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Doc T
02-03-2004, 08:43
33 y/o male skydiving, falls badly and c/o pelvic pain and R foot pain. You note that he is somewhat diaphoretic but awake and talking and never lost consciousness.

his pulse is regular...at about 90 bpm
you can easily obtain a radial pulse

you, of course, are in the field with little to help you out at the moment so you and your team members are it...with whatever you would normally have at hand.

doc t.

shadowflyer
02-03-2004, 08:57
DX--Possible Pelvic fracture and RT Tib/Fib fracture as well as RT ankle fracture.

TX--BSI/Scene Safe/

--Primary Survey--BP, what is it? Pupils PERRL? Resp?

--Maintain C-Spine precautions.

--Fully Immobilize on back board if possible.Full Meal Deal.

--DCAP-BTLS

--Check for Pelvic stability and also check for distal pulses on lower extremities.

--Stabilize any obvious fractures. Maintain distal pulse check throughout.

--If pelvis unstable wrap and compress as best you can to help stop internal bleeding. From what I have read you can bleed out very quickly from hip fracture.

--Manage shock with appropriate IV fluid therapy.

--Call for EVAC.

Doc T
02-03-2004, 11:32
good start...

scene is safe.
as for BP... radial pulse palpable...that makes your BP at least???
he's talking and complaining of pain so airway is intact.

not certain the medics carry penlights but i'll make PERRL

what is DCAP? I'm civilian...is this a military acronym?

pelvis rock leads to LOTS of pain but no boney crepitance appreciated. Right foot is swollen/bruised/tender. Pulses are intact.

what would be appropriate management of shock? how much fluid? when to start?

the topic is obviously PELVIC fractures... so

what are the three different types?
how can you distinguish them clinically?
Which types tend to bleed?
what can you do in the field to possibly decrease bloodloss?

am on call...slow for the moment...more later if time allows.

doc t.

Surgicalcric
02-03-2004, 12:50
Originally posted by Doc T
what is DCAP? I'm civilian...is this a military acronym?
Deformity, Contusion, Abrasion, and Puncture. Its not military in origin, but civilian EMS terms. It is taught as a part of the EMT curriculum now. Its just another acronym to keep up with.

pelvis rock leads to LOTS of pain but no boney crepitance appreciated. Right foot is swollen/bruised/tender. Pulses are intact.
Splint with SAM splint and elastic bandage in position found.

the topic is obviously PELVIC fractures... so what are the three different types?
Stable, Partially Stable(Open Book, open Symphysis Pubis), and Unstable(Disruption of Sacroiliac Joint)

how can you distinguish them clinically?
--Stable: No movement or crepitance with pelvic rock/tilt or downward pressure on symphysis pubis

--Partially Stable: Movement, pain, and/or crepitance on Symphysis Pubis without pain to the sacrum.

--Unstable: Movement and/or crepitance on pelvic rock/tilt and Symphysis Pubis, edema, and pain to the sacrum.

Which types tend to bleed?
Partially Stable and Unstable, but Unstable by far the worse.

what can you do in the field to possibly decrease bloodloss?
External fixation utilizing a compression splint such as MAST or pillows and 9' strap across the pelvis and knees thus by closing the bleeding fracture surface and allowing a clot to form.

shadowflyer
02-03-2004, 12:56
1. BP of 90 and above for the systolic will get you a palpable radial pulse.


2. DCAP-BTLS is memory aid for assessment we are learning in medic school.

D - deformities
C - contusions/crepitation
A - abrasions
P - penetrations/paradoxical movement
B - burns
T - tenderness
L - lacerations
S - swelling


3. Shock Mgmt--What---2 18G IV NS
When---Signs of shock warrant it.
How much---Still digging for that. I do know that 1500cc blood loss is not uncommon for hip fractures.

3. 3 types of pelvic fractures--

A. Femoral neck fractures
B. Intertrochanteric fractures
C. Subtrochanteric fractures


4. TX/DX of Pelvic fractures-- (I had to dig for this) Since I dont know it off the top of my head ...yet.

In patients who experienced trauma, perform a primary survey and stabilize as needed.

Take a detailed secondary survey because of the high likelihood of other associated injuries. As many as 69% of patients with femoral head fracture-dislocations had major associated injuries, including other extremity injuries, intraabdominal or intrapelvic injuries, neck injuries, and head injuries.

Pay particular attention to vital signs and secondary manifestations of shock such as changes in skin, mental status, and urine output. Hip fractures are associated with blood volume losses of up to 1500 cc.


Inspect and palpate for deformity, hematoma formation, laceration, and asymmetry.

Observe the natural position of the extremity, as this alone often indicates the type of injury the patient has sustained.

Femoral head fracture: Most often, this occurs as a result of hip dislocation; therefore, the position of the extremity is abduction, external rotation, and flexion or extension for anterior dislocation. With posterior dislocation (most common type), the extremity is held in an adducted and internally rotated position.


Femoral neck fracture: Extremity is held in a slightly shortened, abducted, and externally rotated position, unless the fracture is only a stress fracture or severely impacted. In this case, the hip is held in a natural position.


Intertrochanteric fracture: Extremity is held in a markedly shortened and externally rotated position.


Subtrochanteric fracture: Proximal femur usually is held in a flexed and externally rotated position.

Trochanteric fracture
No deformities are noted on observation.
Apply lateral to medial pressure on hips through greater trochanters.


In assessing range of motion (ROM), first test external and internal rotation with extremity in extension. If the patient has a fracture, especially a displaced one, the remainder of ROM exam is extremely painful, of limited diagnostic use, and potentially dangerous. If the patient has pain with the initial ROM exam, obtain x-ray prior to completing.


Perform a detailed distal neurovascular exam.


If patient is a trauma victim, assess for pelvic fracture by stressing pelvis anteriorly to posteriorly through iliac crests and symphysis pubis, and laterally to medially through iliac crests.

Doc T
02-06-2004, 07:18

Doc T
02-06-2004, 07:57
Okay no pictures forthcoming until I get home and my other half can resize them...

three types of pelvic fractures based on mechanism of injury (young and burgess classification)

lateral compression
anteroposterior compression
vertical shear

ap compression and vertical shear open the pelvic ring and have increased incidence of bleeding. Lateral compression doesn't seem to have the same sort of bleeding problems...probably because the venous plexus around the sacrum isn't disrupted. As for arterial bleeding pretty much all types can have fractures that shear across a vessel...we treat those with embolization rather than surgical intervention and obviously in the field that wouldn't be an option.

AP compression or open book type fractures may have benefit from a sheet wrapping/velcro device/ MAST trouser since they all help close back down the ring.

Vertical shear typically needs traction to bring the leg/pelvis back down to its normal orientation.

Pics will come later.

doc t.

Great responses above btw...lots of useful information.

Surgicalcric
02-06-2004, 10:05
Once again, I missed the mark with what you were looking for with the type(s) of Fx.

We learned them as the types I listed above, but I do remember talking with Dr Miller(Orthopaedics) about the classification system after a nasty open pelvic Fx one evening.

I will add more detail next go round and stop expounding on a paramedic level so much.

JD

Doc T
02-06-2004, 10:31
maybe i just don't ask my questions correctly...

pelvic fractures are also classified as stable and unstable...

your answer wasn't wrong...

doc t.