The Pre-brief
You are stuck in traffic on your way to work when you learn that a vehicle with one passenger crashed into a tree causing traffic to back up. You decide to assist the basic life support (BLS) crew who arrived at the scene first. As you approach the crash scene, you recognize the crew from working in the hospital, but you also find a young male with multiple injuries who is being extricated from the vehicle. After receiving permission from the state trooper and EMS crew, you begin your primary assessment which reveals a male in his mid forties, awake, but in obvious distress. You see no external bleeding. You easily identify an open tib-fib fracture on the right lower extremity. As the EMS crew is stabilizing the C-spine and applying oxygen, you begin your secondary assessment which is concerning for an unstable pelvis. One of the EMTs yells out the vital signs: HR 122, BP 70/palp. The Advanced Life Support and other backup units are on their way. What do you do?
An overview of pelvic fractures
Pelvic fractures are mostly caused by motor vehicle collisions and falls from height. They are associated with high morbidity and mortality. The three main patterns of pelvic fractures are: Vertical shear, anteroposterior compression, and, most commonly, lateral compression. Most traumatic pelvic fractures result in venous bleeding, but up to 15% of cases result in arterial bleeding. Up to 4 Liters of blood can enter the retroperitoneal space from a pelvic trauma. Timely recognition and stabilization of pelvic fractures can save lives.
What Can I Do About These Acutely?
There are a number of commercial devices available to stabilize the pelvis until definitive therapy is achieved. If any of these devices are not available immediately, then a bedsheet or blanket can be used instead. The sheet is folded lengthwise and wrapped around the patient’s hips directing the force inward on the greater trochanters. Never wrap the sheet over the iliac crests because it may worsen bleeding. Once wrapped around the pelvis, the sheet should be pulled crosswise until it’s snug enough to pull the sides of the pelvis close together.
Patients with injuries from polytrauma can present acutely ill and with significant hemodynamic instability. If securing the airway is a priority, then clinicians should optimize resuscitation before proceeding with rapid sequence intubation. When an unstable pelvic fracture is suspected or identified in the initial evaluation, it is recommended that some sort of stabilization is in place prior to the administration of the RSI agents. The sedative agent may further cause vasodilation in an already hypovolemic patient. Giving a paralytic drug will cause muscle relaxation which may accelerate bleeding due to loss of muscle tone across an unstable pelvic fracture. Start intravenous fluid or ideally give blood products as appropriate. These patients should be transferred to a trauma center for definitive care with external or internal fixation along with angiographic embolization in the case of arterial bleeding.
The Debrief
- Trauma patients with unstable pelvis have high morbidity and mortality
- Stabilize pelvic fractures with any available commercial devices, or by using a bedsheet
- The bedsheet should be wrapped around the greater trochanters
- Definitive therapy for unstable pelvic fractures is with external or internal fixation, and angiographic embolization
