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Pelvic Trauma
maroju
In a trauma patient with suspected pelvic injury (which does not look obviously deformed), does clinical assessment of its integrity have a good sensitivity and specificity? Or would you much rather resort to imaging as soon as possible (mind you, this is a centre without trained personnel in FAST!!!).
 
stemlyns
I seriously doubt the sensitivity and specificity of Pelvic rocking/swinging(so called clinical assessment of integrity of pelvis) and it can cause uneccassay pain and disrupt the already tamponaded blood clot and worsen the hemorrhage.
I think Xray is best to diagnose/rule out a pelvic fracture and for this reason it is part of initial screeing of the trauma patient.
 
maroju
More queries...
1)In such a scenario, what is the best way to ensure the integrity of the pelvis during transfers (from scene to ambulance, ambulance to hospital trolley, x-ray/scanner etc).

2) If there is a clinical suspicion of a pelvic fracture, is log-roll indicated (though sounds common sense!!!)...

3) Is PR examination part of assessment of pelvic injuries?
 
stemlyns
I presume in most cases when you are suspecting pelvic trauma the patient is likely to come on a long spinal board(as he will be suspected of having spinal tauma as well).If patient is not on the spinal board then i would jusy wrap the pelvis in a blanket and the recent evidence even against doing any manuiplualtions(what we might do by doing these blanket wrapping).There are lot new devices(all fancy American) but still not widely avaiable to use.If patient is on spinal board then the transfering is very easy as you know.I think most of the trauma series xrays can be done in trauma/resus room with portable device(which will avoid unnecessary transfering.

I agree with you that irrespective of suspected pelvic trauma pt needs log roll and that should not be delayed under any circumstances as it is essential part of secondary survery.

Yes PR is is part of pelvic assessment.Any blood in the rectum with a proven pevlic fracture is compound fracture and the patient needs washout and colostomy(joint care of ortho and gen surgeons).
 
maroju
I fully agree with some form of pelvic splintage (blanket / towel / broad strappings / Sam Splints / indegenously built pelvic splints etc). But I think that it is good practice to apply the splintage immaterial of whether the patient is on spinal board or not if there is suspicion of pelvic injury!!!

If the aim of minimising pelvic movement is to preserve the clot / prevent further pelvic bleeding, I am not entirely convinced of the need for a log-roll when there is suspected significant pelvic injury. Yes it is an essential part of secondary survey. But the total time of your primary survey gets prolonged until the pelvis has been reasonably stabilised (as part of C in C-ABCDE!!!).

Off late, use of long spinal boards as tools for transfer has been strongly discouraged. This is purely used as an extrication device at the scene of incident. We use 'scoop-stretchers' for transfers (I am mindful that many centres may not have them!!!). The spinal boards being absolutely hard and flat, are not suited to conform to the contours of the spinal column, let alone the pain this would cause the patient. Also with the use of these scoops, movement of pelvis and spine could be reduced to bare minimum (which is not possible with a spinal-board!!!).
Edited by maroju on 18-08-2008 20:15
 
morpheus
the need for a log roll is evidently debated not only in my circles but world over.
i had the opportunity to interact with one of the very very few ATLS instructors in India, very closely.
and her opinion was that its still debatable.
but from what i have realized is....that you avoid a log roll.
do a straight lift of the patient.
it is extremely difficult to do... but then again...if you have adequately strong manpower... do a straight lift of the patient.
the question of the PR without a log roll is also one thats a lil complicated..
i would suggest doing the PR from straight below down rather than the conventional method.

the split stretchers are good.... unfortunately they are way more heavier than the usual spinal boards...so hmmm if you have a 100 kg man... well you better have muscles too.
Also the most difficult part of using a spinal board is taking it apart.
i have realized that its impossible to remove both the parts simultaneously....so for a momentary time period you are going to have spinal movement.
And leave footprints in the sands of time.......
 
maroju
I feel there is a slight confusion with the names of the kit!!!
Morpheus, did you mean the usual spinal board/long spinal board/long back board when you mentioned 'split-stretcher' and vice versa??

Modern scoop-tretchers' (Ferno) are much more lighter than most spinal boards. They come in all shapes and forms. You have foldable ones, retractable ones. You also have the option of having plastic ones (do not get too hot or cold based on weather!!!). The old fashioned scoop stretchers used to be a bit fiddly while clamping and unclamping. This problem seems to have been fixed in the newer versions.

Morpheus, you are suggesting 'Straight lift' as a better option to 'log-roll'. Is this for assessment of the back or for moving the patient from the spinal board/scoop-stretcher onto hospital bed?
Edited by maroju on 18-08-2008 21:03
 
morpheus
hmmm i think you are right about the confusion of the name. cos the scoop stretchers we were using were the fiddly aluminium ones... really uncomfortable to use.
the straight lift... i know its difficult to believe that you can use it for the back exam... but a quick exam can be accomplished with it. But it definitely needs muscles and a lot more people as compared to a log roll. Also its definitely easier to lay down the pelvic binder during the straight lift than the log roll.


And leave footprints in the sands of time.......
 
maroju
Straight lift as a quick manouvre to examine the spine doesnot somehow appear to me to be a good idea...
It is a totally uncontrolled manouvre, presumably done by several people, who clearly do not have the faintest idea as to how high to lift or even where to hold the patient. Assuming the patient has a significant spinal injury, you could potentially make it worse!!!
I have resorted to it on a couple of occassions, but that was only in the pre-hospital setting, to get my patients from 'rollover' RTCs where there was no way of getting a spinal board in. This was done purely for extrication. Believe me, it was not a good feeling.
Increasingly, the emphasis on an 'early' log-roll is on the wane. This is mainly to avoid potential 'clot disruption' should there be a significant pelvic injury. If one can rule out any significant injury by FAST and X ray of pelvis, you could then log roll the patient for examination of the back. If the trauma system is well organised in a centre, it shouldn't take more than 10-15 minutes to get all of this done.
(It might be useful to document gross neurology of the patient (extremities/sphincters/priapism) before attempting log-roll)
Edited by maroju on 23-09-2008 12:07
 
shajoo
pelvic # is a silene killer. clinically only open book pelvic # wih wide open PS jt can be sometimes appreciated. none other can be seen on clinical exam.ATLS protocal includes AP chest xray and pelvic xray as ajuncts to primary survey becoz both are life threatening. so AP pelvic xray gives a good amount of information
 
shajoo
secondly, these swinging maneuvers should be discouraged .reason is that when there is pelvic bleed then a retroperitoneal / pelvic hematoma is formed which has a tamponading effect of the ongoing bleeder.when we excessively move the pt then this clot / hematoma is dislodged leading the pt pt to exsaguinate.i have seen many cases like that in my trauma centre.pt came with very high severity of mechanism of injury with high suspicious of pelvic # and every EP coming and swinging the pelvis and the pt who was a transient responder of shock to the fluids then went into hypovolumic shock. In EM 2 pts shoulddd beeeee physically handle with extreeee careee otherwise u will lose ur pt. 1. hypothermic pts and second pelvic # pt.
 
morpheus
i agree.
thats why the concept of a trauma team is important. so that you can have one assessment only, and everyone knows for sure what was seen in the assessment.
but there is recent research which shows that pelvic thrust as a manouvre is neither sensitive nor specific for diagnosing even open book fractures.
but i guess till further research is done we will continue to do so.
thats the drawback of evidence based medicine, cant practice and cant not practice it...
regards
anunaya
And leave footprints in the sands of time.......
 
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