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Three Part Question

In [trauma patients with unstable pelvic fractures] is [pelvic immobilisation with a T-pod or pelvic immobilisation with a wrapped sheet] better [at haemorrhage control]?

Clinical Scenario

A patient is bought to the Emergency department with pelvic trauma. One of the members of the trauma team mentions that the new T-pod pelvic binder is better than the traditional wrapped sheet. You wander if there is any evidence to support this

Search Strategy

Medline 1980 - May 2011 using the nhs library interface.
[ [Pelvis ti.ab OR Pelvic ti.ab]AND[Splint ti.ab. OR immobilisation ti.ab.]AND[Trauma ti.ab]]
OR [Tpod ti.ab]

Search Outcome

This search yielded 19 papers. Afer reading the abstracts, only one paper directly compared te TPOD to the wrapped sheet. 4 papers looked at the effectiveness of PCCD. Theses papers were reviewed but deemed not relevant to the questions. One systematic review of PCCD and one clinical trial have been included in the review of the evidence but are do not directly answer the question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Tan et al July 2010 The Netherlands	3 year prospective study of patients presenting to the Emergency department with untreated unstable pelvic fractures. n = 15 Patients with pre-hospital pelvic stabilisation excluded (n = 48)	Blood pressure and heart rate was measured before nad 2 minutes after application of the T-POD. ATLS guidlines were used to assess response (good, transient, poor). Plain radiographs were used to measure fracture reduction.	Increase in MAP ( 64.7 - 81.2mmHG P < 0.04)		Blood pressure and heart rate are not reliable measurments of circulatory response 120 seconds after a painful procedure. No outcome measurements. Majority of patients excluded because of pre-hospital treatment. Small numbers No comparision group Missing data (3/15 no repeat x-ray and 5/15 - repeat BP/HR not recorded)
			Decrease in heart rate 106 (range 80bpm - 140) to 93bpm (range 80 - 127) p < 0.04
			No compications reported
DeAngelis NA August 2008 United States	Cadaver study n = 12	Unstable pelvic fractures (Tile B1) were created in 12 non-embalmed human cadavers. Circumfrential bed sheets and the T-pod were used to reduce the fractures. Fracture reduction was measured using plain radiographs	Circumfrential bed sheet reduces the symphysic diastases by 21.9mm and achieve normalisation (<10mm) in 2/12		Cadaveric study and bio-mechanical data. Limited application to in-vivo patients. Small numbers.
			T-pod reduces the symphysic diastases by 32.2mm and achieve normalisation (<10mm) in 9/12
Spanjersberg W R October 2009 The Netherlands	Systematic Review of the literature looking at PCCD in unstable elvic fractures		Only small quantity of low level papers found

Comment(s)

A previous BestBet has found that there is lack evidence for pelvic immobilisation. However, pelivc immobilisation with either a bed sheet or PCCD (pelvic circumfrential compression device) such as the T-POD is the normal standard of care and advised by ATLS. PCCD are becoming increasing popular. Several cadaveric studies demonstrate bio-mechanical improvement. DeAngelis et al suggested that the T-POD demonstrates better mechanical reduction than a simple wrapped sheet Tan et al attempted to demonstrate a haemodynamic improvement but this flawed paper struggles to find any meaningful conclusions. Spanjersberg's systematic review found similarly lacking evidence in this area. No evidence exists that demostrates an improvement in clinical outcome. They suggest that whilst the PCCD are promising, their safety and effectiveness in individual fractures types is not known and their complication rates (skin necrosis, nerve palsy) is also not known. Research in this area is difficult as patients with unstable pelvic fractures often have multiple injuries.

Clinical Bottom Line

Insufficient evidence currently exists to recommend the T-POD over the traditional wrapped bed sheet. A large, prospective, randomised controlled study is required to safety and efficacy of PCCD.

Level of Evidence

Level 3 - Small numbers of small studies or great heterogeneity or very different population.

References

1. Tan et al Effect if a new pelvic stabilzer (T-pod) on reduction of pelvic volume and haemodynamic stability in unstable pelvic fractures Injury July 2010 (41/7) 1017 - 1021
2. DeAngelis NA Use of the trauma pelvic orhotic device (T-POD) for provisional stabilisation of anterior-posterior compression type pelvic fractures: A cadaveric study Injury 39/8 (903-6)
3. Spanjersberg W R Effectiveness and complications of pelvic circumfrential compression devices in patients with unstable pelvic fractures: A systematic review of literature Injury Oct 2009: 40/10; (1031-35)