The Use of Pelvic Binders in Tactical Combat Casualty Care: TCCC Guidelines Change 1602

## Col Stacy Shackelford, MD; Rick Hammesfahr, MD; MSG (Ret); MSG Daniel Morissette, SO-ATP; Harold Montgomery, SO-ATP; Win Kerr, SO-ATP; CAPT (Ret) Brad Bennett, PhD, NREMT-P; Col (Ret) Warren Dorlac, MD; CAPT Stephen Bree, MD; CAPT (Ret) Frank Butler, MD

Journal of Special Operation Medicine 2017 (1) 135-147

#### Description with Key Points:

Pelvic fractures can result in massive bleeding and death. Dismounted improvised explosive device (IED) attacks, gunshot wounds and motor vehicle accidents often result in pelvic fractures. IED attacks have been the major cause of combat related injuries during the Afghanistan conflict. ?Twenty-six percent of service members who died during Operations Iraqi and Enduring Freedom had a pelvic fracture.? For these reasons, the CoTCCC conducted an extensive review of the literature which led to the addition of pelvic binders to the TCCC guidelines.

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? Emergent treatment options for pelvic fractures include pelvic binder, external fixation, internal fixation, direct surgical hemostasis, preperitoneal pelvic packing, and pelvic angiography and embolization. Of these, the only treatment available to prehospital providers is the pelvic binder.

? Although definitive evidence demonstrating improved survival with pelvic binder use is lacking, the existing evidence addressing the management of pelvic hemorrhage recommends pelvic binder use for initial management of pelvic fracture hemorrhage.

? Placement of the binder at the level of the pubic symphysis and greater trochanters was shown to reduce the unstable pelvic fracture most effectively with the least amount of force.

? It is more likely that splinting of pathologic fracture motion allows clot formation and is the mechanism that aids in hemostasis.

? Hemorrhage with stable fracture patterns is unlikely to be controlled with a pelvic binder. However, since it is not possible to differentiate a stable from an unstable fracture pattern in the prehospital environment, all suspected pelvic fractures should have a binder applied.

? Applying a pelvic binder is unlikely to increase injury or bleeding. Prolonged use or overtightening may cause pressure ulcerations.

? A pelvic binder should be applied for cases of suspected pelvic fracture in severe blunt force or blast injury with one or more of the following indications:

- Pelvic pain
- Any major lower limb amputation or near amputation
- Physical exam findings suggestive of a pelvic fracture
- Unconsciousness
- Shock

? There is very weak evidence to suggest that a commercial device is more effective in controlling hemorrhage than an improvised sheet. There is no evidence that any commercial compression device is better than another.

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# Take Home Message:

The CoTCCC recommends the use of pelvic binders for all cases of suspected pelvic fracture. A commercial device is recommended for consistency and ease of training, however improvised compression is acceptable if a suitable commercial device is not available.
A pelvic binder should be considered in the control of hemorrhage during the ?circulation? stage, after control of massive external hemorrhage and addressing airway or respiratory compromise, and before reassessment of tourniquets and intravenous access.