Examiner un bassin: Peu faible en préhospitalier

Clinical Examination of the Pelvic Ring in the Prehospital Phase.

Van Leent EAP et Al. Air Med J. 2019 Jul - Aug;38(4):294-297.

 

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Bien que ce travail soit réalisé sur des trauma fermés,  il milite pour un emploi systématiques des ceintures pelviennes dès lors qu'il existe la notion de trauma à haute énergie

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INTRODUCTION:

Instable pelvic fractures are associated with significant hemorrhage and shock. Instability of the pelvic ring should be tested with the manual compression test (MCT) and instable pelvic ring fractures should prompt mechanical stabilization. However, the accuracy of the prehospital MCT in patients, that sustained a high energetic trauma, is still unknown.

SETTING:

Radboudumc Nijmegen, level 1 trauma center, the Netherlands.

METHODS:

This prospective blind observational study included all patients after a high impact blunt trauma treated by an experienced Helicopter Emergency Medical Service (HEMS) physician. Nominal arranged questionnaires were filled in by the HEMS physician prior to the radiological examination of the patient.

RESULTS:

We included 56 patients of which 11 sustained a pelvic ring fracture. 13 patients were treated with pelvic compression devices, of which only five patients had a pelvic ring fracture. Prehospital performed clinical examination by the HEMS physicians had an overall sensitivity of 0.45 (95% CI 0.16-0.75) and a specificity of 0.93 (95% CI 0.29-0.96).

CONCLUSION:

Pelvic ring instability cannot accurately be diagnosed in the prehospital setting, based on the MCT. The use of the pelvic binder should standard in high impact blunt trauma patients, independently of the MCT or trauma mechanism.

Et pourquoi pas un ballonet pré-pelvien ?

Minimally invasive preperitoneal balloon tamponade and abdominal aortic junctional tourniquet versus open packing for pelvic fracture-associated hemorrhage: Not all extrinsic compression is equal.

Do WS et Al.  J Trauma Acute Care Surg. 2019 Jan 10. doi: 10.1097/TA.0000000000002203

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On propose souvent la réalisation d'une hémostase temporaire par a pose de sondes à ballonet. Ce travail (partiellement déjà présenté en 2016) rapporte une expérience de ce type avec un produit initialement dédié à la chirurgie pariétale herniaire. La simplicité de sa pose et son efficacité semblent prometteurs du moins chez le cochon.

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BACKGROUND:

Minimally invasive preperitoneal balloon tamponade (PPB) and abdominal aortic junctional tourniquets (AAJT) have been proposed as alternatives to open preperitoneal packing (OP) for the management of pelvic fracture-associated hemorrhage. We hypothesized that the PPB (SpaceMaker Pro) and AAJT would result in similar rates of survival and blood loss versus OP METHODS: 32 swine underwent creation of a combined open-book pelvic fracture and major iliac vascular injuries. Animals were randomized to no intervention (n=7), OP (n=10), PPB (n=9), or AAJT (n=6) at a mean arterial pressure <40 mmHg following initiation of uncontrolled hemorrhage. Survival (up to 60 min + 10 min after intervention reversal), hemodynamics, extraperitoneal pressures, blood loss, and associated complications were compared between groups.

RESULTS:

Prior to injury, no difference was measured between groups for weight, hemodynamics, lactate, and hematocrit (all p>0.05). The injury was uniformly lethal without intervention, with survival time (mean) of 5 min, peak preperitoneal pressure (PP) of 14 mmHg, blood loss of 960 g, and peak lactate of 2.6 mmol/L. Survival time was 44 min with OP vs. 60 min with PPB and AAJT (p<0.01). Peak PP (mmHg) was 19 with OP, 23 with PPB, and 23 with AAJT (p>0.05). Blood loss (g) was 850 with OP, 930 with PPB, and 600 with AAJT (p>0.05). Peak lactate (mmol/L) was 3.3 with OP, 4.3 with PPB, and 6.3 with AAJT (p<0.01). Only 33% of AAJT animals survived intervention reversal vs. 60% for OP and 67% for PPB (p<0.01). Necropsy revealed bowel/bladder injury in 50% of AAJT subjects vs. 0% in all other arms (p<0.01).

CONCLUSIONS:

PPB is a safe and potentially effective alternative to OP for the management of lethal pelvic fracture-associated hemorrhage. AAJT offers a similar survival benefit to PPB but has concerning rates of ischemia-reperfusion and compressive abdominal organ injury.

 

Stabilisation pelvienne:

Les attelles de type Sam Splint sont INCONTOURNABLES en médecine militaire comme on peut le voir dans une brochure spécifique. Certains proposent de l'utiliser comme base d'une stabilisation pelvienne.

 

Stabilisation pelvienne: Simple est efficace

 Comparison of circumferential pelvic sheeting versus the T-POD on unstable pelvic injuries: A cadaveric study of stability
Prasarn ML et All. Injury. 2013 Jun 27. pii: S0020-1383(13)00256-8

Objectives: Commercially available binder devices are commonly used in the acute treatment of pelvic fractures, while many advocate simply placing a circumferential sheet for initial stabilization of such injuries. We sought to determine whether or not the T-POD would provide more stability to an unstable pelvic injury as compared to circumferential pelvic sheeting.
Methods: Unstable pelvic injuries (OTA type 61-C-1) were surgically created in five fresh, lightly embalmed whole human cadavers. Electromagnetic sensors were placed on each hemi-pelvis. The amount of angular motion during testing was measured using a Fastrak, three-dimensional, electromagnetic motion analysis device (Polhemus Inc., Colchester, VT). Either a T-POD or circumferential sheet was applied in random order for testing. The measurements recorded in this investigation included maximum displacements for sagittal, coronal, and axial rotation during application of the device, bed transfer, log-rolling, and head of bed elevation.
Results: There were no differences in motion of the injured hemi-pelvis during application of either the T-POD or circumferential sheet. During the bed transfer, log-rolling, and head of bed elevation, there were no significant differences in displacements observed when the pelvis was immobilized with either a sheet or pelvic binder (T-POD).

Conclusions: A circumferential pelvic sheet is more readily available, costs less, is more versatile, and is equally as efficacious at immobilizing the unstable pelvis as compared to the T-POD. We advocate the use of circumferential sheeting for temporary stabilization of unstable pelvic injuries.

Stabilisation pelvienne: Vraiment utile !

Emergency stabilization of the pelvic ring: Clinical comparison between three different techniques

Pizanis A. et All. Injury. 2013 Aug 2. pii: S0020-1383(13)00316-1.

Background: Emergency devices for pelvic ring stabilization include circumferential sheets, pelvic binders, and c-clamps. Our knowledge ofthe outcome ofthese techniques is currently based on limited information.

Methods: Using the dataset of the German Pelvic Trauma Registry, demographic and injury-associated characteristics as well as the outcome of pelvic fracture patients after sheet, binder, and c-clamp treatment was compared. Outcome parameters included transfusion requirement of packed red blood cells, length of hospital stay, mortality, and incidence of lethal pelvic bleeding.

Results: Two hundred seven of 6137 (3.4%) patients documented in the German Pelvic Trauma Registry between April 30th 2004 and January 19th 2012 were treated by sheets, binders, or c-clamps. In most cases, c-clamps (69%) were used, followed by sheets (16%), and binders (15%). The median age was significantly lower in patients treated with binders than in patients treated with sheets or c-clamps (26 vs. 47 vs. 42 years, p = 0.01). Sheet wrapping was associated with a significantly higher incidence of lethal pelvic bleeding compared to binder or c-clamp stabilization (23% vs. 4% vs. 8%). No significant differences between the study groups were found in sex, fracture type, blood haemoglobin concentration, arterial blood pressure, Injury Severity Score, the incidence of additional pelvic packing and arterial embolization, need of red blood cell transfusion, length of hospitalisation, and mortality.

Conclusions: The data suggest that emergency stabilization ofthe pelvic ring by binders and c-clamps is associated with a lower incidence of lethal pelvic bleeding compared to sheet wrapping.

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Stabilisation pelvienne: Un état des lieux à lire

The use of pelvic binders in the emergent management of potential pelvic trauma

Chesser TJS et all. Injury, Int. J. Care Injured 43 (2012) 667–669

PelvicBinder.pdf

Stabilisation pelvienne: Au bon niveau

Ce document est à mettre en lien avec l'impotrance d'un positionnement correct de ces dispositifs. Il s'agit seulement d'une fois sur 2 d'un positionnement au niveau des grands trochanter. Dans près de 40% des cas le positionnement était trop haut.

Accurate placement of a pelvic binder improves reduction of unstable fractures of the pelvic ring. Bonner TJ et all.  J Bone Joint Surg Br. 2011 Nov;93(11):1524-8.

Stabilisation pelvienne: Sam Sling, Tpod ou autre chose ?

Une présentation d'une publication portant sur la comparaison du T Pod, de la Sam Pelvic sling et du Pelvic binder qui sont les 3 dispositifs les plus couramment utilisés.

StabPelv.pdf

http://www.medicalsca.com/files/jb__js_-_pelvic_devices_c...

Pelvic Fracture Hemorrhage—Update and Systematic Review

http://www.east.org/Content/documents/practicemanagementg...