question about MAST/PASG

[reaper]

ACE,

All three counties I work for carry mast pants. All three have protocols for the use of mast, for hip fx stabilization only???

[ERDoc]

Ace,

I'd be pretty impressed to see a pt come in with MAST on to stabilize a pelvis fracture. What do you think we do when a pt comes in with an open-book pelvic fracture (no, it is not necessarily an open fx)? We take a sheet, wrap it around the pelvis and apply pressure to keep the pelvis stable so that none of the great vessels are injured from the bone fragments. Sounds like a poor man's version of MAST to me (assuming you don't inflate the leg compartments). I realize that you cannot xray the pelvis in the field so you cannot tell if there is an open-book fx or not, but I don't see the problem with it (obviously you have to follow your local protocols). Sure, we'll probably take them off as soon as we get the pt, but it still stabilized the pelvis during transport. I'd like to see the literature that says that MAST is contraindicated in a pelvic fx. I don't think that you would find anyone (at least EM trained) that would have a problem with stabilizing an unstable fx.

[Ace844]

Ace,

I'd be pretty impressed to see a pt come in with MAST on to stabilize a pelvis fracture. What do you think we do when a pt comes in with an open-book pelvic fracture (no, it is not necessarily an open fx)? We take a sheet, wrap it around the pelvis and apply pressure to keep the pelvis stable so that none of the great vessels are injured from the bone fragments. Sounds like a poor man's version of MAST to me (assuming you don't inflate the leg compartments). I realize that you cannot xray the pelvis in the field so you cannot tell if there is an open-book fx or not, but I don't see the problem with it (obviously you have to follow your local protocols). Sure, we'll probably take them off as soon as we get the pt, but it still stabilized the pelvis during transport. I'd like to see the literature that says that MAST is contraindicated in a pelvic fx. I don't think that you would find anyone (at least EM trained) that would have a problem with stabilizing an unstable fx.

"ER Doc,"

With all respect, I said that an indicated use was for a pelvic FX as I stated when I said this;

"Usually MAST is most often used "at splinting pressures" for A) an unstable pelvis B.) severe Bilat lower extermity trauma C.) any combination of A and B D.)Traumatic arrest . "

I was against it's use in an isolated hip Fx as posted by "medic RN", and "Ruffems", as further evidenced by "Ruffs" statement of

"The mast has fallen out of favor over the years and I don't recall the last time I've put one on except for a hip fracture and it did a wonderful job."

and "Medic Rn's" statement of

"In several areas, MAST/PASG have been used (and some still use) to stabilize a hip fx."

As far as your starement of

"I'd like to see the literature that says that MAST is contraindicated in a pelvic fx. I don't think that you would find anyone (at least EM trained) that would have a problem with stabilizing an unstable fx."

My statement of "contraindication" applied to an (open Hip-read-upper femur/femoral head FX) as evidenced by my statement of

"I Find it hard to justify under the circustances of a hip Fx (UNLESS IT WERE SO BAD AS TO BECOME OPEN, which would contrindicate their use anyway...) "

To repeat I think MAST is a great tool for the use of stabilizing the pelvis, and bilat/severe lower ext trauma....I guess I am abit confused with your contention with my post "ER DOC" as we agree.....

out here,

Ace844

[ERDoc]

"ER Doc,"

With all respect, I said that an indicated use was for a pelvic FX as I stated when I said this; "Usually MAST is most often used "at splinting pressures" for A) an unstable pelvis B.) severe Bilat lower extermity trauma C.) any combination of A and B D.)Traumatic arrest . "

I was against it's use in an isolated hip Fx as posted by "medic RN", and "Ruffems", as further evidenced by "Ruffs" statement of

and "Medic Rn's" statement of

To repeat I think MAST is a great tool for the use of stabilizing the pelvis, and bilat/severe lower ext trauma....I guess I am abit confused with your contention with my post "ER DOC" as we agree.....

out here,

Ace844

I stand corrected. It did not register that they were talking about hip fxs. There's no purpose to use them in HIP fxs, but they are good for PELVIC fxs. The question is, how do you reliably tell the difference in the field?

[Ace844]

I stand corrected. It did not register that they were talking about hip fxs. There's no purpose to use them in HIP fxs, but they are good for PELVIC fxs. The question is, how do you reliably tell the difference in the field?

"ER Doc,"

I don't believe there is a concreete "reliable" way like your thinking to tell the difference. I find for me H@P makes the biggest difference pre-hospital. In the setting of shock, gross hematuria, global pelvic crepitus, open book sx's you described, or rocking/pelvic loading creates gross crepital sounds/feelings I err on the side of Pelvic Fx. In isolated lower extremitiy trauma with shortening/rotation, etc...I tend to go with Hip Fx. and treat that. As you mentioned in your previous post, at this time there is no widespread EMS radiology services available to us.

My big concern is that someone who is just starting will read "ruff's @ MedicRn's posts" and apply MAST on a Hip Fx patient improperly (READ-THIS SHOULD NOT BE HAPPENING AT ALL, AND CERTAINLY not to splinting pressure, and on a hip RATHER THAN PELVIS FX) and think its ok and run into problems....As this is not an indicated usage as I'm sure you'll agree and have above. If someone can produce evidenced based literature that shows MAST use in HIP FRACTURES works and is efficacious....I'm all ears....."RUFF@MedicRN, be careful if you are doing this in your practice as you can see even our resident "ER Doc" agrees and states this; "There's no purpose to use them in HIP fxs," food for thought.

out here,

Ace844

[Dustdevil]

Way to trash the guy's topic. :?

Jim, I concur with MedicRN here. The total treatment you depict will depend upon how severe you make the injury and the patient's condition. Since you are talking MAST and hemostats, I am assuming you mean it to be a life-threatening wound with arterial bleeding. In this case, you'll want to go for the inner thigh. If you want to be very realistic with the treatment, you will have the medics rapidly apply direct pressure with a fistful of dressings, throw him on a backboard, and immediately haul ass towards the hospital. If possible, they will take a fireman or other first-responder to the hospital with them, and he/she will keep the direct pressure applied to the wound while the medic applies oxygen and starts IV's. If enroute to the hospital the direct pressure just isn't doing the trick (an extremely rare occurrence), then the medic would fashion a tourniquet out of a triangular bandage, just above the wound. Typically, there is really nothing else we do in the urban EMS field other than direct pressure. Most ambulances don't even have hemostats. And unless your medic is a former combat corpsman, he is unlikely to know how to use one anyhow.

MAST would not be a totally unreasonable adjunct for this wound, since it applies pressure to the wound AND splints the limb, both of which are indicated. But you would inflate ONLY the section on that particular leg since you would not be using it as an actual anti-shock garment.

Personally, on this scenerio, I would hold direct pressure to the effected vessel(s), titrate NS or LR to BP and apply large qualities of diesel or aviation fuel. Hemostats would only serve to damage the vessel making surgical repair difficult or maybe even impossible (read leg amputation).

[flightmedic608]

Hello, as much as it pains me..I am in agreement with Dust. He presents a very clear and concise way to treat this injury. On the thoughts of hip fractures...I have used the KED placed inverted on the affected side and this has stabilized the affected area wonderfully, while not changing circulation and allowing access to the patient. If there are any questions about how to placed the inverted KED on a patient, please feel free to ask.

Sean

[Ace844]

Way to trash the guy's topic. :?

Jim, I concur with MedicRN here. The total treatment you depict will depend upon how severe you make the injury and the patient's condition. Since you are talking MAST and hemostats, I am assuming you mean it to be a life-threatening wound with arterial bleeding. In this case, you'll want to go for the inner thigh. If you want to be very realistic with the treatment, you will have the medics rapidly apply direct pressure with a fistful of dressings, throw him on a backboard, and immediately haul ass towards the hospital. If possible, they will take a fireman or other first-responder to the hospital with them, and he/she will keep the direct pressure applied to the wound while the medic applies oxygen and starts IV's. If enroute to the hospital the direct pressure just isn't doing the trick (an extremely rare occurrence), then the medic would fashion a tourniquet out of a triangular bandage, just above the wound. Typically, there is really nothing else we do in the urban EMS field other than direct pressure. Most ambulances don't even have hemostats. And unless your medic is a former combat corpsman, he is unlikely to know how to use one anyhow.

MAST would not be a totally unreasonable adjunct for this wound, since it applies pressure to the wound AND splints the limb, both of which are indicated. But you would inflate ONLY the section on that particular leg since you would not be using it as an actual anti-shock garment.

"DustDevil @ flightmedic608,"

Sounds like we agree as well. If you notice the only part which seems to be different is the MAST/PASG part. Please read below.

"Jim" originally wrote, "Hi all - i do research for a tv show and we're debating the best way to depict a paramedic treating a young man with a GSW to his leg.

Thought this would be a good place to get input. Imagine the kid's bleeding pretty badly and they are arriving at a hospital...

Would the paramedic have applied PASG? A tourniquet? Splinting of some kind? Someone even said in extreme cases they would use hemos to hold the femoral artery?

Any help would be appreciated. "

Ace844 wrote, "jim",

A patient suffering an injury like the one you describe is unlikely to be placed in MAST pant's for treatment. But, I do agree with the advice of speaking with someone in your area about local protocols as they vary across the nation.

Also, I think it'd be unlikely that some one would use hemostats to "clamp" an artery in the leg (outside of the hospital, and get away with it, as they'd most likely have to "go fishing in the wound" to do so). I think more than likely you'll find someone watched "Black Hawk Down" a few to many time and is trying to be a "cowboy" in their pre-hospital practice. More than likely if this person did this they would no longer be practicing for very long afterwards...hopefully !!!

The treatment is expose, look for the exit wound, dress and bandage, use direct pressure, and elevate to the extent possible, estyavlish 2 large bore IV's and fluid resus. as needed, monitor, O2, and depending on the path of the missile spinal immobilization, followed by rapid transport to an ER and shortly there after an OR.

My contention for "Jim" when I say that MAST would be unlikely to be placed is not due to the fact that it isn't indicated or a good use in this case as I agree with you statement above....

However, it has been my experience that MAST application would be UNLIKELY in this case because of the following factors, and outside the setting of a rural or prolonged transport setting:

A.) Most services don't use the MAST a great deal, and thus it will take precious additional time in applying them "with unpracticed lack of ease", and even more likely, reapplying/readjusting a few times

B.) Most services because they are rarely used store them in the ambulance an inconveinently accessible place.

C.) The crew most likely "going into the call" unless MAST was specifically requested by a FR or other crew, etc... Wouldn't likely take them with all of their other equipment when they go to eval this patient.

So it is my contention that the combination of all of these factors can make for a significant and potentially lifethreatening M@M increase for this patient, allowing the benefit of it's application to be mitigated.....

I mean really think about it. If you only have a 10-15 min tx time to a level 1 center, why would one potentially add 10-15 minutes additional on a scene to apply the MAST (It may take that long because as mentioned it's probably been awhile since you've used them...)?!?!?!!? Furthermore, wouldn't that 10-15 min be best spent getting this patient to an ER/OR and a place where more definitve/surgical care could be done, in some centers this patient may be brought to "the OR" quite rapidly.

Lastly, I gave this advice because we all complain about how inaccurate these TV shows/Movies are when they portray us and our actions!! now here "jim's" giving us a legitimate chance to possibly change that at least once!!!!!

Hope this helps,

Ace844

[Ace844]

Hello, as much as it pains me..I am in agreement with Dust. He presents a very clear and concise way to treat this injury. On the thoughts of hip fractures...I have used the KED placed inverted on the affected side and this has stabilized the affected area wonderfully, while not changing circulation and allowing access to the patient. If there are any questions about how to placed the inverted KED on a patient, please feel free to ask.

Sean

"flightmedic608,"

So you don't advocate the use of MAST in the situation you describe in this post...correct..??

out here,

Ace844

[flightmedic608]

Hi. I would not say that I would not use MAST, I am always open to more adjuncts for patient care. I would be hesitant to place the MAST on an isolated extremity trauma, there are quicker more effective therapies immediately available i.e. direct pressure, tourniquet etc... I think on my list of treatment modalities it would be at the bottom.

Sean