Stuart Pelvic Harness for the Management of Pelvic Fractures in the Pre-Hospital Setting - Essay Example

?Evidence-based initiative: The introduction of the Stuart pelvic harness for the management of pelvic fractures in the pre-hospital setting About two million individuals are being serviced for pre-hospital care by the St John Ambulance Western Australia (Australian Bureau of Statistics, 2011). Related services include initial prehospital care and transport to the nearest hospital facility, or in some cases emergency care with subsequent transportation to the nearest emergency unit. The care and services administered by the paramedics from the St John Ambulance relate to emergency life-saving services. Individual care varies significantly based on patient case. One of the cases often requiring emergency intervention are pelvic fractures. The St John Ambulance Western Australia (2012) seeks to ensure the quality of emergency health services, ensuring first aid services to the general public utilising available resources to the fullest. The application of evidence-based practice helps ensure the fulfilment of the above goal. Evidence-based practice allows for the efficient and effective application of resources ensuring standard practice in emergency services (Freshwater and Rolfe, 2012). The St. John Ambulance Western Australia is applying various measures in order to effectively ensure prehospital management of pelvic fractures. This evaluation seeks to guarantee that the interventions being considered are supported by evidence-based practice. The aspect being assessed includes accidents, elderly falls, and pelvic fractures. After adequate evaluation of these aspects, the focus was later specified to pelvic fractures, mostly on the role of the compression splints, including the Stuart pelvic harness, the Dallas pelvic binder, the Sam Sling, or the T-POD pelvic stabilizer in the management of pelvic fractures in the pre-hospital setting. Pelvic fractures Pelvic fractures are emergency and life-threatening injuries which are often identified during an initial evaluation of patients experiencing major trauma. The incidence of pelvic fractures among patients with blunt trauma is at 5% and 11.9% (Duane, et.al., 2002). The early identification as well as the immediate prehospital management of pelvic fractures is an important measure in reducing blood loss and preventing further complications for the patient. These fractures can also be used to determine the energy transfer and impact of injury which would indicate appropriate triage for the patient. Mortality rates for these patients who eventually reach the hospital setting are at 7.6 to 19% (Lee and Porter, 2006). Even as exsanguinating haemorrhage during pelvic fractures are a major concern, studies indicate that the other abdominal and pelvic injuries seen through the fracture from the energy transfer can cause death among these patients. Deaths due to open pelvic fractures are much higher, close to 50% (Lee and Porter, 2006). Prehospital management of pelvic fractures include various interventions, including prehospital assessment. Pelvic fractures are often caused by road traffic collisions, especially where the patient is seated at the front of the vehicle during a head-on collision, or is hit at the side (Lee and Porter, 2007). These fractures are also seen in pedestrian and motorcycle collisions (Lee and Porter, 2007). Falls among elderly patients, especially those with osteoporosis is also implicated for pelvic fractures. These fractures are often identified through the circulatory assessment using CAcBCDE after resuscitation of significant bleeding, airway, and breathing issues (Lee and Porter, 2007). General health teachings support the use of springing the pelvis in order to detect tenderness or instability and determine pelvic fracture and possible internal haemorrhage (American College of Surgeons Advanced trauma life support, 2004). Different types of springing have been suggested, with usual methods including compression or distraction of the fractured area (Lee and Porter, 2006). However, the current practice is that springing can be an unreliable test as it can only identify major pelvic disruption; it may also dislodge clots and cause persistent blood loss. In general, the prehospital respondent initially needs to determine the mechanism of injury in order to indicate possible pelvic fracture (Sauerland, et.al., 2004). Features which may be used as signals for significant pelvic injury during examination includes deformity in the pelvic area, bruising or swelling seen in the pelvic region, leg length discrepancy, or rotational problems of the lower limb (Lee and Porter, 2007). Injuries on the pelvic area or bleeding in the rectum, vaginal, or urethral areas may also indicate pelvic fracture. For alert patients, the presence of pain may also be determined. Positive responses require the routine immobilisation of the pelvic area (Sauerland, et.al., 2004). For unconscious patients, palpation of the pelvic area to detect instability and skin breaks can be carried out. The emergency management of pelvic fractures also calls for the internal rotation of the lower limbs in order to decrease the pelvic volume; circumferential wrapping around the pelvis is also needed (American College of Surgeons Advanced trauma life support, 2004). Stabilising the pelvic ring injuries must be immediately carried out following injury (Lee and Porter, 2006). As clotting mechanisms are also still in place, and before the patient is transported, stabilisation is needed. Bleeding following pelvic ring fracture is often seen following injury to the sacral venous plexus (Starr, et.al., 2000). Along with circumferential stabilisation, the bleeding can be stopped, and the decreased movement of the bone ends then prevents the disturbance of the formed clot. Haemodynamic stability can be ensured following reduction where there is significant injury to the artery (Starr, et.al., 2000). Pneumatic anti-shock clothing has also been commonly used to splint pelvic fractures. Their application however has been known to decrease access to the abdominal and pelvic region (Simpson, et.al., 2002). They are also difficult to put on and do not actually ensure pelvic reduction. External fixators have also been recommended in the prehospital setting; however these fixators are often not applied properly. Various commercial material compression splints have also been manufactured, including the Stuart splint, the London splint, and the Dallas Pelvic binder (Lee and Porter, 2007). They are usually placed at the greater trochanter areas and are in direct contact with the patient’s skin. The use of compression splints will therefore be considered for this evidence-based study. Search Strategy : The following clinical question was formulated and reads below as: What is the extent of evidence supporting the use of the Stuart pelvic harness and other commercialised compression splints in the management of pelvic fractures in the prehospital setting? A search of various databases including PubMed, CINAHL, The Cochrane Library, and EMBASE was carried out using the PICO question: Patient, intervention, comparison, and outcome of interest. The search words: pelvic fractures and compression splints and prehospital setting were used for this study. In order to support the relevance of the studies discovered, inclusion criteria were applied. Such criteria include the following: The study must be level of evidence I (systematic review of randomised controlled trials) or level of evidence II (well designed randomised controlled trials) The study must have been carried out in the emergency or prehospital setting The study must refer to pelvic fractures; other types of fractures were not included in this study Only human studies were included Measures on the outcomes of treatment were specified Only studies undertaken in the last fifteen years were to be included Only studies in English were included The search went back 15 years because there were significant writings published within the 15 year period which needed inclusion in the paper. They also provide a background on pelvic fractures and stabilisation measures. It also allows for comparison of the evidence for compression splint use for pelvic fracture patients. Evidence level classifications were based on research recommendations. There were about 156 studies which were gathered based on the search. Upon evaluating the studies for relevance, only 15 turned out to be relevant to the level of evidence needed. There were three randomised controlled trials. Two were already cited in one of the systematic reviews. Another randomized controlled trial was not included because it included a discussion on femoral neck fractures. Another study highlighted the combined use of compression splints. In the end, there were 6 studies deemed relevant for this review. External fixation In the study by Meighan and colleagues (1998), the authors interviewed emergency units in Scotland in order to establish their skills and ability to stabilize pelvic fractures presenting to them in the prehospital setting. The study revealed that only 8 out of the 31 units would have been able to ensure stability of the fracture within an hour from the injury. The eight did not have the sufficient emergency management tools available to them (Meighan, et.al., 1998). In effect, a pelvic splint was used in the hospital setting, and was an effective alternative in controlling bleeding. It also served as an example for use by the nursing staff and emergency personnel in the emergency units. Vermeulen and colleagues (1999) discussed the prehospital application of an external pelvic compression belt or the Geneva belt for 19 patients. Their tool was used by paramedics within 3 seconds upon suspicion of pelvic fractures. The study discovered 13 patients with a pelvic ring lesion. Two of the patients who indicated no problems during their initial pelvic x-ray even with fractures; this supports adequate reduction of the fracture using this tool (Vermeulen, et.al., 1999). Various commercial splints have since been used. One study sought to establish the mean force needed to manage unstable open book pelvic fractures. This prompted the establishment of the new commercial splints which applied controlled stabilisation with autostop buckles to decrease over compression (Bottlang, et.al., 2002). Krieg, et.al., (2005) applied such device to momentarily manage pelvic fractures among 13 patients and they established effective reduction from radiologic findings, without complications and with evidence of pain relief for some conscious patients. Vermeulen and colleagues (1999; 2005) discussed effective anatomical reduction in two case studies. For these case studies, the two patients manifested with pelvic fractures which were diagnosed by a plain x-ray. A Stuart pelvic harness was used and the patient went through a CT scan after. The scan indicated close to a total anatomical reduction. This supports the importance of practitioners guaranteeing that the emergency centre is apprised of the presence of the pelvic splint and that it should stay immobilized during the resuscitation process, and also that the splint must not be removed immediately (Vermeulen, et.al., 2005). Where the first plain x-rays indicate no fracture, but with clinical suspicion being high, it would be important to momentarily ease the splint and repeat the x-ray or to carry out the CT scanning. Reasons for introducing compression splints into the prehospital setting: Based on the studies above, the use of compression splints is an important intervention for pelvic fracture reduction and stabilization (Croce, et.al., 2007). The use of the compression splints has been known to stabilize the patient during transport and to reduce the pelvic fracture, allowing improved outcome following surgery. Although some of these studies discussed specific kinds of compression splints, these splints have varying levels of efficacy (Croce, et.al., 2007). Regardless of levels of efficacy, most of these splints still present with favourable results for patients. Consequently, this information can be applied to all kinds of compression splints applied for pelvic fractures. The importance of stabilizing is the important consideration for compression splints as failure to stabilize the fracture prior to transport may exacerbate the patient’s condition (Biffl, et.al., 2001). Based on the above evidence, this author suggests the introduction of compression splints in the prehospital setting for pelvic fractures. Before suggesting such proposal to the St John Ambulance, the application of this practice has to be assessed, with considerations made on the issues or challenges in its implementation. Studies indicate that the use of compression splints to stabilize pelvic fractures is considered an effective tool in decreasing haemorrhage and in stabilizing the fracture (Croce, et.al., 2007). Studies also indicate that this device must be used the soonest time possible (Grotz, et.al., 2005). It can be applied at the accident scene or later in the emergency department. However, the soonest possible time it can be applied is still the best time. Early stabilization of pelvic fractures is beneficial for various reasons (Grotz, et.al., 2005). It allows for clot formation at the injured area by decreasing mobility; it can also decrease pelvic volume which eventually seeks to assist tamponade venous bleeding; it assists in securing patient comfort. This may decrease the need for narcotics and assist in the transport process (Wayne, 2006). Numerous non-invasive interventions and devices have been made available in order to ensure stabilization of pelvic fractures in the pre-hospital setting. These interventions include vacuum bean bags, anti-shock trousers, and compression splints, including the Dallas Binder and the T-POD (Wayne, 2006). The US Office of Naval funded a study by the Legacy Biomechanics Laboratory in order to study the use of compression splints and devices for the stabilization and reduction of pelvic fractures. Results indicated that the proper force needed to reduce and stabilize a pelvic fracture is at 150-180 N (15-18 Kg) (Wayne, 2006). Results indicate that using the compression sling around the hips is more effective as compared to wrapping it around the iliac crest at the waist. The compression splint, especially the Dallas Binder provided adequate stabilization for the prehospital setting (Bottlang, et.al., 2002). The compression splint also had an autostop buckle which has been designed to stop compression based on the desired force (Bottland, et.al., 2002). About 16 adult patients were assessed over the period of 16 months with the patients manifesting stable pelvic fractures. The study indicated that with the use of compression splints, the pelvic fractures can be rapidly reduced and stabilized (Bottland, et.al., 2002). No complications have been seen from the use of the splints, even when applied to internal rotation injuries which are vulnerable to internal collapse. The compression splints can be used by paramedics at the accident scene in order to secure effective stability before, during, and after the transport (Bottlang, et.al., 2002). Physicians in the emergency department can use the device as well to ensure stability of the patients. Most deaths from pelvic fracture have been attributed to exsanguination and patients who are often haemodynamically unstable (Krieg, et.al., 2005). Where the bleeding is controlled the soonest possible time, complications are less likely to occur and survival would register at higher rates. In the past few years, pelvic compression devices have been used in the emergency setting to manage bleeding and provide stability to the patient (Krieg, et.al., 2005). These binders are usually light and portable. The study by Simpson, et.al., (2002) established that pelvis straps decreased unstable pelvic fractures when used around the greater trochanters, with the symphysis pubis is pulled to 180N. The device was able to ensure internal/external stability and ensured better flexion stability. The use of the TPOD has also indicated efficacy in managing the pelvic fracture patient (Wayne, 2006). The study by Krieg, et.al., (2005), indicated that binders at 140 N were able to decrease externally rotated pelvic fractures under emergency settings without any complications manifesting and some pain relief for alert patients. It has been established that the reduction of the pelvis is more efficient when the binding is applied at the greater trochanter level (Routt, et.al., 2002). In the study by Vermeulen, et.al., (1999), significant reduction was seen among 15 patients where the TPOD was applied. This presents results similar to the patients with the SAM Pelvic Sling II. There was a favourable reduction in 19 patients where the pelvic strap belt was applied (Vermeulen, et.al., 1999). Case reports indicate complete reduction of the pelvic fracture with the use of the Stuart pelvic harness and the Sam Sling. Earlier compression splints including the Medical Anti Shock Trousers did not indicate any significant benefit (Mattox, 1989), however outcomes indicate that the use of other earlier devices have not been assessed much. In one study comparing the stabilisation using a pelvic binder (TPOD) for the pelvic external fixation, less transfusion for patients was required for the TPOD group (Nunn, et.al., 2007). The length of hospital stay was shorter and mortality rates were lower. Better haemodynamic status was also observed for patients applying the compression splints (Nunn, et.al., 2007). Issues on the pelvic binder causing secondary displacement of lateral compression fracture which may lead to more damage. A slight increase in internal rotation and reduction for the pelvic inlet in unstable LC type II fracture has been seen with the use of compression binders (Bottlang, et.al., 2002). Five patients with partially stable lateral compression fractures indicated a limited over-reduction, however this was not considered clinically relevant (Krieg, et.al., 2005). No studies on binder use for unstable lateral compression fractures have been carried out, and no possible damage to vascular structures have been detected with internal rotation from binding. Nevertheless, the extent of displacement for the pelvic fracture would likely be more significant during the injury, not so much afterwards where the binder is applied (Krieg, et.al., 2005). In general therefore, compression splints or pelvic binders have become important devices in the prehospital setting in managing bleeding and in the reduction of the injury. There is limited evidence on the biomechanical benefits of the splints, however reports indicate that they help manage unstable pelvic fractures and they help ensure clot stabilisation. Issues and barriers to change: To support the effective application of this evidence-supported intervention, it is important to consider the different barriers and issues and to address these before it is proposed to the St. John Ambulance services. Barriers to implementation include the allocation of resources to fund and equip the necessary emergency paramedic units. In effect, issues on cost, training, information, and available technology represent problems in the implementation of the appropriate changes in the practice. In terms of cost, the use of the compression binders requires the purchase of several compression splints per unit and paramedic services. This would extend to the emergency departments of hospitals. However since it is an important and essential resource in the efficient delivery of emergency services, allocation must be made by the government. The appropriate binders would have to any of the following: Stuart pelvic harness, Dallas pelvic binder, the Sam Sling, or the TPOD which have all indicated efficient usage based on the evidence presented above. Allocations for the training of the paramedics on the appropriate use of these compression splints would also have to be made. Training is an important element in the efficient delivery of health services (Aehlert, 2011). The paramedics have to undergo the necessary training to learn about the binders, how to use them, and how to ensure their efficient and continued use. The maintenance of the equipment is very much also a part of their training process, helping ensure that the resources are well maintained and would be ready for use (Aehlert, 2011). In most hospital equipment, maintenance is a crucial element, especially as it helps ensure efficient patient outcomes. The splints must be stored at a clean and dry place in the ambulance, or at the emergency departments, at easy reach of paramedics responding to emergency calls (Yokley and Sutherland, 2007). This equipment must also be regularly assessed for possible defects, with these defects managed before use. Regular maintenance by the manufacturer must also be ensured in order to ensure regular and efficient use (Yokley and Sutherland, 2007). Compression splints are used for patients suffering from pelvic fractures, after car wrecks or falls, and other traumatic incidents. Replacing its use would be based on wear and tear as well as on damage on the equipment. The actual cost involved in the use of compression splints involves the cost of the equipment itself, atleast 10 for each unit. The training of the paramedics would also be an added cost in the use of this resource. Purchase in bulk can reduce cost, and training in groups would allow efficient distribution of resources. Where these costs are adequately addressed, the paramedics would be able to ensure the efficient delivery of health services, the prevention of complications for pelvic fracture patients, as well as the stabilization of the fracture, the control of haemorrhage, and the reduction of the pelvic fracture. Implementation of practice initiative: Various studies and information have been secured and such data can now be presented to St John Ambulance. A development process would be required for this proposal. This process would include the presentation of evidence and documentation for the use of the compression splints. It would also include the process which would be followed by a proposal form which would formally present the idea to the institution. As this is carried out, plans for clinical training would be carried out, with various processes enumerated based on specific requisites. The paramedic-supported pathways for clinical practice improvement would be used in order to carry out and plan the clinical adjustments. This would also involve the submission of documents with the Administrators of the St John Ambulance institution. The administrators would also have to establish a plan or draft based on the proposal. Further review by the institution would be carried out, with paramedics also assessing the inclusion of the splint in their practice. Changes to the proposal would likely be introduced at some point during the discussions between and among the administrators. A final draft would then be submitted to the Medical Policy Committee and to the different directors of the St John Ambulance. The committee and the directors would then evaluate the proposal and later decide if the proposal can be implemented to the institution. The implementation would mostly involve the assessment of the equipment and other materials needed for the introduction of compression splints into the practice, appraising the staff and training them on the application of the resource. An assessment of the clinical practice guideline would also be made before the changes in the practice would be implemented This author plans to submit this initiative or proposal to the Executive Manager of Clinical Governance of the St John Ambulance once evaluated for initial feedback by the university. This may imply changes to the overall statements and indications for the proposal. Such amendments would be carried out as soon as possible in order to allow the evidence-based practice to be implemented. By applying clinical skills, this author is allowing evidence-based care to impact on patient outcomes. Evidence-based practice is important in maximising care and managing improved patient outcomes. It is also important in establishing quality care in the practice and in the general health care services and practice. Conclusion In general, introducing the compression splints in the management of pelvic fractures in the prehospital setting, based on literature has become an important addition to the improvement of ambulance services. The addition aims to improve the stability and promote the reduction of the fractures; managing haemorrhage is also at the very core of the use of compression splints. The application of compression splints for pelvic fractures within the St John Ambulance Service for Western Australia paramedics will eventually help guarantee that care to be administered to patients suffering from pelvic fractures would be supported by reliable evidence. Evidence-based practice is not an expensive venture, and it would not take up much more time than is necessary; however when used in the practice, it will allow the St John Ambulance Service to improve its practice and fulfil its goals. References American College of Surgeons (2004). Advanced trauma life support. 7th edn. Chicago, IL: American College of Surgeons. Biffl, W., Smith, W., 7 Moore, E. (2001). Evolution of a multidisciplinary clinical pathway for the management of unstable patients with pelvic fractures. Annals of Surgery, 233, 843–50. Bottlang, M., Simpson TS, Sigg J, Krieg JC, Madey SM, & Long WB. (2002). Noninvasive reduction of open-book pelvic fractures by circumferential compression. J Orthop Trauma, 16, 367-373. Bottlang, M. Krieg, J., Mohr, M. & Simpson, T. (2002). Emergent Management of Pelvic Ring Fractures with Use of Circumferential Compression, Journal of Bone & Joint Surgery, 84-A Suppl 2; 43-47. Croce, M. Magnotti, L. Savage, S. Wood II, G. & Fabian, T. (2007). Emergent pelvic fixation in patients with exsanguinating pelvic fractures. Journal of the American College of Surgeons, 204(5), 935-939. Duane, T., Tan, B. & Golay, D. (2002). Blunt trauma and the role of routine pelvic radiographs: a prospective analysis. J Trauma, 53463–468.468. Freshwater, D. & Rolfe, G. (2012). Deconstructing Evidence Based Practice. Melbourne: Routledge. Grotz, M., Allami, M., Harwood, P., Pape, H., & Krettek, C. (2005). Open pelvic fractures: epidemiology, current concepts of management and outcome. Injury, 36, 1–13. Krieg, J. Mohr, M., Ellis, T. & Simpson, T. (2005). Emergent Stabilization of Pelvic Ring Injuries by Controlled Circumferential Compression: A Clinical Trial. Journal of TRAUMA Injury, Infection, and Critical Care, 59 (3), 659-664 Lee, C. & Porter, K. (2007). The prehospital management of pelvic fractures. Emerg Med, 24(2), pp. 130–133. Mattox, K., Bickell, W., Pepe, P., Burch, J., & Feliciano, D. (1989). Prospective MAST study in 911 patients. Journal of Trauma, 29, 1104–1111. Meighan, A., Gregori, A., & Kelly, M. (1998). Pelvic fractures: the golden hour. Injury, 29211–213.213. Nunn, T., Cosker, T., Bose, D., & Pallister, I. (2007). Immediate application of improvised pelvic binder as first step in extended resuscitation from life-threatening hypovolaemic shock in conscious patients with unstable pelvic injuries. Injury, 38, 125–8. Routt, M. Simonian, P. & Swionthkowski, M. (1997). Stabilisation of pelvic ring disruptions. Orthop Clin North Am, 28369–388.388 Sauerland, S., Bouillon, B., & Rixen, D. (2004). The reliability of clinical examination in detecting pelvic fractures in blunt trauma patients: a meta?analysis. Arch Orthop Trauma Surg, 124123–128.128. Simpson, T., Krieg, J. & Heuer, F. (2002). Stabilization of pelvic ring disruptions with a circumferential sheet. J Trauma, 52158–161.161. Starr, A. & Griffen, M. (2000). Pelvic ring disruptions: mechanisms, fracture pattern, morbidity and mortality. An analysis of 325 patients. OTA Annual Meeting, Texas, USA. St John Ambulance Western Australia (2012) Quality System. Retrieved from http://webserver.ambulance.net.au/quality/quality_system.htm Vermeulen, B., Peter, R., & Hoffmeyer, P. (1999). Prehospital stabilization of pelvic dislocations: a new strap belt to provide temporary hemodynamic stabilization. Swiss Surg, 543–46.46. Wayne, M. (2006). New Concepts in the Prehospital and ED Management of Pelvic Fractures. Israeli Journal of Emergency Medicine, 6(1), 39-43 Yokley, R. & Sutherland, R. (2007). Emergency!. Sydney: Jones & Bartlett Learning. Read More