Evaluating external compression device use in prehospital pelvic fracture management and patient outcomes
OA Version
Citation
Abstract
BACKGROUND: Pelvic Circumferential Compression Devices (PCCDs) are the recommended treatment for suspected pelvic injury in the prehospital setting. PCCDs are designed to control pelvic instability and reduce volume in unstable pelvic ring fractures to decrease severe pelvic hemorrhage which is a common cause of death in these patients. Historically, pelvic fractures are difficult to diagnose in the field, and PCCDs are often applied inaccurately or not at all in the prehospital setting. Most of the evidence on their practical benefits on patient outcome has shown mixed results, and there are no multi-center studies in the United States of America (U.S.) that investigate this device's effects on patient care in the typical prehospital setting. OBJECTIVE: Our study aims to characterize the patient demographics, identify associated factors, and investigate the association of PCCD use on vital sign changes, mortality, and hospital length of stay in prehospital patients with pelvic injuries.
METHODS: We conducted a retrospective analysis using the ESO Health Data Exchange for patients over 18 years old with pelvic injuries transported by EMS in 2022. Data on demographics, scene details, vital signs, injury type, and hospital outcomes were collected for patients with and without PCCD application. Statistical analyses included chi-squared or Fisher's exact tests with adjusted residuals for categorical data, Wilcoxon rank-sum tests or a Welch’s t-test for numerical data, and multivariate logistic regression for mortality and injury type prediction.
RESULTS: The study included 6,333 patients, predominantly adults over the age of 60 4,245 (67.18%), and females 3,900 (61.70%), especially those aged 75+ 2,281 (36.01%). Falls 2,733 (46.42%) and traffic accidents 1,478 (25.10%) were the main injury causes, with pubis 2,492 (39.35%), sacrum 1,326 (20.94%), and acetabulum 1,302 (20.56%) fractures being the most common. PCCDs were applied in 75 (1.2%) patient cases, with disparities in application based on age, gender, and injury mechanism, favoring younger males involved in traffic accidents while older females who fell were less likely to receive a PCCD. Disrupted unstable pelvic ring injuries, constituting 69 (1.1%) cases, saw PCCDs applied in only 5 (7%) instances. Notably, PCCD application did not significantly affect hospital length of stay, mortality, or overall outcomes, though it was associated with more critical patients and increased pain reduction. Mortality was 3.6%, with higher rates in disrupted unstable pelvic ring injuries (10%). Significant predictors of disrupted stable/unstable pelvic ring injuries included prehospital shock, traffic accidents, and traumatic incidents, while risk factors for mortality encompassed disrupted stable pelvic ring injuries, older age, traffic accidents, unconsciousness, and low SpO2.
CONCLUSION: This study offers critical insights into the management of pelvic fractures in the U.S. prehospital setting, signaling there is a significant underutilization of PCCDs despite existing guidelines recommending their use for all suspected pelvic traumas. The findings suggest a need for expanded PCCD usage and heightened provider awareness of the nuances associated with age and gender comorbidities in pelvic trauma. Furthermore, our analysis highlights a particularly prevalent scenario where many older patients with severe pelvic injuries do not present with any prehospital shock and raises the question if applying PCCDs to these patients is beneficial as a hemorrhage control device. This challenges the overarching suggestion to apply a PCCD and advocates for further clinical research if PCCDs have a greater benefit than risk for many patients as there were no noted changes in length of stay, mortality, or patient outcome. Our results show that further prehospital provider education is necessary to help identify and treat potentially life-threatening pelvic injuries as they carry significant mortality and the possibility of shock. We have also demonstrated that there are possible pain reduction effects with the PCCD that require closer examination to determine if they were solely due to the PCCD. Additional research is needed to determine the optimal opportunity PCCD should be applied, and a more detailed risk-benefit ratio, specifically for patients with severe pelvic injuries who are not in shock.
Description
2024
License
Attribution 4.0 International