Trauma Skills 3:
Pelvic Fracture Stabilization
Pelvic fracture stabilization is crucial to preventing blood loss as well as to providing support and minimizing damage to the pelvic ring. The goal of treatment for pelvic fracture stabilization is early control of life-threatening hemorrhage. Returning pelvic bones to correct position helps to reduce pelvic volume and control venous bleeding. To help minimize jarring the pelvic bones and to prevent further injury and pain, lift patients for posterior examination instead of rolling them. Several stabilizing and reduction options are currently available. These include the Sheet Wrap Method, Sam Sling, Trauma Pelvic Orthotic Device (T-POD), Vacuum Bean Bags, and External Pelvic Fixator. Consider these options as temporizing measures until more definitive stabilization can be achieved. If the patient continues to show signs of shock or hemorrhage after application of a pelvic stabilizing method, prepare the patient for angiography (and possible embolization) or surgical intervention.
The Sheet Wrap Method is intended specifically for stabilizing and reducing open book pelvic ring disruptions. Treatment involves wrapping a patient's pelvis circumferentially using an ordinary folded bed sheet. Carefully center the sheet under the patient, over the area of the femoral trochanters and the pubic symphysis. (See Figure 1.) Move the pelvis as little as possible.
Figure 1. Position for sheet placement in pelvic ring disruptions
Wrap the sheet tightly around the patient’s pelvis to gradually compress the pelvis at this level. Cross sheet ends and twist from opposing sides, applying adequate pressure. Use towel clamps to secure sheet ends. (See Figure 2.) Carefully avoid folds and creases that may result in skin damage if the sheet is left in place for an extended period. Remove gravel, glass shards, and other objects for the same reason. This Sheet Wrap Method results in some reduction of the fracture by splinting it, thus reducing internal blood loss.
Figure 2. A Pelvic Sheet Wrap Patient
Advantages. Sheeting allows more complete evaluation of the perineum and lower extremities, as well as vascular access at the groin. Sheet wrapping can be a great advantage when transarterial study and embolization of pelvic bleeding is available. A sheet wrap avoids compression of muscle compartments that are prone to the development of compartment syndromes. When correctly applied, a sheet wrap does not interfere with respirations and provides non-invasive external "fixation." Sheet wrapping is also the most cost-effective treatment.
Disadvantages. Sheeting does not provide splinting of lower extremity dislocations and fractures. This method may not increase systemic vascular resistance and blood pressure support in conditions such as neurogenic shock and septic shock. Prehospital use of this method has not been studied. The compression of the sheet may extend skin and wound areas that are already injured. Exercise caution when placing a sheet over open skin areas due to burns or traumatic injury.
Unstable or floppy pelvis by palpation
Open book pelvic ring disruption. Pubic symphysis diastasis is > 2.5 cm on AP pelvis radiograph.
Hypotensive patient without other obvious reasons for hypotension (ie, abdominal, chest, or extremity injuries).
Skin issues: Open wounds or burns: Sheet wrapping may extend injury if too tight and may cause further skin problems.
Pregnancy: Consider using the sheet wrap method while communicating with a trauma consultant. If the sheet wrap method is recommended and the patient is in a Pneumatic Anti-Shock Garment (PSAG or Military Anti-Shock Trousers [MAST]), carefully decompress the abdominal and leg compartments one by one, pausing to administer more blood and fluids if the patient’s blood pressure falls. If a precipitous fall in blood pressure occurs, re-inflate the compartments and do not attempt to remove the PASG prior to transfer.
If the patient has knee, femur, or tibia/fibula fractures or dislocations, attempt decompression of the PASG as described. If decompression may be accomplished safely, inspect the patient’s lower extremities and perineum. Then, re-inflate the leg compartments to splint the injuries as needed. With the abdominal compartment opened, pass a folded sheet around the pelvis and compress the pelvic fracture as described.
Other Stabilization Methods.
The SAM Pelvic Sling II is a force-controlled circumferential pelvic sling belt manufactured by SamMedical. For more information, go to http://sammedical.com/sam_sling.html
Trauma Pelvic Orthotic Device (T-POD) is manufactured by Cybertech. For more information, go to http://www.pyng.com/products/t-pod/?pi=79
The External Pelvic Fixator is ordinarily applied only by orthopaedic surgeons.
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Nye AL, Trauma Director, Hennepin County Medical Center, Personal communication. August 23, 2002.
Simpson T, Krieg JC, Heuer F, Bottlang M. Stabilization of Pelvic Ring Disruptions with a Circumferential Sheet. J Trauma. 2002;52(1):158-161.