma. 2009;23(5):361–364.
20. Simpson T, Krieg JC, Heuer F, et al. Stabilization of pelvic ring disruptions with a circumferential sheet. J Trauma. 2002;52(1):158–161.
21. Spanjersberg WR, Knops SP, Schep NW, et al. Effectiveness and complications of pelvic circumferential compression devices in patients with unstable pelvic fractures: A systematic review of literature. Int. J Care Injured. 2009;40(10):1031–1035.
22. Bonner T, Eardley W, Newell N, et al. Accurate placement of a pelvic binder improves reduction of unstable fractures of the pelvic ring. J Bone Joint Surg Br. 2011;93(11):1524–1528.
23. Stewart M. Towards evidence-based emergency medicine: Best BETs from the Manchester Royal Infirmary. BET3: Pelvic circumferential compression devices for hemorrhage control: Panacea or myth? Emerg Med J. 2013;30(5):425–426.
24. Cullinane DC, Schiller HJ, Zielinski MD, et al. Eastern Association for the Surgery of Trauma practice management guidelines for hemorrhage in pelvic fracture—update and systematic review. J Trauma. 2001;71(6):1850–1868.
25. Knops SP, Schep NW, Spoor CW, et al. Comparison of three different pelvic circumferential compression devices: A biomechanical cadaver study. J Bone Joint Surg Am. 2011;93(3):230–240.
26. Kragh JF, Murphy C, Dubick MA, et al. New Tournique Device Concepts for Battlefield Hemorrhage Control. U.S. Army Med Dep J. 2011:38–48.

Penetrating Pelvic Trauma: Junctional Hemorrhage
Civilian EMS providers most frequently encounter patients with blunt pelvic trauma. However, penetrating pelvic injuries do occur and can be very difficult to treat in the prehospital setting. Penetrating wounds to the groin or buttock region—the junction between the body trunk and leg—can result in life-threatening junctional hemorrhage. In fact, in recent military conflicts, junctional hemorrhage has been identified as a leading cause of potentially preventable death.26 Management of severe junctional hemorrhage from penetrating pelvic trauma is challenging because direct pressure often fails and this area of the body isn’t amenable to standard tourniquet application.26 As a result, the development of junctional compression devices, or “junctional tourniquets,” has become an area of significant research. We’ll review a few of them.

It’s the opinion of these authors that there’s no “best device.” Rather, each product brings something different to the management of these critically injured patients. We will omit basic application instructions and descriptions, which can be found on the respective product websites. Instead, the goal is to discuss specific characteristics of each device that can be used in the decision-making process of selecting one device versus another.

SAM Junctional Tourniquet: The SAM Junctional Tourniquet (SJT), from SAM Medical Products, is a belt-like device with included inflatable modules called target compression devices (TCDs) that can be affixed to the belt or its removable auxiliary strap. The SJT is unique in that it combines a fully functional pelvic binding device with a junctional compression device. In some poly-trauma patients, the need to simultaneously compress a bleeding junctional injury and stabilize the pelvis is certainly plausible. From a cost-effectiveness and simplicity of training perspective, having a device that does both pelvic binding and junctional compression is beneficial.

A small disadvantage of the SJT, in comparison to the SAM Pelvic Sling II, is that the Pelvic Sling II has a slick surface on the backside that may make application easier in some prehospital situations. On the SJT, this slick surface was replaced by the addition of a cord required for the connection of the auxiliary strap.

A very unique aspect of the SJT is that it can also be used for axillary compression. SAM Medical Products proposes wrapping the device around the torso and then using an auxiliary strap to apply one of the inflatable units over the subclavian vasculature to stop bleeding in the axilla. Without further study, we have some reservation regarding this application because the instructions state the device should be secured around the chest until the buckle clicks (the buckle senses the amount of force applied and clicks when it is appropriately tightened). In other words, the SJT is applied around the chest wall with the same amount of force as it would be around the bony pelvis for pelvic stabilization. Although this is a potentially life-saving application for a unique and versatile device, we would like to see additional research demonstrating no unforeseen respiratory consequences.

Junctional Emergency Treatment Tool: The Junctional Emergency Treatment Tool (JETT), from North American Rescue, is also a belt-like device that utilizes pressure pads affixed to screw-like mechanisms that can be tightened to provide unilateral or bilateral junctional compression. The JETT is unique in that it is a dedicated junctional compression device and does not function as a pelvic binder. Some providers may see this as a disadvantage while others may appreciate the dedicated function. In the case of a patient with truly isolated penetrating pelvic trauma (gunshot or stab wound), it may be reasonable to apply junctional compression without also stabilizing the pelvis. The relatively small packaging combined with its quick and simple application may make the JETT ideal for this scenario. Of note, the JETT isn’t adaptable to axillary injuries and thus can only be utilized in the groin.

T-POD Responder: The T-POD Pelvic Stabilization Device, from Pyng Medical, is an easy-to-use pelvic binder that’s becoming a favorite of emergency providers around the globe. It’s a long band of material that can be easily sized and then tightened using an included pulley system but doesn’t have a pressure-sensing buckle like the SJT.

The T-POD, like the JETT, has only one dedicated function. However, it’s pelvic stabilization rather than junctional compression. Thus, if junctional hemorrhage is also present, providers must resort to manual compression to control potentially life-threatening bleeding. In many prehospital care scenarios, this may not be a logistical issue as often times a rescuer can be dedicated to providing such compression. However, in some transport environments such as in the back of a helicopter, this may not be feasible. Lastly, a point that should not be overlooked is that the T-POD is much more affordable than the other devices reviewed.

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The Need for Speed in Care of Critical Pelvic Wounds Identified in Military Report
A recent article in the Wall Street Journal (WSJ) discussed the findings of a team of military medical specialists who spent six months reviewing the autopsy reports from 4,016 men and women who died on the battlefields of Iraq and Afghanistan.

They pieced together the evidence to determine the exact cause of death of each soldier, and concluded nearly 25% of Americans killed in action over 10 years—almost 1,000 of our troops—died of wounds they could have potentially survived.1

The most important finding by the military in a report that appeared in the Journal of Trauma and Acute Care Surgery in 2012 was that in nine out of 10 cases, troops bled to death from wounds that might have been stanched. In 8% of these cases, soldiers succumbed to airway damage that better care might have controlled.2

Active-duty and retired military trauma specialists say a new internal report concluded that the military still hasn’t fully adopted battlefield aid techniques that could’ve kept many wounded alive in Afghanistan. They say that some of those techniques have been used to great effect—and with little extra cost—by elite commando units such as the Army Rangers for more than a decade, but not in the forward aid stations/clinics.1

David Smith, deputy assistant secretary of defense for force health protection and readiness says that “the primary lifesaving components of the latest casualty care guidelines are readily implemented across the theater but that the wider military hasn’t uniformly implemented the lessons learned from elite units.” 1

The military casualty report, completed in May, was conducted by a medical research team that visited 26 frontline clinics—and found that only one frontline casualty care clinic had fully implemented the latest guidelines. According to the report:

  • Only 2/3 possessed junctional tourniquets, crucial to stopping hemorrhaging for injuries too close to the victim’s trunk for normal tourniquets;
  • Tranexamic acid, approved by the military as an anti-bleeding agent, was not put it in medics’ kits according to 90% of aid stations in Afghanistan; and
  • Just 12% of medics carried ketamine, the painkiller now recommended instead of morphine because it doesn’t cause a drop in blood pressure or breathing.

In November of 2013, U.S. Marine Gen. Joseph Dunford, then-commander of allied forces in Afghanistan, ordered use of the junctional tourniquets. In February, he ordered that nasal ketamine replace morphine as the primary battlefield pain killer. In March, he ordered medical personnel in the war zone to “maintain proficiency” in the latest battlefield-care techniques.1

The WSJ article says military doctors report that bureaucratic issues have stalled efforts to fully implement the most successful battlefield care techniques. It further reports that the Pentagon has generals in charge of dentistry, nursing and veterinary care, but no single general is in charge of care for wounded soldiers before they reach a surgeon’s table. It says that, in fact, frontline first responders—mostly Army medics and Navy corpsmen—take orders from combat commanders who are likely to be infantry, tank or artillery officers, not from the military’s top doctors.1

At 11 p.m. on Friday, Sept. 12, a gunmen opened fire on the Blooming Grove Pennsylvania State Police barracks with a .308-caliber rifle killing a corporal and critically wounding another trooper from a gunshot wound to the pelvis that severed his femoral artery.

Trooper Alex Douglas survived because of rapid field care and helicopter transport to a trauma center, but medical personnel had a difficult time controlling the femoral bleed in an area where a standard tourniquet could not be used.

A junctional tourniquet could have made a significant difference in the early controlling of this officer’s severe hemorrhage.

We have to learn from these military, law enforcement and civilian shortcomings about the need for early stabilization of devastating pelvic injures and implement procedures and devices proven to stem massive pelvic hemorrhage in the field.
— A.J. Heightman, MPA, EMT-P

References
1. Phillips MM. (Sept. 19, 2014.) Are U.S. soldiers dying from survivable wounds? Despite advances in care, the military failed to save some troops in Iraq and Afghanistan from ‘potentially survivable’ wounds. Wall Street Journal. Retrieved Oct. 7, 2014, from http://online.wsj.com/articles/are-u-s-soldiers-dying-from-survivable-wounds-1411145160.
2. Eastridge BJ, Mabry RL, Seguin P, et al. Death on the battlefield (2001–2011): Implications for the future of combat casualty care. J Trauma Acute Care Surg. 2012;73(6):S431–S437.

 

Patient Care, Trauma

Critical Management of Deadly Pelvic Injuries

Issue 12 and Volume 39.

It’s 2 p.m. on a Saturday when you’re dispatched to the northbound lanes of Interstate 75 at mile marker 80 for reports of a motorcycle accident. En route, highway patrol notifies you there’s a single male rider involved in a high-speed crash. On arrival, you find a 22-year-old male lying on the highway 40 feet from his motorcycle, wearing a helmet and body gear. He’s conscious but confused. His breathing is fast and shallow. A radial pulse is barely palpable and his skin is cool and pale.

The responding engine company prepares for packaging as you and your partner complete your rapid trauma assessment, obtain vital signs and prepare for transport. You’re 25 minutes from the trauma center and suspect this young man has serious internal injuries.

Introduction to Pelvic Trauma
Pelvic fractures represent approximately 3% of all skeletal injuries annually in the United States1 and account for 9% of trauma patients admitted to the hospital.2 These injuries range from benign to rapidly life-threatening, with an overall mortality of 10–16%.2 However, open pelvic fractures, which represent approximately 2–4% of pelvic injuries, have the highest mortality rate at nearly 45%.1,3 Pelvic fractures most frequently occur in patients 15–28 years old who sustain high-energy, side-impact mechanisms of injury such as high-level falls or motor vehicle collisions (MVCs),4 but serious pelvic injuries can also occur from minor mechanisms such as ground-level falls. This is especially true in elderly patients.

Pelvis Anatomy
The pelvis is a ring-shaped bony structure consisting of the sacrum, coccyx, and three innominate bones: the ilium, ischium and pubis. The innominate bones join to form the acetabulum—the socket in which the head of the femur sits to form the hip joint. The joint between the sacrum and ilium (sacroiliac joint, or SI joint) is the strongest joint in the body, and the pubic symphysis is the weakest link in the pelvic ring. (See Figure 1 below). The strength and stability of the pelvis is a result of several ligaments that connect the sacrum to the other pelvic bones, and potentially dangerous pelvic instability can result when these ligaments are disrupted.

Figure 1: Pelvic anatomy

 

The primary organs lying within the pelvis are the bladder, rectum, anal canal and urethra, along with the prostate in males and the uterus and vagina in females. Also contained within the pelvis is a vast array of blood vessels, nerves and internal organs. When trauma causes pelvic instability or a fracture, injury to the large network of arteries and thin-walled veins that lie anterior to the sacrum can cause severe internal hemorrhage. Injury to nerve roots, which course through the pelvis, can result in bowel, bladder and sexual dysfunction.

Potential risks of missing an occult pelvic injury outweigh the risks or complications associated with pelvic binding. Therefore, all patients with suspected pelvic trauma should be placed in a binder. Photo courtesy Mike Steuerwald

 

Types of Pelvic Fractures
Injuries include fractures of the sacrum or acetabulum, avulsion injuries, and pelvic ring disruption, which tends to be the most serious. Because the pelvis is a closed ring, it commonly fractures or is disrupted in more than one location. Disruptions are most commonly described by using the Young and Burgess classification scheme, which classifies pelvic ring disruptions into three broad categories based on the direction of the causative injury force: lateral compression injuries, anteroposterior compression injuries and vertical shear injuries.5

Lateral compression injuries usually occur when a significant force is delivered to the side of the body, such as a pedestrian side struck or a T-bone MVC. In the most serious type of lateral compression, the injury force is so great that energy is transmitted through the pelvis to the opposite side, creating an open-book fracture on the side opposite of impact.6

Anteroposterior compression injuries occur when an anterior force impacts the patient, such as in a head-on MVC. The most severe injury causes complete disruption of the SI joint in addition to anterior pelvic ring injuries.

Although rare, vertical shear injuries are structurally devastating as one side of the pelvis is forced upward, separating entirely from the other half of the pelvis. These injuries may result from a head-on MVC in which the occupant’s leg is extended and braced on the brake pedal.6 As a result, the femur is driven upward and causes that side of the pelvis to be displaced superiorly.

An open-book pelvic fracture is a term used to describe any fracture that significantly disrupts the pelvic ring. These injuries combine an anterior pelvic injury causing a widening (opening) of the pubic symphysis, and a posterior pelvic fracture or ligamentous injury.6 Based on the severity of pelvic widening, lateral compression, anteroposterior compression and vertical shear injuries can be termed open-book. If the normally closed anterior pelvic ring is widened greater than 2.5 cm, there’s increased likelihood the posterior pelvis is also injured, thus increasing the volume of the pelvis and the risk of major hemorrhage.6 Though any pelvic fracture can be life-threatening, open-book pelvic injuries have the highest risk of death or disability.

Pelvic Injury Hemorrhage & Associated Injuries
The most feared complication of a pelvic injury is rapid and uncontrolled hemorrhage into the retroperitoneal space, which is capable of accommodating the patient’s entire blood volume. Any pelvic fracture pattern can be associated with significant hemorrhage that occurs from arterial laceration, venous injury, or bone fragments. However, the source of pelvic hemorrhage is found to be a venous injury in 80–90% of cases.8

Additionally, up to 20% of pelvic fractures may result in hemodynamic instability and over 1/3 of patients hospitalized with pelvic fractures will require blood transfusions.3,7

To disrupt the pelvic ring requires a significant force of injury, equivalent to instantly coming to a stop from 30 miles per hour.9 As a result of these high-energy impacts, pelvic fractures are frequently associated with potentially life-threatening, coexisting injuries to the head, chest, abdomen or spinal column. Over 80% of patients with unstable pelvic fractures will also have additional musculoskeletal injuries.9 Patients with pelvic trauma suffer damage to intra-abdominal organs in 16.5% of cases with the spleen, liver and bowel most frequently injured.3 Rectal injuries occur in approximately 5% of patients predisposing to the risk of late onset infection and sepsis.

The bladder and urethra are also frequently injured, with males being ten times more likely to sustain this injury then females.10 Lastly, in the presence of an unstable pelvic fracture, up to 50% of trauma patients may experience some degree of associated neurologic injury.6

Assessment
Pelvic pain is the most common finding in patients with pelvic fractures who are awake and alert,11 but pain in the lower back, groin or hip may also be an indication.12 In addition, patients may have a leg length discrepancy (one leg shorter than the other) or a rotational deformity. Bruising over the flank, bony prominences of the pelvis, pubis, perineum or scrotum are also suggestive of significant pelvic injury. Wounds over the pelvis or bleeding from the rectum, vagina or urethra are signs that a bone fragment may have penetrated the skin and thus an open pelvic fracture may exist. If pelvic trauma is causing an associated nerve injury, the patient may experience loss of bowel or bladder control.10

Classic teaching encourages “rocking” or “springing” the pelvis to identify pelvic tenderness or instability and thus a possible source of internal hemorrhage. However, this technique has proved to be very unreliable, detecting only the most severe pelvic disruptions.9,12,13 Furthermore, this maneuver may be dangerous to the patient by further displacing fracture fragments and dislodging formed blood clots, resulting in worsening hemorrhage.6,9 Thus, it’s strongly recommended that providers avoid rocking the pelvis. Instead, gently palpate the bony structures of the pelvis and lower spine for tenderness. Some clinicians also recommend a cautious, one-time only inward compression maneuver of the iliac crests to assess for instability.

EMS Management
Internal hemorrhage is a major cause of death during the first 24 hours after pelvic injury.9,14 Compared to causes of external hemorrhage such as extremity wounds, EMS diagnosis of pelvic fractures can be extremely difficult. Therefore, the most critical aspect of prehospital management of pelvic injuries is having a high suspicion. Early suspicion and identification by EMS allows for the timely triage and treatment required to maximize patient outcomes. (See Table 1 below).

Table 1: EMS pelvic injuries treatment considerations

In 2013, researchers from the United Kingdom published a consensus statement on the prehospital management of pelvic fractures.15 (See Table 2 below). Although some of the statements don’t have considerable scientific support, it’s a valuable resource for any EMS agency.

Table 2: Prehospital management of pelvic fractures

Adapted from Scott I, Porter K. Laird C, et al. The prehospital management of pelvic fractures: Initial consensus statement. Emerg Med J. 2013;30(12):1070-1072.

 

When to stabilize the patient: In general, the literature demonstrates that in the hemodynamically stable, alert and oriented trauma patient with no distracting injury and no signs of pelvic fracture, pelvic stabilization is not required.12,16

However, in trauma patients with an altered level of consciousness (Glasgow coma scale (GCS) < 13), hemodynamic instability or obvious distracting injuries, the clinical assessment for pelvic fracture is devastatingly inaccurate.17 Many experts advocate these patients should be routinely placed in pelvic stabilization as the potential risks of missing an occult pelvic injury outweigh the risks or complications associated with pelvic binding. Some advocate that in the unresponsive blunt trauma patient, the pelvis shouldn’t be palpated for instability at all because the presence of a pelvic injury should be assumed and thus a pelvic binder empirically placed.12

In general, a reasonably conservative approach is to stabilize the pelvis of any trauma patient with a moderate to severe blunt mechanism of injury who has any of the following criteria:

1. Obvious signs of pelvic injury/instability on physical exam;
2. Signs of hemorrhagic shock and reports pelvic or low back pain/tenderness even if the pelvis seems stable; or
3. Signs of hemorrhagic shock and altered mental status regardless of the presence or absence of pelvic pain or instability.

When the pelvis is fractured, pelvic bone fragments can penetrate the rectum, vagina or urethra causing significant injury and bleeding. Blood at the urethral meatus (opening of the penis) is a classic sign of urethral injury secondary to severe pelvic trauma. Photo Edward T. Dickinson

 

Controlling hemorrhage: The goal of pelvic stabilization is to prevent additional vascular and tissue injury from fracture fragment movement while also decreasing pelvic volume in an attempt to tamponade bleeding vessels and bones. With that said, the exact mechanism by which pelvic binding actually contributes to hemorrhage control is controversial.9 Regardless, because appropriate pelvic stabilization plays a role in stopping potentially life-threatening bleeding, it should be considered as part of a provider’s initial trauma treatment.15

Classic teaching on the management of pelvic fractures recommends circumferentially wrapping a bed sheet around the pelvis while taping the lower limbs in internal rotation to reduce the pelvic volume.18,19

Although successful reduction of open-book pelvic fractures with a circumferential sheet has been reported, this technique is often difficult to consistently reproduce, requires multiple providers to accomplish, and frequently doesn’t achieve or maintain the necessary reduction force.12,19,20

In the past 15 years, a variety of commercial external pelvic compression devices have evolved to provide fast, easy and consistent pelvic stabilization (e.g., TPOD, SAM Pelvic Sling). Cadaver and some clinical studies demonstrate the ability of these devices to improve pelvic alignment.21,22 However, research evaluating the efficacy of these pelvic binders in controlling hemorrhage from pelvic fractures has been conflicting. Case series and some clinical studies report improved hemodynamics after pelvic binding along with a decreased need for blood transfusions, but no high-quality study has demonstrated a clear, statistically significant decrease in patient mortality.23,24

Furthermore, there isn’t sufficient evidence to conclusively support one commercial device over another and there’s little evidence that commercially available products ultimately result in better patient outcomes than accurate application and utilization of a circumferential bed sheet.6,15,25

Despite this conflicting literature, in 2011 the Eastern Association for Surgery of Trauma stated in its systematic review that “because of the ease of application, relatively inexpensive cost, low potential for complications, and benefit to pelvic stability, temporary external stabilization devices should be considered for emergent application to all hemodynamically unstable patients with pelvic injuries.”24

In utilizing a pelvic compression device, it’s important to note two points. First, there’s evidence that misplacement of pelvic binders can significantly decrease the ability of the binder to reduce pelvic fractures.22 In a 2011 retrospective review, there was significantly less pelvic fracture reduction (mean difference of 22 mm) when the SAM Pelvic Sling was placed higher than the level of the greater trochanters than when placed correctly directly over the trochanters.22 The large residual gap in the pelvis when compression devices are misplaced may lead to worse patient outcomes and supports the need for adequate training for providers using these devices.

Second, when stabilizing a suspected pelvic fracture, care must be taken not to over-reduce the fracture. Excessive reduction can increase stress on pelvic ligaments, thereby leading to increased hemorrhage and further injury. Over-reduction can be assessed by examining the position of the legs, greater trochanters and knees with the patient in the supine position. The goal is to achieve normal anatomic position of the pelvis, so the lower legs should be symmetric after stabilization.6

Bruising over the perineum or scrotum is highly suggestive for the presence of a significant pelvic injury. Photo Edward T. Dickinson

 

Resuscitation: For any patient with acute, life-threatening bleeding, it’s preferable to replace hemorrhaged blood with blood products. This serves to both optimize the delivery of oxygen to vital organs as well as replenish clotting factors that will help stop continued bleeding. However, until these blood products are available, prompt resuscitation with warmed fluids should be initiated.

Except in those patients suspected of having a coexisting traumatic brain injury, prehospital providers should utilize a permissive hypotension resuscitation strategy.9

Permissive hypotension resuscitation calls for incremental fluid boluses (250 ml) to restore or maintain adequate vital organ perfusion. This is typically defined as the presence of a radial pulse or normal mental status. A systolic blood pressure of approximately 80–90 mmHg is believed to meet this objective in most patients. Providers should avoid overly aggressive IV fluid resuscitation to a normal blood pressure, which can potentially “pop the clot” and worsen hemorrhage into the pelvis. (See “Add a little salt: Permissive hypotension in trauma resuscitation,” by Jeff Beeson, DO, FACEP, EMT-P and Trenton Starnes, NREMT-P, in the April 2013 issue.)

Transport and additional management points: When clinically indicated and logistically feasible, placing a pelvic binder prior to extrication and movement is recommended. When packaging these patients, every reasonable effort should be made to avoid traditional logrolling onto the spine board. The additional weight and lateral compression of log rolling on an unstable pelvic ring injury may cause fracture fragment movement, disrupt internal blood clots, and worsen further bleeding. In support of this teaching, some clinicians describe scenarios in which patients have become hemodynamically unstable after routine logroll in the ED.12 A scoop stretcher, with its ability to separate for placement and removal, is ideal for transfer and movement of this type of patient. When using a scoop stretcher, it’s recommended to not exceed a logroll of 15 degrees.12,18

Pelvic fractures and the associated tissue damage are incredibly painful injuries. Thus, pelvic stabilization plays an important role in pain management. In addition, if a patient with a suspected pelvic fracture is awake and hemodynamically stable, providers should follow local protocols for the early administration of IV narcotic pain medication.

During transport, it’s critical providers constantly reassess these patients for new signs of a hidden injury or hemorrhage that could have also occurred during impact.

Case Conclusion
As you rapidly assess your patient lying on the highway, your partner simultaneously obtains a set of vital signs: blood pressure of 72/42, a heart rate of 110, a respiratory rate of 24 and an O2 saturation of 97% on room air. Your rapid trauma exam reveals a GCS of 12, (eye 3, verbal 4, motor 5), a patent airway, clear lungs and a soft abdomen. Upon inspection of the lower extremities, the left leg appears to be internally rotated. You immediately recognize the potential for a serious pelvic injury and associated internal hemorrhage as the cause for the patient’s hypotension and tachycardia. Your partner rapidly applies a commercially available pelvic binder prior to moving the patient. The responding engine company utilizes a scoop stretcher to avoid logrolling a patient with a potentially unstable pelvic fracture.

In the back of your preheated ambulance, your partner successfully places a 16-gauge IV and you begin to remove the young man’s protective riding gear. Other than an obviously deformed right wrist, you don’t find any other signs of significant injury. En route to the trauma center your patient continues to have an altered level of consciousness with only weak peripheral pulses and significant tachypnea. Your partner administers a 500 cc bolus of warmed normal saline in an attempt to maintain vital organ perfusion. In addition, you administer 1 gram of tranexamic acid (TXA) per protocol. Your partner notifies the receiving trauma center of your patient’s critical condition.

On arrival, your patient’s blood pressure has improved to 94/52 with a heart rate of 102. CT scans and X-rays reveal several broken ribs, a fractured right wrist and a severe open-book lateral compression pelvic fracture. As the patient is taken to the intensive care unit for additional resuscitation, the emergency physician approaches you and compliments your exceptional skill in managing this critically injured patient.

Final Thoughts
Pelvic fractures can range from benign to life-threatening depending on the mechanism of trauma, the extent of vascular injury and the severity of coexisting organ damage. Because pelvic deformities can be difficult to detect and the resulting internal hemorrhage is unseen, timely diagnosis of pelvic injuries is a challenge in the prehospital setting. It’s important for all providers to remember that in a blunt trauma patient with altered mental status or a distracting injury, the ability to assess for a pelvic injury is extremely unreliable. However, by maintaining a high, on-scene suspicion for the presence of a pelvic fracture, EMS providers are uniquely positioned to improve outcomes through rapid pelvic stabilization, calculated resuscitation and timely transport.

References
1. Grotz MR, Allami MK, Harwood P, et al. Open pelvic fractures: Epidemiology, current concepts of management and outcome. Injury. 2005;36(1):1–13.
2. Demetriades D, Karaiskakis M, Toutouzas K, et al. Pelvic fractures: Epidemiology and predictors of associated abdominal injuries and outcomes. J Am Coll Surg. 2002;195(1):1–10.
3. Dente CJ, Feliciano DV, Rozycki GS, et al. The outcome of open pelvic fractures in the modern era. Am J Surg. 2005;190(6):830–835.
4. Melton LJ, Sampson JM, Morrey BF, et al. Epidemiologic features of pelvic fractures. Clin Orthop Relat Res.1981;(155):43–47.
5. Burgess AR, Eastridge BJ, Young JW, et al. Pelvic ring disruptions: Effective classification system and treatment protocols. J Trauma. 1990;30(7):848–856.
6. Fiechti JF, Gibbs MA. An evidence-based approach to managing injuries of the pelvis and hip in the emergency department. Emergency Medicine Practice. 2010;12(12):1–24.
7. Magnussen RA, Tressler MA, Obremskey WT, et al. Predicting blood loss in isolated pelvic and acetabular high energy trauma. J Orthop Trauma. 2007;21(9):603.
8. Gansslen A, Giannoudis P, Pape HC. Hemorrhage in pelvic fracture: Who needs angiography? Curr Opin Crit Care. 2003;9(6):515–523.
9. White CE, Hsu JR, Holcomb JB. Haemodynamically unstable pelvic fractures. Injury. 2009;40(10):1023–1030.
10. Bjurlin MA, Fantus RJ, Mellett MM, et al. Genitourinary injuries in pelvic fracture morbidity and mortality using the National Trauma Bank. J Trauma. 2009;67(5):1033.
11. Gonzalez RP, Fried PQ, Bukhalo M. The utility of clinical examination in screening for pelvic fractures in blunt trauma. J Am Coll Surg. 2002;194(2):121–125.
12. Lee C, Porter K. The prehospital management of pelvic fractures. Emerg Med J. 2007;24(2):130–133.
13. Shlamovitz GZ, Mower WR, Bergman J, et al. How (un)useful is the pelvic ring stability examination in diagnosing mechanically unstable pelvic fractures in blunt trauma patients? J Trauma. 2009;66(3):815–820.
14. Papakostidis C, Giannoudis PV. Pelvic ring injuries with haemodynamic instability: Efficacy of pelvic packing, a systematic review. Injury. 2009;40(suppl 4):S54–S61.
15. Scott I, Porter K, Laird C, et al. The prehospital management of pelvic fractures: Initial consensus statement. Emerg Med J. 2013;30(12):1070–1072.
16. Civil ID, Ross SE, Botehlo G, et al. Routine pelvic radiography in severe blunt trauma: Is it necessary? Ann Emerg Med. 1988;17(5):488–490.
17. Mackersie RC, Shackford SR, Garfin SR, et al. Major skeletal injuries in the obtunded trauma patient: A case for routine radiological survey. J Trauma. 1988;28(10):1450–1454.
18. Limmer D, O’Keef MF. Emergency Care, 12th Edition. Pearson: Upper Saddle River, N.J., pp. 718–720, 2012.
19. Gardner MJ, Parada S, Routt ML. Internal rotation and taping of the lower extremities for closed pelvic reduction. J Orthop Trauma. 2009;23(5):361–364.
20. Simpson T, Krieg JC, Heuer F, et al. Stabilization of pelvic ring disruptions with a circumferential sheet. J Trauma. 2002;52(1):158–161.
21. Spanjersberg WR, Knops SP, Schep NW, et al. Effectiveness and complications of pelvic circumferential compression devices in patients with unstable pelvic fractures: A systematic review of literature. Int. J Care Injured. 2009;40(10):1031–1035.
22. Bonner T, Eardley W, Newell N, et al. Accurate placement of a pelvic binder improves reduction of unstable fractures of the pelvic ring. J Bone Joint Surg Br. 2011;93(11):1524–1528.
23. Stewart M. Towards evidence-based emergency medicine: Best BETs from the Manchester Royal Infirmary. BET3: Pelvic circumferential compression devices for hemorrhage control: Panacea or myth? Emerg Med J. 2013;30(5):425–426.
24. Cullinane DC, Schiller HJ, Zielinski MD, et al. Eastern Association for the Surgery of Trauma practice management guidelines for hemorrhage in pelvic fracture—update and systematic review. J Trauma. 2001;71(6):1850–1868.
25. Knops SP, Schep NW, Spoor CW, et al. Comparison of three different pelvic circumferential compression devices: A biomechanical cadaver study. J Bone Joint Surg Am. 2011;93(3):230–240.
26. Kragh JF, Murphy C, Dubick MA, et al. New Tournique Device Concepts for Battlefield Hemorrhage Control. U.S. Army Med Dep J. 2011:38–48.

Using a circumferential sheet is often difficult to consistently produce pressure, requires multiple providers to accomplish, and frequently doesn’t achieve or maintain the necessary reduction force. Photo courtesy Ben Neal

 

Penetrating Pelvic Trauma: Junctional Hemorrhage
Civilian EMS providers most frequently encounter patients with blunt pelvic trauma. However, penetrating pelvic injuries do occur and can be very difficult to treat in the prehospital setting. Penetrating wounds to the groin or buttock region—the junction between the body trunk and leg—can result in life-threatening junctional hemorrhage. In fact, in recent military conflicts, junctional hemorrhage has been identified as a leading cause of potentially preventable death.26 Management of severe junctional hemorrhage from penetrating pelvic trauma is challenging because direct pressure often fails and this area of the body isn’t amenable to standard tourniquet application.26 As a result, the development of junctional compression devices, or “junctional tourniquets,” has become an area of significant research. We’ll review a few of them.

It’s the opinion of these authors that there’s no “best device.” Rather, each product brings something different to the management of these critically injured patients. We will omit basic application instructions and descriptions, which can be found on the respective product websites. Instead, the goal is to discuss specific characteristics of each device that can be used in the decision-making process of selecting one device versus another.

SAM Junctional Tourniquet: The SAM Junctional Tourniquet (SJT), from SAM Medical Products, is a belt-like device with included inflatable modules called target compression devices (TCDs) that can be affixed to the belt or its removable auxiliary strap. The SJT is unique in that it combines a fully functional pelvic binding device with a junctional compression device. In some poly-trauma patients, the need to simultaneously compress a bleeding junctional injury and stabilize the pelvis is certainly plausible. From a cost-effectiveness and simplicity of training perspective, having a device that does both pelvic binding and junctional compression is beneficial.

A small disadvantage of the SJT, in comparison to the SAM Pelvic Sling II, is that the Pelvic Sling II has a slick surface on the backside that may make application easier in some prehospital situations. On the SJT, this slick surface was replaced by the addition of a cord required for the connection of the auxiliary strap.

A very unique aspect of the SJT is that it can also be used for axillary compression. SAM Medical Products proposes wrapping the device around the torso and then using an auxiliary strap to apply one of the inflatable units over the subclavian vasculature to stop bleeding in the axilla. Without further study, we have some reservation regarding this application because the instructions state the device should be secured around the chest until the buckle clicks (the buckle senses the amount of force applied and clicks when it is appropriately tightened). In other words, the SJT is applied around the chest wall with the same amount of force as it would be around the bony pelvis for pelvic stabilization. Although this is a potentially life-saving application for a unique and versatile device, we would like to see additional research demonstrating no unforeseen respiratory consequences.

Junctional Emergency Treatment Tool: The Junctional Emergency Treatment Tool (JETT), from North American Rescue, is also a belt-like device that utilizes pressure pads affixed to screw-like mechanisms that can be tightened to provide unilateral or bilateral junctional compression. The JETT is unique in that it is a dedicated junctional compression device and does not function as a pelvic binder. Some providers may see this as a disadvantage while others may appreciate the dedicated function. In the case of a patient with truly isolated penetrating pelvic trauma (gunshot or stab wound), it may be reasonable to apply junctional compression without also stabilizing the pelvis. The relatively small packaging combined with its quick and simple application may make the JETT ideal for this scenario. Of note, the JETT isn’t adaptable to axillary injuries and thus can only be utilized in the groin.

T-POD Responder: The T-POD Pelvic Stabilization Device, from Pyng Medical, is an easy-to-use pelvic binder that’s becoming a favorite of emergency providers around the globe. It’s a long band of material that can be easily sized and then tightened using an included pulley system but doesn’t have a pressure-sensing buckle like the SJT.

The T-POD, like the JETT, has only one dedicated function. However, it’s pelvic stabilization rather than junctional compression. Thus, if junctional hemorrhage is also present, providers must resort to manual compression to control potentially life-threatening bleeding. In many prehospital care scenarios, this may not be a logistical issue as often times a rescuer can be dedicated to providing such compression. However, in some transport environments such as in the back of a helicopter, this may not be feasible. Lastly, a point that should not be overlooked is that the T-POD is much more affordable than the other devices reviewed.

*****************

The Need for Speed in Care of Critical Pelvic Wounds Identified in Military Report
A recent article in the Wall Street Journal (WSJ) discussed the findings of a team of military medical specialists who spent six months reviewing the autopsy reports from 4,016 men and women who died on the battlefields of Iraq and Afghanistan.

They pieced together the evidence to determine the exact cause of death of each soldier, and concluded nearly 25% of Americans killed in action over 10 years—almost 1,000 of our troops—died of wounds they could have potentially survived.1

The most important finding by the military in a report that appeared in the Journal of Trauma and Acute Care Surgery in 2012 was that in nine out of 10 cases, troops bled to death from wounds that might have been stanched. In 8% of these cases, soldiers succumbed to airway damage that better care might have controlled.2

Active-duty and retired military trauma specialists say a new internal report concluded that the military still hasn’t fully adopted battlefield aid techniques that could’ve kept many wounded alive in Afghanistan. They say that some of those techniques have been used to great effect—and with little extra cost—by elite commando units such as the Army Rangers for more than a decade, but not in the forward aid stations/clinics.1

David Smith, deputy assistant secretary of defense for force health protection and readiness says that “the primary lifesaving components of the latest casualty care guidelines are readily implemented across the theater but that the wider military hasn’t uniformly implemented the lessons learned from elite units.”1

The military casualty report, completed in May, was conducted by a medical research team that visited 26 frontline clinics—and found that only one frontline casualty care clinic had fully implemented the latest guidelines. According to the report:

  • Only 2/3 possessed junctional tourniquets, crucial to stopping hemorrhaging for injuries too close to the victim’s trunk for normal tourniquets;
  • Tranexamic acid, approved by the military as an anti-bleeding agent, was not put it in medics’ kits according to 90% of aid stations in Afghanistan; and
  • Just 12% of medics carried ketamine, the painkiller now recommended instead of morphine because it doesn’t cause a drop in blood pressure or breathing.

In November of 2013, U.S. Marine Gen. Joseph Dunford, then-commander of allied forces in Afghanistan, ordered use of the junctional tourniquets. In February, he ordered that nasal ketamine replace morphine as the primary battlefield pain killer. In March, he ordered medical personnel in the war zone to “maintain proficiency” in the latest battlefield-care techniques.1

The WSJ article says military doctors report that bureaucratic issues have stalled efforts to fully implement the most successful battlefield care techniques. It further reports that the Pentagon has generals in charge of dentistry, nursing and veterinary care, but no single general is in charge of care for wounded soldiers before they reach a surgeon’s table. It says that, in fact, frontline first responders—mostly Army medics and Navy corpsmen—take orders from combat commanders who are likely to be infantry, tank or artillery officers, not from the military’s top doctors.1

At 11 p.m. on Friday, Sept. 12, a gunmen opened fire on the Blooming Grove Pennsylvania State Police barracks with a .308-caliber rifle killing a corporal and critically wounding another trooper from a gunshot wound to the pelvis that severed his femoral artery.

Trooper Alex Douglas survived because of rapid field care and helicopter transport to a trauma center, but medical personnel had a difficult time controlling the femoral bleed in an area where a standard tourniquet could not be used.

A junctional tourniquet could have made a significant difference in the early controlling of this officer’s severe hemorrhage.

We have to learn from these military, law enforcement and civilian shortcomings about the need for early stabilization of devastating pelvic injures and implement procedures and devices proven to stem massive pelvic hemorrhage in the field.
— A.J. Heightman, MPA, EMT-P

References
1. Phillips MM. (Sept. 19, 2014.) Are U.S. soldiers dying from survivable wounds? Despite advances in care, the military failed to save some troops in Iraq and Afghanistan from ‘potentially survivable’ wounds. Wall Street Journal. Retrieved Oct. 7, 2014, from http://online.wsj.com/articles/are-u-s-soldiers-dying-from-survivable-wounds-1411145160.
2. Eastridge BJ, Mabry RL, Seguin P, et al. Death on the battlefield (2001–2011): Implications for the future of combat casualty care. J Trauma Acute Care Surg. 2012;73(6):S431–S437.