Page 159 - Journal of Special Operations Medicine - Summer 2016

together in the prehospital combat environment as doc- • COL Shackleford recommends adding language to
trinal and routine, and (3) to bring about greater place- the TCCC guidelines that calls for a pelvic binder to
ment of military medical personnel in civilian trauma be applied for cases of suspected pelvic fracture. This
centers and on civilian prehospital platforms. should include:
o securing the legs or binding the thighs together) as
Additionally, he observed that TCCC analgesia proto- exemplified by:
cols are too conservative, that supraglottic airway de- – Casualties with blast injury with amputation
vices must also be included in Tactical Field Care in – Casualties with blunt trauma and
addition to nasopharyngeal airways and cricothyroid- • SBP <100mmHg, HR >100
otomy, that pediatric trauma care should be addressed, • GCS score ≤13
and that TCCC training should be more realistic and • Pelvic pain or distracting injury
include “real-life injured” role players.
22. CoTCCC Action Items: Dr Frank Butler reviewed
21. The Role of Pelvic Binders in TCCC: COL Stacy ongoing and proposed CoTCCC action items.
Shackelford briefed the group on the topic of adding
pelvic binders to the TCCC Guidelines. She noted that Current CoTCCC action items:
pelvic fracture is a common and serious injury among • TCCC trademark issues. The Joint Trauma System is
the combat injured. Twenty-six percent of Servicemem- pursuing cancellation of a TCCC trademark inappro-
bers who died in Operation Enduring Freedom/Opera- priately issued to an individual uninvolved with the
tion Iraqi Freedom had a pelvic fracture, and casualties US Military TCCC effort. The US Military conceived
with bleeding pelvic fractures and hemodynamic insta- and published the term “Tactical Combat Casualty
bility have up to a 40% mortality rate. Pelvic binding is Care” and “TCCC” more than a decade before the
the only prehospital intervention with which to address trademark application.
pelvic fractures; it may be helpful with venous bleeding • DOD-FDA Military Use Panel for Combat Casualty
but is probably ineffective against arterial hemorrhage. Care medications. The current FDA regulatory struc-
Commercially available circumferential pelvic compres- ture for medications is not well configured to support
sion devices include the Pelvic Binder, the T-POD, and combat casualty care in the US Military. This issue
the SAM Sling. has been noted in several published papers and pur-
suit of a solution to this situation is ongoing.
Col Shackelford then reviewed the following clinical • Medical Rapid Fielding Initiative. There still not an
questions with regard to pelvic binders and discussed organized DoD-level effort in place to accomplish the
the evidence on each: rapid fielding of newly recommended combat casu-
• Does a pelvic binder stabilize pelvic fractures? Ca- alty care equipment and medications to deployed and
daver studies indicate it does. deploying US military units. This expedited fielding
• Does a pelvic binder decrease the bleeding from a pel- should be accompanied by the collection of focused
vic fracture? There is evidence that it does. feedback on the performance of the newly fielded
• Does the use of a pelvic binder improve survival? The items. This need for such a program has been noted in
clinical evidence that it does is weak. Col Shackelford several published papers and pursuit of a solution to
also noted that bleeding from some pelvic fracture this situation is ongoing.
patterns may not be reduced by pelvic compression. • Prehospital Trauma Life Support (PHTLS) 9th edi-
• Who should get a pelvic binder? (1) Dismounted IED tion, Military Version. Work on the next edition of
casualties with lower extremity amputations; (2) ca- the PHTLS textbook is underway. Any members of
sualties with blunt trauma and systolic blood pres- the group wishing to volunteer their help with this ef-
sure (SBP) <100mmHg, or heart rate (HR) >100, or fort should get in touch with Dr Giebner.
Glasgow Coma Scale (GCS) score of ≤13; or pelvic • Improving the standardization of TCCC training in
pain in the presence of a distracting injury the DoD
• Is there harm in applying a pelvic binder? A pelvic
binder is unlikely to increase injury or bleeding when Proposed TCCC Guidelines changes coming to a vote:
applied acutely, but longer use of a pelvic binder may • iTClamp
cause pressure ulcers and there is some chance that a • Pelvic binders in TCCC
pelvic binder may make breathing more difficult. • iGel as the TCCC SGA of choice
• Which pelvic binder is best? There is weak evidence
that the available commercial devices are better than Potential TCCC Guidelines Changes:
the use of a sheet to reduce pelvic fractures. None of • Higher initial dosing of ketamine
the commercial devices has so far been shown to be • Include casualty positioning recommendations for
superior to the others. performing needle chest decompression

CoTCCC Meeting Minutes 145