„Clear-the-Pelvis-Algorithmus“: Handlungsempfehlung zur Freigabe des Beckens nach nicht invasiver Stabilisierung mittels Beckengurt im Rahmen der Schockraumversorgung

Abstract

Severe brain, thoracic and intrapelvic injuries, as well as heavy bleeding, are the main causes of death in patients with major trauma. Unstable pelvic ring fractures can cause this bleeding and the so-called "C problem". This is usually due to haemorrhagic shock caused by the loss of large volumes of blood from the presacral venous plexus, iliac vessels and the fracture surfaces. Many clinical studies have shown that, in the preclinical setting, unstable pelvic ring injuries are often underestimated. The application of a non-invasive external pelvic ring stabilisation (pelvic binder) is therefore recommended if a pelvic fracture is possible. Several circumferential pelvic binders have been developed and their prehospital use is increasing. Clinical and biomechanical studies have demonstrated that there is a favourable haemodynamic effect in unstable fractures, due to rapid closure of the pelvic ring. It is unclear whether the pelvic binder can be safely removed in a presumably haemodynamically stable patient. A correctly placed pelvic binder leads to anatomical closure of the pelvic ring. Therefore unstable pelvic ring fractures may be clinically and radiologically overlooked. This is a particular problem in unconscious patients. Furthermore, the real severity of the injury may then be underestimated in the diagnostic evaluation. Unconsidered opening of the pelvic binder can thus provoke renewed deterioration of the circulatory situation, especially if the injury was adequately treated by the binder and the C problem was controlled. The aim of this article is to describe procedures for handling pelvic binders, particularly as to how to deal with an already applied pelvic binder and how to "clear the pelvic region" while reducing the risk of haemodynamic instability. A detailed analysis of the literature and a Delphi-like discussion among several experts were performed. The following points were raised: 1) Assessment of the clinical situation, including trauma kinematics. 2) Assessment of the haemodynamic status. 3) Check of the need to open the pelvic binder for diagnostic/therapeutic measures before completing all diagnostic tests. 4) Assessment of the radiology diagnostic testing and release of the pelvic region. The result is a so-called "clear the pelvis algorithm" which describes a structured approach according to specific criteria and which specifies the circumstances under which the pelvic binder can be opened. Additional studies are necessary to analyse the applicability and safety of this algorithm in a clinical context. Our advice is not to "clear" the pelvis if no X-rays or CT scans of the pelvis have been carried out without (or with an opened) pelvic binder.

The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition

“…Correctly placed pelvic binders lead to anatomical closure of the pelvic ring, with a favourable haemodynamic effect. These devices are increasingly being used in the pre-hospital setting if a pelvic fracture is suspected [76, 77]. Unstable pelvic ring fractures may be clinically and radiologically overlooked during initial assessment, especially in unconscious patients, and the time point for opening and/or removal remains controversial.…”

Ergebnisse nach Plattenstabilisierung der Symphysensprengung

“…Bei Verdacht auf eine instabile Beckenverletzung kann präklinisch ein Beckengurt zur temporären Stabilisierung angelegt werden. In der Klinik erfolgt dann die Diagnostik durch konventionelle Röntgenbilder (a.-p., Inlet, Outlet) oder eine Computertomographie [ 1 ]. Bei relevanter symphysärer Diastase besteht die Möglichkeit, die bindegewebige Gelenkzerreißung der Symphyse mit einer Symphysenplatte zu stabilisieren [ 2 , 3 ].…”

“…Um die Maskierung einer Symphysenverletzung zu vermeiden, kann bei kreislaufstabilen Patienten die Bildgebung (im Konsens mit anderen beteiligten Disziplinen) auch ohne Beckengurt erfolgen. Es wird aber darauf hingewiesen, dass dieser Punkt Gegenstand kontroverser Diskussionen ist und die Etablierung eines einheitlichen „Clear-the-pelvis“-Algorithmus noch aussteht [ 1 ]. Gibt es in der klinischen Untersuchung oder der CT-Diagnostik weiterhin Unklarheit bezüglich der Stabilität, so ist die manuelle Stabilitätstestung unter Durchleuchtung der konsekutive Schritt zur weiteren Beurteilung mit hoher Sensitivität [ 12 ].…”