Page 159 - Journal of Special Operations Medicine - Spring 2017

The Use of Pelvic Binders in Tactical Combat Casualty Care

TCCC Guidelines Change 1602

7 November 2016

Stacy Shackelford, MD; Rick Hammesfahr, MD; Daniel Morissette, SO-ATP;
Harold Montgomery, SO-ATP; Win Kerr, SO-ATP; Michael Broussard, PA-C;
Brad Bennett, PhD, NREMT-P; Warren Dorlac, MD; Stephen Bree, MD; Frank Butler, MD

Proximate Cause for This Change
caused by blast injury, 15% by gunshot wounds, and
Blast injuries resulting from improvised explosive device 4.5% by motor vehicle crash. 5
(IED) attacks have been a major cause of combat injury in
the Afghanistan conflict. Dismounted IED attacks are Emergent treatment options for pelvic fractures include
1,2
frequently associated with pelvic fractures, which in turn pelvic binder, external fixation, internal fixation, direct
3
may result in massive hemorrhage and death. Pelvic frac- surgical hemostasis, preperitoneal pelvic packing, and
4
ture is also frequently caused by penetrating trauma and pelvic angiography and embolization. Of these, the
8
high-energy blunt trauma such as motor vehicle crash. 5 only treatment available to prehospital providers is the
pelvic binder.
The Committee on Tactical Combat Casualty Care
(CoTCCC) reviewed the use of pelvic binders in 2008 Although definitive evidence demonstrating improved sur-
and decided at the time that there was insufficient vival with pelvic binder use is lacking, every publication
evidence of benefit to warrant their addition to the identified in our review addressing the management of
TCCC Guidelines. At the February 2016 meeting of the pelvic hemorrhage recommends pelvic binder use for ini-
CoTCCC, CAPT Stephen Bree, the UK Liaison Officer tial management of pelvic fracture hemorrhage 4,9–24 includ-
to the US military and an experienced combat medical ing both civilian 25–29 and military practice guidelines. 30–32
provider, was asked to present the top three items that In general, the risk:benefit assessment of the intervention
he thought needed to be changed about TCCC. One of and the potentially devastating nature of pelvic hemor-
those three items was to add the use of pelvic binders to rhage have led numerous authors to recommend the use
the TCCC Guidelines. Col Stacy Shackelford presented of pelvic binders for initial control of pelvic hemorrhage.
a review of this topic for the committee. An extensive re-
view of the literature and consideration by the CoTCCC In 2016, the Committee on Tactical Combat Casu-
led the committee to recommend that pelvic binders be alty Care considered whether the use of pelvic binders
reconsidered for addition to the TCCC Guidelines. should be included in the TCCC guidelines. Seven spe-
cific questions were addressed regarding the prehospital
use of pelvic binders:
Background
Pelvic fractures are common in combat injuries, and 1. Does a pelvic binder stabilize the pelvic fracture?
may be highly lethal. Twenty-six percent of service 2. Does a pelvic binder control bleeding from a frac-
members who died during Operations Iraqi and En- tured pelvis?
during Freedom had a pelvic fracture. The pelvic frac- 3. Does a pelvic binder improve survival?
tures resulting from direct combat, to include blast 4. Who should get a pelvic binder?
injury and gunshot wounds, had a much higher mor- 5. Is there any harm in applying a pelvic binder?
tality than those resulting from motor vehicle crash or 6. What is the best type of pelvic binder?
fall. Bleeding pelvic fractures associated with hemody- 7. Where does pelvic binder fit into priorities?
6
namic instability may have up to 40% mortality. An-
4
terior compression injuries (open book fractures) are The PubMed, MEDLINE, and Cochrane databases
associated with the highest mortality (48%). Among were searched 1 Jan 1990–1 Apr 2016 for articles under
7
military casualties, 76% of fatal pelvic fractures are combinations of the keywords pelvic fracture, pelvic

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