a bad day....

[Doc T]

Your team is fast roping and one person loses his grip and falls approximately 20 feet to the ground landing on his buttocks. He remains awake and alert but complains of excruciating pelvic pain. He attempts to get up but is unsuccessful. ABC’s reveal an intact airway, good respiratory effort and a palpable radial pulse.…

There is no place for the helicopter to land. The nearest LZ is approximately three clicks away. The nearest vehicle will take about an hour to reach you.

What is your differential? Treatment plan? Concerns?

Doc t.

[RsovRanger]

Crepidus, grimace when I check for pelvic stability?

He's breathing and talking. That's always good.


Crepidus and grimace tell me he's got a pelvic fracture. Lack of that tells me he just fell hard as hell and is going to require Xrays to diagnose exactly what's making it so he can't stand up.

With the pelvic fracture I would be checking for distal pulses to the injury as well as neuromuscular response to see what is involved with the injury. I would be suspecting a pelvic fracture with possible spinal compression injury due to the MOI.

Given what I carry, I'd be tying cravats together and creating a diaper style splint to stabilize the pelvis, then getting 2 saline locks in prior to loading him up in a skedco and dragging his ass to the HLZ because with men to help we'd make it to the HLZ faster than the land response, as well as quicker evac time. I'd keep track of his mentation, breathing and his pulse/ palp BP because if he does have a pelvic fracture he can lose a hell of alot of blood due to that. 2+ liters if I remember correctly.

I'd also counsel the individual on holding onto the rope the next time he fastropes, because in training it's not worth getting hurt because you can't learn much from a gurney.

[Doc T]

Originally posted by RsovRanger
pulses distal to suspected injury?

how about neuromuscular response as well?

Crepidus, grimace when I check for pelvic stability?

He's breathing and talking. That's always good.

femoral pulses regular but mildly tachy, dorsalis pedis and posterial tibial weakly palpable...

neuro intact, lower extremities noted to be externally rotated, no distal shortening...

crepitus and patient grimaces and hollers loudly when you check for pelvic stability... you can feel it move under your compression...

he is still breathing and talking at this point...abet a bit tachypneic and cussing loudly.

doc t.

[RsovRanger]

sorry was editing my response when you fired that off.

[RIT_MEDIC]

Originally posted by Doc T
femoral pulses regular but mildly tachy, dorsalis pedis and posterial tibial weakly palpable...

neuro intact, lower extremities noted to be externally rotated, no distal shortening...

I would have started actual lines on this guy instead of the hep-locs, but then agian I dont use those things on trauma Pt's,...(2) 16 ga NS.

Could the external rotation cause compression of the femoral artery?

Regardless, I would realign the legs so the toes are up and tie them together with a cravat and recheck the pulses.

crepitus and patient grimaces and hollers loudly when you check for pelvic stability... you can feel it move under your compression...

he is still breathing and talking at this point...abet a bit tachypneic and cussing loudly.
doc t.

I bet he would be...

How about some MS for that pain, or one or RR's Phentanyl lollipops.

I think also checking the spine for any deformities, tenderness would be in order here. A fall from 20+/- feet could definately cause some compression.

Definately Sked him to EVAC point. Re-Eval Pt at intervals and keep him talking as we Exfil'd to keep a check on his mentation.

James D.

[mac3982]

would try the fentynal iv nothing by mouth, ms dependin what the bp is position of function or in place dependin on riged splints or vac splints and such for limbs, unstable ok just read the whole post , sorry bind the leggs together for stability check pulses treat for shock 2, 18ga or larger, prefer at least 16s if possible , hot lz or trainin "mis hap"stablize pelvic as much as possible, with the men on hand hump him out, monitor bp due to blood loss and possible internal lower abd. injuries, c- spine and also possible neuro injuries as well... stablize move out!

[Doc T]

Originally posted by RsovRanger


Given what I carry, I'd be tying cravats together and creating a diaper style splint to stabilize the pelvis, then getting 2 saline locks in prior to loading him up in a skedco and dragging his ass to the HLZ because with men to help we'd make it to the HLZ faster than the land response, as well as quicker evac time. I'd keep track of his mentation, breathing and his pulse/ palp BP because if he does have a pelvic fracture he can lose a hell of alot of blood due to that. 2+ liters if I remember correctly.



The fracture described would be an open book pelvic fracture, or one with opening of the ring... the pubis widens as do the sacroiliac joints causing the legs to externally rotate. No real concerns about arterial compression as much as you'd be concerned about both venous bleeding at the sacral plexus as well as small arterial bleeders that can occur. By opening the ring you can truely allow for massive bleeding by the patient as it takes alot of bleeding to start the tamponade effect... open book fractures average about an 10 unit blood loss but can bleed as much as 80-90 units worth if given the chance. By closing down the ring (the splint you described) you can truely decrease bleeding exponentially. Will try to post pictures of the last patient we had...incredible difference.


Do you have a picture of the diaper style splint you'd create? I am curious. Acutely, in the trauma bay we simply tie a sheet around the patients hips and its amazing how much that simple maneuver works to reduce the widening....it is certainly quick and easy. They make all sorts of more expensive devices that do the same thing but the sheet works well. Do you all ever carry MAST suits?

doc t.

[Doc T]

Originally posted by RIT_MEDIC
I would have started actual lines on this guy instead of the hep-locs, but then agian I dont use those things on trauma Pt's,...(2) 16 ga NS.

How about some MS for that pain, or one or RR's Phentanyl lollipops.

I think also checking the spine for any deformities, tenderness would be in order here. A fall from 20+/- feet could definately cause some compression.

Definately Sked him to EVAC point. Re-Eval Pt at intervals and keep him talking as we Exfil'd to keep a check on his mentation.

James D.

heplocks would probably be more indicated with a palpable radial pulse and mentation since you cannot be sure how long transport time would be....if pulse exam changed indicating BP below 90 then I'd agree with fluids here...

studies seem to show that a pressure of about 80 systolic "pops the clot"... no one knows for sure in each individual where that threshold is but most would say keep the patient on the lower side of things to avoid increased bleeding in transport...

and yes, spinal precautions would be indicated...very common to have lower spinal fractures associated with pelvic fractures...

doc t.

[Bandaid]

A little FYI on a pelvic fracture complication. This compliments Rsov's suggestion about stabilize and need to evac due to potential blood loss.

As many as 40 % of pts who have a pelvic fracture have been noted to have an intra-abdominal source of bleeding that contributes to mortality and morbidity after blunt trauma;

Magnitude of Bleeding:
- magnitude of blood loss often goes unrecognized;

- retroperitoneal space may accumulate upto 4 liters of blood before venous tamponade occurs;

- fractures w/ 3-cm pubic symphysis diastasis will cause doubling of normal volume of pelvis, which would allow several units of addition blood to accumulate before a tamponade effect occurs;

-fractures w/ posterior instability, avg blood loss is > 15 units pRBC compared to avg of 5 pRBC required for pelvic frx w/o posterior instability


EDITORS NOTE: somehow missed Doc T's note above concerning blood loss potential.... double posted info not intended. Will refresh page before post next time... ;)

[RIT_MEDIC]

Doc T:

In addition to MAST pants, which we no longer carry on the Bus, you can also use a KED to stabilize a pelvis fracture in a similar manner as it is used on a hip Fx. I have never seen the diaper splint from cravats and am curious about this as well. I have used a sheet more than once also.

As for the fluids, hanging fluids has always been in our standing orders for all major trauma. I guess its hard to break old habits.

I had read a story in regards to B/P and blowing clots out. I will try to find it and post it here.

James D

[Bandaid]

Good reading on Tx of pelvic fractures....

http://www.swsahs.nsw.gov.au/livtrauma/education/newsletters/june98.pdf

Its on pages 1,2,5 (screwed up order on the website format)

[SWAT Doc]

RIT_Medic,

Good call on the KED, we like to use them turned upside down with the "chest" straps used to pull tension on the pelvis. Our local EMS also has DCd the use of MAST and I believe BTLS has removed it from their criteria.

RR,

Do you carry a "one-size fits all" adjustable c-collar in your pack?

Doc T,

Does reduction of the fracture with splinting stem the blood loss consistant with this type of injury or is it a purely surgical intervention?

[Doc T]

Originally posted by SWAT Doc
[B

Doc T,

Does reduction of the fracture with splinting stem the blood loss consistant with this type of injury or is it a purely surgical intervention? [/B]


reduction on the fracture will help take care of venous bleeding from the posterior plexus of veins found by the sacrum...it will not do much for arterial bleeding though. Surgery, besides the placement of an exfix, does little to control pelvic bleeding any longer...we typically rely on our interventional radiology colleagues to angio these patients and embolize any arterial bleeding they see.... they are much more effective than we can ever hope to be in the OR. In fact, if you do have to explore someone with a pelvic fracture early and a large pelvic hematoma is seen intraoperatively, you do everything in your power to stay out of the hematoma because once you enter it you will stir up audible bleeding. It is not a pretty sight.

doc t.

[SWAT Doc]

Originally posted by Doc T
you do everything in your power to stay out of the hematoma because once you enter it you will stir up audible bleeding. It is not a pretty sight.

doc t.

Doc T.,

Can you explain what "audible bleeding" is? Apologies if this is a stupid question.

[Doc T]

Originally posted by SWAT Doc
Doc T.,

Can you explain what "audible bleeding" is? Apologies if this is a stupid question.

not a stupid question... surgeon's term... wasn't really thinking when I typed it....

we say its audible bleeding when its so fast and furious that the suckers cannot keep up with the losses and you can imagine that it has a sound....

aortic bleeding when its ruptured, bad complex liver injuries, entering expanding hematomas...

its all bad... but makes for fun cases!

[SWAT Doc]

Doc T,

Thanks. I asked four other guys in the room about the term and got about the same "deer-in-headlights" look from all of them...didn't feel so bad after that.

[RsovRanger]

Originally posted by Doc T
The fracture described would be an open book pelvic fracture, or one with opening of the ring... the pubis widens as do the sacroiliac joints causing the legs to externally rotate. No real concerns about arterial compression as much as you'd be concerned about both venous bleeding at the sacral plexus as well as small arterial bleeders that can occur. By opening the ring you can truely allow for massive bleeding by the patient as it takes alot of bleeding to start the tamponade effect... open book fractures average about an 10 unit blood loss but can bleed as much as 80-90 units worth if given the chance. By closing down the ring (the splint you described) you can truely decrease bleeding exponentially. Will try to post pictures of the last patient we had...incredible difference.


Do you have a picture of the diaper style splint you'd create? I am curious. Acutely, in the trauma bay we simply tie a sheet around the patients hips and its amazing how much that simple maneuver works to reduce the widening....it is certainly quick and easy. They make all sorts of more expensive devices that do the same thing but the sheet works well. Do you all ever carry MAST suits?

doc t.

Don't really need a picture... tying a sheet around the hips and across his "junk" as well.. multiple cravats. I'll see if I can aquire enough cravats around the house to do one. We have MAST trousers in our drop zone kits however we do not carry them manpack due to field expedient replacements for the few things that they're good for... just not a good tactical decision.

Your mentioning of the increased BP blowing clots is exactly why I wouldn't push fluids right off the bat, not to mention that our SOP is to not push fluids unless he has controlled bleeding and is in shock Plus with a high speed changing out guys drag there's a good chance that you'd yank out the IV. Hence why we use saline locks. Saline locks allow you to maintain central line access even if the IV tubing is yanked out by some idiot/mishap.

We carry narcs and I would definately use them given the oppertunity, but I have yet to get a good trainup to where I am comfortable administering narcotics other than the lollypops. They're idiot proof.

Mac: The lollypops aren't actually EATEN. The drug is absorbed transcutaniously inside the mouth, circa a hogs leg of copenhagen in your lip percolating your system with nicotine. They are just put in that form for ease of administration.

[RIT_MEDIC]

Originally posted by Doc T
...aortic bleeding when its ruptured, bad complex liver injuries, entering expanding hematomas...

its all bad... but makes for fun cases!

I remember a patient we took to the OR(infamous 17) from The Bay. She had been in a rollover MVA, ejected through drivers window. Presented with bilat femur Fx(secured w/ a sager splint),...off subject. She was crashing hard and fast and Dr Argialla(sp) decided it was now or nothing.

As soon as she was moved over to the table and she was draped and prepped he went to work. What made this case stick out in my mind was her liver looked like hamburger. Unfortunately the young lady died. This was circa 1998. I cant remember who all was in the OR, but I distincly remember looking at Dr A and seeing the look on his face when he realized there was nothing that could be done.

James D

[RIT_MEDIC]

Originally posted by RsovRanger
Your mentioning of the increased BP blowing clots is exactly why I wouldn't push fluids right off the bat, not to mention that our SOP is to not push fluids unless he has controlled bleeding and is in shock Plus with a high speed changing out guys drag there's a good chance that you'd yank out the IV. Hence why we use saline locks. Saline locks allow you to maintain central line access even if the IV tubing is yanked out by some idiot/mishap.

It is just our SOP to start (2) large bore IV's with the fluid hanging on serious trauma.

We carry narcs and I would definately use them given the oppertunity, but I have yet to get a good trainup to where I am comfortable administering narcotics other than the lollypops. They're idiot proof.


MS is a wonderful thing.

James D

[RIT_MEDIC]

Originally posted by SWAT Doc
RIT_Medic,

Good call on the KED, we like to use them turned upside down with the "chest" straps used to pull tension on the pelvis. Our local EMS also has DCd the use of MAST and I believe BTLS has removed it from their criteria.




Do you guys use the KED for hips also? Sometimes I use the KED and sometimes I use a scoop stretcher and a pillow w/ 9' straps. Depends on the patient and situation.

I am glad we dont have MAST on the Bus. I hated those things anyway. Cumbersome in the field, time consuming(cuts into my 30 min patient contact time too much to be of any real value as I see it). If I were further from the ER maybe...but it would have to be much further.

James D

[Doc T]

Originally posted by RIT_MEDIC

I am glad we dont have MAST on the Bus. I hated those things anyway. Cumbersome in the field, time consuming(cuts into my 30 min patient contact time too much to be of any real value as I see it). If I were further from the ER maybe...but it would have to be much further.

James D

I asked about the MAST suit because it does such a great job stablizing the pelvis/long bone fractures... wouldn't recommend it short term but if you are in a situation where you transport time is long or you are stuck with a patient that you cannot transport than its a great device. That said, I haven't seen one used in quite some time...since my residency. MAST suits have their own set of difficulties...one that many people don't know how to properly apply them and two that often patients need to be intubated when you inflate the abdominal compartment as it doesn't leave much room for breathing....

RsovRanger...
how are you trained to inflate them? just inflate until the velcro cracks? that is what most of the paramedics did.... in the hospital we hooked it up to manometry... just curious since you said they are in available in some situations...

doc t.

[RsovRanger]

Inflating until the velcro cracks is what we're taught to do.. Pretty much the only instances that we'd use those things is for longbone/pelvic injuries.
I would only be inflating it until it imoobilized the pelvis if I was taking care of this patient.


Venous access is what we strive for with the saline locks. Unless the bleeding is controlled and he's in shock... what benifit are you providing the patient by feeding him fluids? Diluted blood so he bleeds pinkish koolaid?

[RIT_MEDIC]

I did not say I agreed with the SOP RR, just that hanging fluids is the method we use. We also dont "run the fluids in" unles they are hypotensive. They are usually kept at KVO.

James D

[Doc T]

Originally posted by RsovRanger

Venous access is what we strive for with the saline locks. Unless the bleeding is controlled and he's in shock... what benifit are you providing the patient by feeding him fluids? Diluted blood so he bleeds pinkish koolaid?

is this addressed to me? If you look back I said heplock unless you lose the radial pulse..... or are you arguing to go more hypotensive than that before starting any volume replacement...

I guess for the group.... at what level shock do you start to drop your blood pressure?

doc t.

[Doc T]

Originally posted by RsovRanger
Inflating until the velcro cracks is what we're taught to do.. Pretty much the only instances that we'd use those things is for longbone/pelvic injuries.
I would only be inflating it until it imoobilized the pelvis if I was taking care of this patient.


just an FYI...it is contraindicated to inflate the abdominal portion without inflated the legs for those with no experience with the device. Inflating only the abdominal compartment leads to decreased outflow from the legs, venous congestion and possibly compartment syndromes.... or so I am told...have never personally seen it done.

[RsovRanger]

AH.. I'm being opaque again... I thought about that with the trousers before I posted it, and neglected to mention it... iF you put those things on everything gets pumped up...

The saline lock stuff was directed at RIT.. I was suprised that we agreed on something for once ;) LOL

[RIT_MEDIC]

Originally posted by Doc T
...how are you trained to inflate them? just inflate until the velcro cracks? that is what most of the paramedics did.... in the hospital we hooked it up to manometry... just curious since you said they are in available in some situations...

doc t.

The book answer is until the systolic b/p rises to greater than 100, the velcro crackles, or the pop-off valves release.

Most of the time in the field it is just easier, as you stated, to listen to the velcro.

On the subject of IV access and fluids. Would you rather see the PT's come in with 'Locs instead of with fluid hanging? I do remember it being a hastle to change out the tubing in the Bays when needing to infuse blood, platlets, etc . Also when we talk about 'Locs are what are we talking about, ie short section of tubing with a med port and a leur adapter or the short stumpy 1" luer lock?

Also does your EMS providers there use the same tubing as the hospital or is it a repeat of this fiasco?

Thanks,

James D

[Doc T]

Originally posted by RIT_MEDIC
[B
On the subject of IV access and fluids. Would you rather see the PT's come in with 'Locs instead of with fluid hanging? I do remember it being a hastle to change out the tubing in the Bays when needing to infuse blood, platlets, etc . Also when we talk about 'Locs are what are we talking about, ie short section of tubing with a med port and a leur adapter or the short stumpy 1" luer lock?

Also does your EMS providers there use the same tubing as the hospital or is it a repeat of this fiasco?

Thanks,

James D [/B]

Patients typically come with lines started...not heplocked...or no line at all....don't think they carry heplocks to be honest...

fluids run slowly unless hypotensive in which case paramedics typically run the fluid wide open...but short transport times and OR's on hold for trauma 24/7...not the same as what the military medics face...


tubing still gets changed out for blood transfusion...and typically use the level one infuser anyway so its warmed...

[SWAT Doc]

RIT_MEDIC,

To be honest, hip/pelvic problems are about all I have used the KED for recently, given my current job I don't get a lot of use for them for vehicle extrication. They are small and compact enough to fit it the SOT truck and make a good "expedient" half-board when used in conjunction with a rapid extrication stretcher.

Most of the street guys I know start heplocks (they use the same ones as the two local trauma centers) and then piggyback the fluid into them. If it's trauma they have "Y" type large bore tubing but the hangup comes when they get to the ED when the tubing is not compatible with the pumps there. But, at least they don't have to go through the hassle of changing out a patent line and try to find another one.

Our fluid resus protocol has a lot of "ifs" and "ors" in it. The main two for a stopping point once it has been initiated are: (1) mentation and (2) systolic BP of 90.

[MP18D]

A couple days ago, our trauma co-ordinator RN showed a new pelvic fx device. It is a cloth (looks like hypalon raft type material) corset with laces. Goes on the backboard/gurney prior to rolling the pt on it. Gets laced up tight over the anterior groin/abd. Looks like it would do a great job of stabilizing complex pelvic fx's. Haven't used it yet. Not sure where to get it, doubt it has an NSN yet but will check if interest warrants. Is simple, lightweight, and takes the place of a whole lot of "drive-on rags" used for diapers!!! Like Doc T says, wrapping up the open book type fx does wonder for the BP without a big crystalloid infusion, if ur in the field.

RSOV, way back when I was at MedLab, we were taught to half-hitch IV tubing around forearm or thumb to help secure it. Did/do it still for field IVs and have not had one pull out yet (as far as I can remember-CRS) Is that still taught?? Bear in mind this was before OPsite-we just taped hell out of the catheter hub...

Mike

[RsovRanger]

That works. Linebackers work pretty good. But someone running by at a dead sprint, or 2-4 guys dragging a skedco as fast as they can run will still yank one out.

[MP18D]

I have wondered, why doesnt someone make a collar like is used for central line/art line catheters, that wrap around and can then be taped in place?? We suture those, but if made a little larger, could be used with tape. Darn near impossible to yank out as proven while our pt's are always being moved to CT etc....
Hmmm

Mike

[RsovRanger]

That's what a linebacker is. Adhesive backed velcro end with fuzzy fabric attached. You use the adhesive end and double it over the IV line and then wrap around to attach it to itself and it's very reliable.

[Doc T]

Originally posted by MP18D
I have wondered, why doesnt someone make a collar like is used for central line/art line catheters, that wrap around and can then be taped in place?? We suture those, but if made a little larger, could be used with tape. Darn near impossible to yank out as proven while our pt's are always being moved to CT etc....
Hmmm

Mike

are you talking about the little white pieces that hook on the line? obviously your patients aren't as clever as mine if those keep them from pulling them out...we lose about two central lines a week since we had to start all the documenting for restraints!

i miss the old non safety peripheral IVs that had holes for you to suture them in!

doc t.

[MP18D]

Yup, they fit over past the hub of the catheter, and can then suture them instead of the wings on the catheter itself. Like if you cant/dont advance the cath all the way...
If they were made longer/wider, in the field they would secure the hub itself on peripheral IVs.

I know what you mean....just had to replace an art line that was a nasty stick. Took me 2 tries and 15 mins on the wrist earlier today; started to lighten up on the vec and darned if it wasnt the 1st thing to go. Went femoral and slipped right in...amazing what a little fluid resus will do!!!!

Then again, maybe someone beat me to it w/the "linebacker" that RSOV uses. gotta be better than 10m of tape in CTM tests......

Mike

[Doc T]

so no one answered my question....

what amount of blood loss does the average 70kg man have to have in order to become hypotensive? or simply stated, how much of his blood volume does he have to lose before he starts to drop his BP...

doc t.

[MP18D]

Since no one else has answered...or we are the only ones not busy tonite:

20% of circulating volume will bring orthostatic BP changes, if I remember correctly.

> 20% will show up in supine BPs.

Unless on BP meds, specifically beta blockers. Then all bets are off!

Mike

[mac3982]

dependin on pt history i believe its abot 20 to 30 percent loss of total blood vol, shit mp got it out first! go tread!

[Bandaid]

................................Class I.........ClassII.....ClassIII.....ClassIV
Blood loss(%).......... <15.............15-30.......30-40........>40
Blood Loss(ml) ..........<750.......750-1500...1500-2000..>2000
Pulse rate ...............Normal........100-110...120............>120
Systolic....................Normal.........Normal. ....Low...........Very Low
Diastolic...................Normal.........High... ......Low...........Very Low
Capillary Refill..........Normal.........Slow........Slow... ........Absent
Mental State............Alert.............Anxious...Confu sed...Lethargic
Resp. Rate...............Normal.........Normal.....Tachy .........Tachy
Urine Output............>30 ml/hr.....20-30......5-20 ml .....<5 mls/hr

***above reference is for average adult with no medicines that could alter baselines as suggested prior by MP18D.

Doc T... Not a lot of recent personal experience on this matter, but I researched and refreshed myself about the topic. I LOVE the quizzes!!:D Keep them coming.

I want to thank all you EMT's, medics, and Doc's that are posting these strings. I really enjoy learning from your experiences and hope to contribute (in a small way) when I can. If this type of posts(above) is to general and basic concerning the way in which everyone wants this forum to proceed, then let me know and I will abstain from posting items which are not "my personal experiences". Just trying to help... Professionally
JBM

[Doc T]

Originally posted by Bandaid
................................Class I.........ClassII.....ClassIII.....ClassIV
Blood loss(%).......... <15.............15-30.......30-40........>40
Blood Loss(ml) ..........<750.......750-1500...1500-2000..>2000
Pulse rate ...............Normal........100-110...120............>120
Systolic....................Normal.........Normal. ....Low...........Very Low
Diastolic...................Normal.........High... ......Low...........Very Low
Capillary Refill..........Normal.........Slow........Slow... ........Absent
Mental State............Alert.............Anxious...Confu sed...Lethargic
Resp. Rate...............Normal.........Normal.....Tachy .........Tachy
Urine Output............>30 ml/hr.....20-30......5-20 ml .....<5 mls/hr

***above reference is for average adult with no medicines that could alter baselines as suggested prior by MP18D.
JBM

so notice above.... decreased in BP is already CLASS III hemorrhage.... or in the average male about a 1500cc blood loss... I am not certain how well that is appreciated all the time.

thanx bandaid...you saved me having to copy the chart!

doc t.