The Effectiveness of Pelvic Circumferential Compression Devices Essay

considered as one of the most common injuries that can result from the different forms of accidents and traumas that can lead to high amount of hemorrhage from any of the following injuries namely, the venous plexus lesion, arterial injury, and localized bleeding of the specific fracture sites (Knops et al. 101). The said condition has high incidence of mortality and recorded as the third leading cause of death in vehicular accident cases specifically motor vehicles (Wayne 39).Pelvic circumferential compression device is defined as an apparatus commonly in the form of a belt with a mechanism for tightening that is put around the pelvis that had been fractured. It works by constricting and preventing any form of movement, thus, it stabilizes the fractured pelvis. The Pelvic Binder, T-POD and the SAM Sling are the most common types of PCCDs (Knops et al. 101. Spanjersberg et al. 1031).The Effectiveness of Pelvic Circumferential Compression Devices Essay. Due to the need for immediate method to manage pelvic fracture or trauma, studies on the application of the pelvic circumferential compression devices are prevalent while studies that are focused on the effectiveness of the said devices are scarce. This can be attributed to the fact that applications of new development in PCCDs are immediate due to the need e.g. in emergency cases or emergency medical services (EMS). This can be observed in the data presented in references and guidelines in cases of pelvic injuries. One example is the Advanced Trauma Life Support wherein PCCDs are indicated to be the main method to manage unstable pelvic fracture (Spanjersberg et al. 1031).The role of the PCCDs in managing pelvic fracture specifically in EMS can be considered essential on the basis of the need of such cases for immediate care. If the pressure on the skin exceeding 9.3 kPa continuously affects a person for 2 to 3 hours, the safety of the patient is affected and the effectiveness of the procedure is affected (Knops et al. 101).The objective of the paper is to present the 

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Pelvic fractures can cause massive haemorrhage. Early stabilisation and compression of unstable fractures is thought to limit blood loss. Reposition of fracture parts and reduction of pelvic volume may provide haemorrhage control. Several non-invasive techniques for early stabilisation have been proposed, like the specifically designed pelvic circumferential compression devices (PCCD). The purpose of this systematic review was to investigate current evidence for the effectiveness and safety of non-invasive PCCDs. To investigate current literature the search string: “pelvi* AND fract* AND (bind* OR t-pod OR tpod OR wrap OR circumferential compression OR sling OR sheet)” was entered into EMBASE, PubMed (Medline), PiCarta, WebofScience, Cochrane Online, UptoDate, CINAHL, and Scopus. All scientific publications published in indexed journals were included. The search resulted in 17 included articles, none of which were level I or II studies. One clinical cohort study (level III) and 1 case-control study (level IV) were found. These showed a significant reduction of pelvic volume after applying a PCCD, without an effect on outcome. Other included literature consisted of 4 case series (level V). The Effectiveness of Pelvic Circumferential Compression Devices Essay. Two biomechanical analysis studies of fractures in human cadavers showed pelvic stabilisation and effective volume reduction by PCCD, especially when applied around the greater trochanters. Finally, 7 case reports (level VI) and 3 expert opinions (level VII) were identified. These case reports suggested complications such as pressure sores and nerve palsy. PCCDs seem to be effective in early stabilisation of unstable pelvic fractures. However, prospective data concerning mortality and complications is lacking. Some complications, like pressure sores have been described.

A pelvic circumferential compression device (PCCD) is a belt that is wrapped around a fractured pelvis and tightened with a closing mechanism. The SAM Sling® is one of the most common PCCDs used for trauma management. Although the use of the SAM Sling® for reduction and stabilization of unstable pelvic ring fracture has become the standard of care in most relevant trauma scenarios, it is not usually used for stopping continuous hemorrhage of the peripheral soft tissue of the pelvis without unstable pelvic ring fractures.

Case presentation
We report the case of a 79-year-old woman with life-threatening and unexpected continuous subcutaneous and intramuscular hemorrhage of the buttocks and groin area. She did not have unstable pelvic ring fractures but had hemorrhagic shock and acute traumatic coagulopathy (ATC). By use of the SAM Sling®, the hemorrhage was controlled, and she was eventually rescued.

Conclusions
We propose the use of the SAM Sling® to stop continuous bleeding in the state of ATC regardless of unstable pelvic ring fracture.

Keywords: Pelvic circumferential compression device, Pelvic fracture, Hemorrhage shock, Acute traumatic coagulopathy
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Background
A pelvic circumferential compression device (PCCD) is commonly used in the acute treatment of unstable pelvic ring fractures for the reduction of pelvic volume and the initial stabilization of the pelvic ring [1]. The SAM Sling® (SAM Medical Products, Newport, OR, USA) is one of the most common PCCDs [2]. Although the use of the SAM Sling® for unstable pelvic ring fracture reduction, stabilization, and lifesaving hemorrhage control has become the standard of care in most trauma situations [[3], [4], [5]], it is not usually used to control hemorrhage of the peripheral soft tissue of the pelvis without unstable pelvic ring fractures.

Moreover, hemorrhagic shock sometimes triggers acute traumatic coagulopathy (ATC) through the dysfunction of the coagulation cascade caused by a defect of the platelet and coagulation factors following massive hemorrhage. In this state, hemostasis of the subcutaneous hemorrhage is no longer possible, which can result in a fatal outcome. Herein, we report a case of life-threatening ATC following pelvic subcutaneous hemorrhage, which was successfully treated with the use of the SAM Sling®. The Effectiveness of Pelvic Circumferential Compression Devices Essay.

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Case presentation
A 79-year-old woman with a history of hypertension was injured in a bicycle-car accident and transferred to our emergency department with a high-energy trauma injury. She had no history of hematologic disease or of taking antithrombotic drugs. She was 152 cm in height and weighed 55 kg. On physical examination, she had swelling of the left head. Her vital signs on admission were: Glasgow Coma Scale (GCS), E1V2M5; temperature, 35.9 °C; heart rate (HR), 124 beats/min; left arm blood pressure (BP), 119/85 mm Hg; respiratory rate, 18 breaths/min; and 100% oxygen saturation, on a 100% non-rebreather reservoir mask at 10 L/min of oxygen. Because she was in a state of hypovolemic shock upon arrival of the hospital, she was administered a transfusion of both red blood cells (RBC) and fresh frozen plasma (FFP) at the initial treatment. She was intubated because of severe cognitive impairment (GCS score ≤ 8). To detect the hemorrhage in the trunk, contrast-enhanced, total-body computed tomography (CT) scanning was performed. It revealed a traumatic subarachnoid hemorrhage, head ecchymoma, stable pelvic ring fracture (AO/OTA classification, 61-A2) (Fig. 1), and slight subcutaneous hemorrhage of the right groin area (Fig. 2a).

Fig. 1
Fig. 1
Radiograph and 3D-computed tomography (CT) scan showing a stable pelvic fracture.

Fig. 2
Fig. 2
(a) The initial enhanced computed tomography (CT) scan shows slight subcutaneous hemorrhage of right groin area (arrow).

(b) The other enhanced CT scan shows extravasation of both the right superficial circumflex iliac artery and right superficial epigastric artery, as well as the subcutaneous arteries of the gluteal (arrows).

She was transported to the intensive care unit (ICU) after 3 h and 30 min of the treatment in the emergency room. After admission to the ICU, her BP gradually decreased and her HR increased, despite continuous transfusion of both RBC and FFP since her initial arrival in the emergency department. Because of insufficient improvement in both hemoglobin levels (6.5–8.0 g/dL) and vital signs (low systolic BP, 70–80 mm Hg; high HR, 100–120 beats/min), we performed another contrast-enhanced, total-body CT (Fig. 2b). Then, we found subcutaneous hemorrhage demonstrated as extravasation from the right superficial circumflex iliac artery, the right superficial epigastric artery, and the subcutaneous arteries of the gluteal. Furthermore, blood examination showed that platelet count was 1.6 × 104/μL, prothrombin time-international normalized ratio (PT-INR) was 1.25, fibrinogen was 114 mg/dL, and fibrin depredation products (FDP) were 28 μg/mL, all of which indicated that the patient was in a state of acute traumatic coagulopathy (ATC) following the hemorrhagic shock. Therefore, we promptly added platelet transfusion to her management protocol. The Effectiveness of Pelvic Circumferential Compression Devices Essay. To enhance the control of the hemorrhage in the subcutaneous tissues and muscles of the pelvis, we used the SAM Sling® for circumferential compression (Fig. 3). Her blood pressure reverted back to normal levels within about 30 min (Fig. 4). Three hours after equipping the SAM Sling®, we confirmed an improvement in hemoglobin value (10.9 g/dL) and platelet count (9.0 × 104/μL), with her vital signs stabilized. Then, we removed the SAM Sling® from the patient. Ultimately, the total time that the patient wore the SAM Sling® was 3 h and 15 min. The total transfusion values for this case were: RBC, 2240 mL; FFP, 2400 mL; platelet count (PC), 200 mL. After the removal of the SAM Sling®, we found there were no skin complications. The patient was discharged from the ICU to the ward seven days later. After that, her vital signs were stable in the ward. Although the patient was recovered from a state of the life-threatening hemorrhagic shock, eventually, she had aftereffects of left hemiparesis caused by the subdural hematoma.

Fig. 3
Fig. 3
The SAM Sling® for circumferential compression of multiple regions of bleeding.

Fig. 4
Fig. 4
Due to insufficient improvement in both hemoglobin value, according to blood gas analysis, and vital signs, we performed contrast-enhanced, total-body computed tomography (CT) scan and blood examination 4 h after admission to the intensive care unit (ICU). We applied the SAM Sling® approximately 5 h after admission and blood pressure reverted to normal within about 30 min. FFP, fresh frozen plasma; PC, platelet count; RBC, red blood cells.

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Discussion
This is the first report to state the usefulness of the SAM Sling® for treating continuous hemorrhage of the pelvis without unstable pelvic ring fracture. Our usage of the SAM Sling® may not be typical, but we found it was effective for hemorrhage control in the peripheral soft tissues without complications. With regard to the initial enhanced CT findings, it was difficult to predict the subsequent continuous hemorrhage resulting in severe hemorrhagic shock and subsequent ATC. The pelvic fracture was a stable fracture and thus we could not anticipate that severe hemorrhagic shock from this fracture was a likely consequence.

In this case, we selected the non-invasive, circumferential compression by device for treating this patient because there were several bleeding sites in the subcutaneous tissues and muscles. Methods of circumferential compression include bed-sheet wrapping, internal rotation and taping of the lower extremities, PCCDs [6]; bed-sheet wrapping is the common procedure for the hemorrhage in the pelvis. We chose a PCCD because it can be installed in a short time without specialized skills and it could provide more secure compression on the hemorrhage site than bed-sheet wrapping.

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PCCDs act by applying pressure onto the pelvis. Consequently, pressure is also applied on the skin overlying the pelvis and thus is associated with the risk of skin breakdown; therefore, upon achievement of hemodynamic stability, PCCDs should be removed as soon as possible to prevent this risk [7]. Tissue damage may occur if a continuous pressure exceeding 9.3 kPa is sustained on the skin for more than 2 or 3 h [2,7]. Compared with other PCCDs, some suggest the merit of the SAM-Sling® with the lowest risk of tissue damage [7]. In this case, it took 3 h to ensure that the patient recovered from the state of ATC with the evaluation of blood examinations. Ultimately, we applied the SAM-Sling® for as long as 3 h, fortunately, no skin complications developed.The Effectiveness of Pelvic Circumferential Compression Devices Essay.

In addition to the hemorrhagic shock, the patient was in a state of ATC, which induces the deterioration of the coagulation mechanism, ultimately inducing a vicious circle of hemorrhage. ATC is an endogenous process, driven by the combination of tissue injury and shock that is associated with increased mortality and worse outcomes in polytrauma patients. Continued blood loss, hypothermia, acidosis, and hemodilution potentiate ATC, leading to a global derangement in all components of hemostasis including coagulation, anticoagulation, fibrinolysis, platelets, and endothelium [8,9]. Because the pathology of ATC rapidly worsens and becomes difficult to manage, early intervention is required. Considering that we had to administer both plasma and platelet transfusions, after unresponsive hemodynamic state to crystalloid infusion, we should have initiated the platelet transfusion earlier in the treatment course [10]. While reviewing the treatment of the patient who had critical ATC, we assumed that she could not be treated with PCCD use only. We concluded that the combined treatment, including coagulation therapy, volume addition, and PCCD use, contributed to the improvement of ATC and recovery of the patient. The Effectiveness of Pelvic Circumferential Compression Devices Essay.