Stabilisation pelvienne: Les genoux sont importants

Pelvic pressure changes after a fracture: A pilot cadaveric study assessing the effect of pelvic binders and limb bandaging

Morris R et Al. Injury  http://dx.doi.org/10.1016/j.injury.2015.12.009

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Stabiliser un bassin pour lequel il existe une suspicion de fracture est une des composantes majeures du sauvetage au combat. Ceci vise à réduire la mortalité par hémorragie non garrotable ou non comprimable. Il existe des ceintures spécifiques pour cela. Ce travail est intéressant car il illustre la complémentarité des ceintures pelviennes ET de l'immobilisation des genoux. Cette dernière permet à elle seule d'augmenter la pression intra-abdominale et partant probablement de réduire le saignement. Donc n'oublier pas d'immobiliser les genoux. Que vous disposez ou pas de ceinture pelvienne, cela sert.

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Objectives: Pelvic binders are a life-saving intervention for hypovolaemic shock following displaced pelvic fractures, thought to act through increasing intra-pelvic pressure to reduce venous bleeding. This cadaveric study assesses changes in intra-pelvic pressure with different binders augmented by bandaging the thighs to recruit the femora as levers to close the pelvis. Access to femoral vessels via an in situ binder was also assessed.

Methods: Two embalmed cadavers were used with unstable pelvic injuries (OA/OTA 61-C1) created through disrupting the pelvic ring anteriorly and posteriorly. To measure intravesical pressure, which reflects intra-pelvic pressure, a supra-pubic catheter was inserted and connected to a water manometer whilst a spigot was placed in a urethral catheter to reduce leakage of fluid. The common and superficial femoral arteries were dissected in the left groin for each specimen prior to any intervention to allow inspection following binder application. A SAM pelvic sling II, Trauma Pelvic Orthotic Device (T-POD), Prometheus pelvic splint and an improvised pelvic binder were used on each cadaver, with each applied following lower limb bandaging with the knees slightly flexed. The groins were then inspected to assess if the femoral vessels were visible. Statistical analysis was performed in SPSS using a paired samples t test to determine if any difference existed between initial pelvic pressure in specimens compared to pressures with bandaging on and binders applied.

Results: Bandaging the lower limbs alone produced a significant increase in both peak and steady mean intra-pelvic pressure, 15.69 cmH2O and 12.38 cmH2O, respectively, compared to the baseline pressure, 8.73 cmH2O (p = 0.002 and p = 0.001, respectively). Applying the pelvic binder with the bandaging in place increased intra-pelvic pressure compared to the baseline (peak pressure of 25.38 cmH2O (p < 0.001) and steady pressure of 15.13 cmH2O (p = 0.003)). Steady mean pressures between bandaging alone and bandaging with the binder applied were not significantly different (p = 0.09), whilst the peak pressures were significantly greater when the binder was applied (p = 0.005). The improvised binder and T-POD both required cutting to access the femoral vessels which resulted in decreasing efficacy.

Conclusions: Intra-pelvic pressure was significantly increased through bandaging the lower limbs alone, and this represents a simple measure to increase intra-pelvic pressure and therefore efficacy of the binder. Access to the femoral vessels varied with binder type and represents an important consideration in polytrauma patients.