STANDARD OPERATING PROCEDURE PELVIC INJURY AND SPLINTAGE

Transcription

1 STANDARD OPERATING PROCEDURE PELVIC INJURY AND SPLINTAGE DATE APPROVED: 11 August 2015 APPROVED BY: Clinical Governance & Quality Committee IMPLEMENTATION DATE: 13 August 2015 REVIEW DATE: June 2018 LEAD DIRECTOR: Medical Director IMPACT ASSESSMENT STATEMENT: No adverse impact on Equality or Diversity Document Reference Number: CLN Procedure 025 (Version 3)

2 Page 2 of 10 Change Control: Document Number CLN Procedure Document Pelvic Injury and Splintage SOP Version One Owner Medical Director Distribution list All staff and relevant partners Issue Date June 2012 Next Review Date June 2018 File Reference PR Author Head of Clinical Practice - Trauma Change History: Date Change Authorised by May 2012 Draft Medical Director June 2012 Reviewed and amended Head of Medical Director Clinical Practice June 2012 Reviewed by Heads of Clinical Medical Director Practice and Clinical Performance and Governance Managers comments incorporated June 2012 Sent to CQGC for approval Medical Director June 2012 Approved by CQGC Medical Director January 2013 October 2014 August 2015 Reviewed and amended Head of Clinical Practice Reviewed and amended Head of Clinical Practice- FPHC consensus statement incorporated Reviewed at Clinical Steering Group no changes required agreed to amend next review date to June 2018 Medical Director Medical Director Medical Director

3 Page 3 of 10 CONTENTS 1 Introduction Prehospital assessment Prehospital management Additional information References... 10

4 Page 4 of 10 1 Introduction 1.1 Early suspicion, identification and management of a pelvic fracture in the pre-hospital environment are essential to reduce blood loss and the risk of hypovolaemic shock. Pelvic fractures are a hallmark of significant injury and are frequently associated with major intraabdominal and vascular injuries. 1.2 Early external pelvic splintage, whilst clotting factors are still functional, will reduce bleeding by apposition of the fracture site and reducing movement of the bone ends which could disrupt established clot. It should be thought of as a treatment option for major haemorrhage. 2 Prehospital assessment 2.1 Consider mechanism of injury: RTC, particularly front seat occupants in head on collisions and patients sitting on side of impact with intrusion Pedestrians Motorcyclists Fall from height Crush injury Simple falls in the elderly 2.2 Look for signs of shock, and the presence of pain in the pelvic area including the lower back, groin and hips. 2.3 Additional indicators of pelvic injury include: Obvious deformity Bruising and swelling over the bony prominences, pubis, perineum and scrotum Leg length discrepancy or rotational deformity of a lower limb (without fracture in that extremity) Wounds over the pelvis or bleeding from the patient s rectum, vagina or urethra if detected indicate an open pelvic fracture. 2.4 THE PELVIS SHOULD NOT BE SPRUNG TO TEST FOR TENDERNESS OR INSTABILITY. This risks disturbing clot and has also been shown to be unreliable in detecting pelvic injuries. 2.5 If trapped within a vehicle whilst suspicion exists of pelvic injury (side impact, mid shaft femoral fracture), the patient should wherever possible be extricated rearwards following roof removal. Rotating the patient or rolling the patient sideways should NOT be attempted unless there is an immediate threat to life as this may convert a simple fracture into a major vascular injury.

5 Page 5 of 10 3 Prehospital management 3.1 Indications for splintage Alert and Orientated Patients without Distracting Injury: Pelvic Splintage should be applied to all patients who have had a mechanism of injury likely to result in pelvic fracture who have signs consistent with pelvic fracture on inspection, or have pain in the pelvic area Trauma Patients with Reduced Conscious Level and/or Distracting Injury: Pelvic Splintage should be applied to all patients who have had a mechanism of injury likely to result in pelvic fracture 3.3 Minimise movement of the patient and avoid log rolling as this is likely to precipitate further bleeding. 3.4 Apply a pelvic splint. 3.5 Obvious wounds in relation to the pelvis should be dressed. 3.6 Application

6 Page 6 of 10 Application continued The middle of the splint should be positioned at the level of the greater trochanter (see red arrow below in Fig 1), if it is positioned too high (at the level of the iliac crest) this can cause the IC joint to widen and potentially worsening any haemorrhage in the case of a fracture. Accurate positioning is vital (see Fig 2). Fig 1 Fig 2

7 Page 7 of 10 The pelvic splint should only ever be applied directly over skin. It is simply pointless to apply over clothing as the splint will need to be released to remove the clothing at hospital and the tamponade effect of the splint will be lost. The pelvic splint should always be cut to size and not folded over (as in Fig 3). This allows for more accurate placement. Staff are reminded that the application of a pelvic splint denotes a suspected fracture of the pelvis and as such the patient triggers the major trauma tool and should be conveyed to a major trauma centre. Fig 3 With thanks to London Ambulance Service. A pelvic binder should be applied prior to extrication where possible. A select group of patients may not need a binder applied Significant pelvic trauma can be excluded in a small group of patients preventing the unnecessary use of pelvic binders. These patients must be haemodynamically stable with a normal Glasgow coma scale. The following flow diagram is an illustration of how patients can be stratified according to the risk of pelvic injury.

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9 Page 9 of 10 Associated femoral fractures should also be reduced. Patients that also have clinically obvious femoral fractures should have these stabilised. If the patient is significantly haemodynamically compromised then in this scenario to prevent unnecessary delay, consideration to pulling the legs out to length (with appropriate analgesia as needed), apply a pelvic binder and then binding the legs together at the knees and figure of 8 around the ankles and feet should be made. If applying any traction causes increased pain or further haemodynamic instability then the legs should be strapped together in the position found. If the patient is haemodynamically stable and there is a low probability of significant pelvic injury or if it is felt that a patient does require a traction splint, for example a patient with an isolated femur fracture, bilateral femur fracture or a patient with severe displaced fracture of a long-bone and possible prolonged transfer time then the clinician could consider the application of traction splint but care must be taken in this approach as counter traction is applied to the pelvis and this could cause further injury. The manufacturers of traction splints do not recommend their use with pelvic fractures however, consideration for a device such as the Kendrick Traction Device (KTD) which allows you to work around the problem of hip and groin trauma and may also be applied more rapidly than older devices whilst still allowing reasonable ease of extrication and packaging. Patients should not be log rolled or transported on a spinal board There is evidence that logrolling patients with significant pelvic fractures can cause clot disruption and further haemodynamic compromise. Patient handling must therefore be approached with care in these patients. Logrolling only has a place in turning a patient onto their back to allow access to their airway. There is no place for routine logrolling in blunt trauma victims. Patients should be moved with the aid of a scoop stretcher. No patient should be logrolled onto or off a spinal board with a pelvic injury. The pelvic binder should be placed next to skin. There is limited information regarding this in the literature. Most of the studies have been performed in accident and emergency departments where clothes were removed. Studies examining the effect of pressure exerted by these devices have been undertaken with only thin undergarments on. There is no evidence that placement over clothes provides the same degree of stabilisation or risk of pressure damage. Ideally pelvic binders should be placed either directly to skin or just over thin underwear. Placement next to skin may allow more accurate positioning of these devices; it will also help prevent the pelvic binder device being removed on arrival at hospital. In certain scenarios it may be appropriate to place the binder over clothes and the fear of undressing someone should not prevent the use of these devices. 3.7 Once the splint has been applied, use a scoop stretcher (with maximal tilt of 15 o ) to lift the patient directly onto stretcher or vacuum mattress for transportation.

10 Page 10 of 10 4 Additional information 4.1 Hospital teams should be encouraged to leave the pelvic splint in situ until definitive care can be initiated. 4.2 The splint should only be removed after a full radiological study excludes instability (images should be performed through the splint or when other means of stabilisation have been initiated). Hospital personnel should be advised that reduction of a pelvic fracture with a splint can make it difficult to see the fracture on x-ray and if the index of suspicion is high, consideration should be given to relaxing tension on the splint and repeat x-ray. 4.3 Consider transfer to a Major Trauma Centre with facilities for pelvic fracture surgical management. Coventry (UHCW) Queen Elizabeth Hospital Birmingham UHNS, Stoke Birmingham Children s Hospital 5 References 5.1 Lee C, Porter K. The prehospital management of pelvic fractures. Emerg Med J 2007; 24: JRCALC. Major Pelvic Trauma Guideline. April London Ambulance Service Clinical Update September 2013 FPHC consensus statement The Pre-hospital Management of Pelvic Fractures: Initial Consensus Statement I Scott, K Porter, C Laird, M Bloch, I Greaves December 2013