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Wed Mar 11 13:18:56 GMT 2009

Excellent.  

The pelvic volume model, however geometrically tidy, never made any clinical sense.  On either side of the peritoneum, blood will find a way.

That said, proper splinting ALWAYS reduces secondary local tissue trauma; and when the local tissues include large or numerous blood vessels, secondary trauma should be a major concern at every phase.

The key, then, is stabilization.  Not reduction, not compression, not tamponade.  Keep those pesky shards of bone still.

This need not imply the use of variously complex and expensive gadgets, ESPECIALLY in the prehospital phase.  As with spine fractures, proper splinting is mostly a matter of assuming that these injuries exist, and handling them judiciously.  If anything, pillows or blanket rolls supporting the iliacs should suffice: inexpensive and reusable, easily removed, and largely exempt from contraindication or complication.

It is thus equally important that direct physical assessments be limited (if not eliminated) in patients with kinematic risk, in favor a simple AP radiograph.  If you can't finagle a quick trauma room pelvic film, it's unlikely you're ready for what's in there anyhow.  Squeezing or rocking the pelvis is a notoriously low-yield assessment, and carries predictable consequences.  We don't rock femurs, after all.

Good conversation.

Pret Bjorn, RN
Bangor, ME USA

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org] On Behalf Of Karim Brohi
Sent: Tuesday, March 10, 2009 6:24 PM
To: Trauma &amp, Critical Care mailing list
Subject: Re: Prehospital pelvic compression

Unfortunately this is one of those orthopaedic myths that continues to
be propagated despite excellent animal data to the contrary.  The
bleeding pelvis does not fill up like water in a bucket.  The volume
of a cone or any other geometrical construct is irrelevant.  Blood
tracks through the retroperitoneum along tissue planes, which are
partially disrupted in trauma. There is no lid on the pelvis.  The
blood tracks posteriorly up the retroperitoneum, through the posterior
abdomen and sometimes even up into the chest.  It also extends
anteriorly up the abdominal wall and out through the sciatic foramina
into the gluteal planes.    If not breached the peritoneum, even that
within the pelvis, remains empty.  Applying a pelvic belt does not
significantly increase pressure within the pelvis  (if properly
applied it's going around bone after all!!)  PLUS pressure can escape
into the abdomen and out into the buttocks

Remember that a vertical shear fracture is essentially an internal
hemipelvectomy.  All tissue planes are disrupted.   Any movement of
the pelvis (and there is a lot with transfers/scoops etc) is totally
without any internal stabililty, and clot is persistently dislodged
and further bleeding & injury insues.  The same is true to a lesser
extent with less severe fracture patterns.

The belt stops bleeding just like any splint does - by holding the
fracture in place so allowing stable clot to form.

Karim

2009/3/10 Rajesh <rajesh84 at asianetindia.com>:
> My impression was that they allow one to prevent the pelvis opening
> up(increasing the volume as it is proportional to the diameter) and help
> control the volume of space available for blood to flow into, thus leading
> to a tamponade effect.It is not to actively control bleeding per se.
>
> K.R.Rajesh FRCS,FRCS(Orth)
> Staff Specialist (Ortho)
> Bega
> NSW
> ----- Original Message ----- From: "McSwain, Norman E Jr."
> <nmcswai at tulane.edu>
> To: <trauma-list at trauma.org>
> Sent: Wednesday, March 11, 2009 4:24 AM
> Subject: Re: Prehospital pelvic compression
>
>
>> First understand the data
>> These devices close the pelvic fracture, however there is NO data that
>> shows that they control hemorrhage. The answer to your question is based on
>> your need.
>> Why were they applied?
>> Is  that outcome needed and
>> beneficial for the patient
>> Does the data support it's use?
>>
>> Typed by the thumbs of
>> Norman on his BlackBerry
>>
>> Norman McSwain, MD
>> Tulane Univ Surgery
>> 504 988-5111
>>
>> ----- Original Message -----
>> From: trauma-list-bounces at trauma.org <trauma-list-bounces at trauma.org>
>> To: trauma-list at trauma.org <trauma-list at trauma.org>
>> Sent: Tue Mar 10 12:03:18 2009
>> Subject: Prehospital pelvic compression
>>
>>
>> Hello!
>> I have a question to all of you regarding the use of prehospital pelvic
>> binders. I work at a small hospital where we dont have access to x-ray of
>> the pelvis in the traumaroom. Currently the prehospital personel applies the
>> TPOD (pelvic binder) in the prehospital setting whenever they suspects a
>> pelvic fracture. The TPOD is often placed before removing the patients
>> cloths. This approach interferes the examination of the patient in the
>> traumaroom because when the pelvic divice is applied prehospital every one
>> is afraid of removing it with the fear of bleeding. Since we dont have acces
>> to plain x-ray in the traumaroom we often leave the TPOD until the trauma-ct
>> is done and we have  pictures. The tpod also makes it difficult to remove
>> the patients clothes and sometimes makes it impossible to make a good
>> examination of the lower back, perineum/rectum. How would yo approach this
>> matter?
>>
>> Johan
>>
>>
>>
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Prehospital pelvic compression