Case of the Month
April 2008

32-year-old male — two-car MVA

Dispatch
It is 0230 hours and your BLS unit is dispatched as part of a multi-unit response to a two car motor vehicle accident.

While en route the dispatcher notifies responding units that this is a two car ‘T’ bone accident with two patients. Both patients are still in trapped and one may be unconscious.

The first arriving engine company takes command and announces that there are two “red” patients. Your BLS unit is directed to assist with the 32-year-old male in the driver’s seat of a black four door sedan.
En route your crew discusses the following considerations:

• Neck and spine treatment
• Rapid assessment and transport
• Additional resources for extrication and patient removal

Scene Size-up
As you roll up you see significant damage to the driver’s side door—the patient is still in the driver’s seat. The windshield is damaged, but not completely fractured. The patient still has his seat belt on and he is moaning and holding his right hip.

There is no sign of fuel or other hazardous substances on the ground, however there is debris scattered over the entire area. He complains of severe pain in his pelvis and in his middle back. Due to the damage to the door of the vehicle, a hydraulic rescue tool will be required to gain access and extricate the patient. You request this from the Incident Commander.

Initial Assessment
You evaluate the patient as best you can while waiting for the extrication team, checking his radial pulse. His rate is about 100 and regular. His face conveys the look of extreme pain. A rapid “blood pat down” finds no evidence of external bleeding and a rapid trauma exam reveals a great deal of pain when palpating the pelvis. The rest of the exam is unremarkable. 

Initial Treatment
Your assessment is: a possible pelvic fracture or hip fracture, and risk of hypothermia for this patient. You cover the patient with blankets to retain heat and to protect him from flying debris from the extrication efforts. You also prepare equipment to receive the patient, including a backboard, and cervical collar; a sheet is placed across the backboard so that the pelvis can be sheet splinted. 

Vital Signs

• Respirations                         24
• Pulse                                 100
• Mental status                      Conscious
• Pulse oximetry                     Not assessed
• Blood sugar                         Not assessed
• Blood pressure                     106/P

Further Evaluation and Treatment
The door is detached and the patient is removed to the backboard. As he is being removed his pain is intensified, however it settles down somewhat once he is in place on the backboard.

Before strapping the patient to the backboard the decision is made to splint the pelvis with the sheet. Your partner crosses the ends of the sheet over the patient and you reach down and apply moderate pressure on the sides of the pelvis inward toward the patient’s midline. While you are stabilizing the pelvis, your partner twists the ends of the sheet and ties them over the pelvis allowing you to release your pressure which the sheet has now taken. The sheet is then secured to the backboard and the rest of the straps are applied.  

The patient is placed in the back of an ALS unit and transported to the local trauma center. During the transport the patient’s discomfort is somewhat decreased by the pelvic sheeting and his vital signs remain stable. 

Pelvic Fractures and Their Treatment
It takes a huge amount of force to cause a pelvic fracture; therefore, if this type of injury is present, other severe injuries must be suspected. Even if the damage is isolated to the pelvis, this type of fracture can result in an exquisite amount of pain and severe secondary injuries, such as nerve damage and or hemorrhage from major vessel damage. 

Treatment for an unstable pelvic fracture should consist of moderate external, circumferential compression by means of a sheet or a commercial splinting device.  Applying pressure in this way can slow internal bleeding and can also reduce pain.  All patients with pelvic fractures should be immobilized on a backboard and transported with ALS intervention.

Unstable pelvic fractures
EMSResponder.com (external website)

Pelvic fractures
eMedicine.com (external website)