Page 165 - Journal of Special Operations Medicine - Spring 2017

Figure 9 Toes secured to prevent external rotation. – 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 examination findings suggestive of a pel-
vic fracture
Photograph by Lt Col James Wiedenhoefer. The above criteria capture high-risk blast injury pa-
• Unconsciousness
• Shock

tients, those with physical examination concerning for
pelvic fracture, those with a compromised physical
exam due to unconsciousness, and hemodynamically

A pelvic binder provides the greatest degree of stabiliza-
and fraught with biases. There is also clinical evidence unstable blunt trauma patients.
demonstrating that hemodynamics improve after appli- tion when applied at the level of the greater trochan-
cation of a pelvic binder in hemodynamically unstable ters rather than at the level of the anterior superior iliac
patients with severe pelvic fracture. There is no indica- spine. Improper placement, however, is common—in
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tion of substantial harm, beyond the risk of pressure in- one study as many as 40% of pelvic binders were placed
jury to the skin, associated with pelvic binder use. too high resulting in inadequate reduction of pubic sym-
physis diastasis. Ideally, the binder should be placed
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A pelvic binder should be converted to external or inter- next to the skin rather than over clothing to allow more
nal fixation as soon as conditions allow, or removed if accurate positioning and prevent the need to remove the
found to be unneeded once imaging is obtained. If defini- device on arrival to the hospital. In tactical situations, it
tive care is delayed beyond approximately 8–12 hours, may not be advisable to remove the clothing; however,
the need for a binder should be reassessed and the binder the pockets should be emptied and gear removed from
loosened if the patient remains hemodynamically stable. the belt before placing a pelvic binder.

The CoTCCC recommends the use of pelvic binders for If a pelvic fracture is suspected, logrolling and unneces-
all cases of suspected pelvic fracture. A commercial de- sary movement of the patient should be avoided. If pos-
vice is recommended for consistency and ease of train- sible, the pelvic binder should be placed before moving
ing, however improvised compression is acceptable if a the patient. Ideally, the patient should be lifted gently
suitable commercial device is not available. onto the litter by two or more people, or a scoop litter
used if available. In a tactical environment, a rigid litter
may not be available; however, excess motion should
Where Does Pelvic Binder Fit Into Priorities?
still be avoided when moving the patient to the litter.
Prehospital medical interventions are prioritized accord- Since logrolling is a common technique used to place ca-
ing to the M-A-R-C-H mnemonic (Massive hemorrhage, sualties onto a litter, avoidance of such motion in cases
Airway, Respiration, Circulation, Head/Hypothermia). of suspected pelvic fracture requires particular training
emphasis.
A pelvic binder should be considered in the control of
hemorrhage during the “circulation” stage, after control The binder should be passed under the thighs and slid
of massive external hemorrhage and addressing airway up to the level of the greater trochanters, carefully lifting
or respiratory compromise, and before reassessment of from behind the back and thighs if needed. If the binder
tourniquets and intravenous access. is passed beneath the lumbar spine and slid down, the
technique is more likely to result in malpositioning the
When possible, the pelvis should be immobilized before binder above the greater trochanters and decreased ef-
moving the patient. Care Under Fire precludes pelvic fectiveness of the binder. If the technique of sliding
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immobilization. down from the lumbar spine is used, particular atten-
tion must be given to proper positioning over the greater
trochanters.
Training
A pelvic binder should be applied for cases of suspected Next, the ankles or feet should be loosely strapped or
pelvic fracture: taped together. This will help control external rotation

Pelvic Binders TCCC Guidelines Change 141