Pre-hospital and emergency department management of pelvic fractures and major trauma centre status: Has practice changed?

Abstract

Introduction: Pelvic fractures are indicative of high-energy injuries and carry a significant morbidity and mortality and pelvic binders are used to stabilise them in both the pre-hospital and emergency department setting. Our unit gained major trauma centre status in April 2012 as part of a national programme to centralise trauma care and improve outcomes. This study investigated whether major trauma centre status led to a change in workload and clinical practice at our centre. Methods: A retrospective analysis of all patients admitted with a pelvic fracture for the six-month periods before, after and at one-year following major trauma centre status designation. Data were retrospectively collected from electronic patient records and binder placement assessed using an accepted method. Patients with isolated pubic rami fractures were excluded. Results: Overall, 6/16 (37.5%) pelvic fracture admissions had a binder placed pre-major trauma centre status, rising to 14/34 (41.2%) immediately post-major trauma centre status and 22/32 (68.8%) (p ¼ 0.025) one year later. Binders were positioned accurately in 4 patients (80%, one exclusion) pre-major trauma centre status, 12 (92.4%) post-major trauma centre status and 22 (100%) at one year. CT imaging was the initial imaging used in 9 (56.3%) patients pre-major trauma centre status, 29 (85.3%) (p ¼ 0.04) post-major trauma centre status and 27 (84.4%) at one year. Discussion: Pelvic fracture admissions doubled following major trauma centre status. Computed tomography, as the initial imaging modality, increased significantly with major trauma centre status, likely a reflection of the increased resources made available with this change. Although binder application rates did not change immediately, a significant improvement was seen after one year, with binder accuracy increasing to 100%. This suggests that although changes in clinical practice often do not occur immediately, with the increased infrastructure and clinical exposure afforded through centralisation of trauma services, they will occur, ultimately leading to improvements in trauma patient care.

In a simulated adult trauma patient, can pelvic binders be applied accurately by paramedics and HEMS paramedics? A pilot observational study

“…Several studies have demonstrated ineffective use of pelvic binders in reducing fractures and promoting clot formation, due to poor accuracy of placement ( Barnes et al, 2017 ; Bonner et al, 2011 ; Henning et al, 2018 ). Data from this pilot study support the findings of existing research.…”

“…Existing research has identified poor accuracy of pelvic binder placement among patients attending hospital with suspected pelvic injuries ( Barnes et al, 2017 ; Bonner et al, 2011 ; Henning et al, 2018 ). There has been little research focusing solely on paramedic-led care, despite recommendations ( Barnes et al, 2017 ), while studies about pelvic binder use in UK HEMS relate to physician-led treatment ( Browne & Corfield, 2016 ; Yong et al, 2016 ).…”

“…Existing research has identified poor accuracy of pelvic binder placement among patients attending hospital with suspected pelvic injuries ( Barnes et al, 2017 ; Bonner et al, 2011 ; Henning et al, 2018 ). There has been little research focusing solely on paramedic-led care, despite recommendations ( Barnes et al, 2017 ), while studies about pelvic binder use in UK HEMS relate to physician-led treatment ( Browne & Corfield, 2016 ; Yong et al, 2016 ). Considering the severe complications documented as a result of inadequate pelvic binder placement, such as pressure sores, tissue necrosis, inadequate pelvic stabilisation and worsening haemorrhage ( Barnes et al, 2017 ; Coccolini et al, 2017 ), the author identified a need for further research relating to paramedic use of pelvic binders.…”

The application of pelvic binders in the pre-hospital setting for people with suspected pelvic fracture: a systematic review

“…Pelvic fractures can be classi ed according to the anatomical location or the mechanism of injury [3] and occur in 8% of major trauma patients and 15.7% of patients with an injury severity score > 15 [4]. These injuries can cause signi cant haemorrhage, with an overall mortality of 14-18% [4] which, in patients with unstable fractures can reach 40-42% [4,5] and 40-60% when associated with ring disruption and shock [6]. It is worth noting that in the recent years there has been an increase in the survival rate after pelvic fractures [7].…”