Pelvic Binders

Procedure, instructions and discussion

Pelvic binders and their application

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Instructions

Indications

• Blunt Trauma

AND

• Suspected pelvic fractures,
• Hypotension or Cardiac arrest

Contraindications (absolute in bold)

• None

Alternatives

• Pelvic sheeting (circumferential compression of the pelvis with a tied sheet)

Consent

VERBAL – IF HAS CAPACITY

• Simple procedure with a low risk of complications

NOT REQUIRED – IF LACKS CAPACITY

• Emergency procedure to prevent significant injury or death

Potential complications

• Pain
• Failure (incorrect position or dislodgement)
• Injury (underlying tissues)
• Pressure injuries with prolonged use (>24 hours)

Infection control

• Standard precautions
• PPE: Non-sterile gloves

Area

• Any bedspace

Staff

• 2-3 clinicians

Equipment

Pelvic binding device such as:

• T-pod splint (utilised by NSW Ambulance)
• SAM Sling

Or

• A Sheet

Positioning

• Patient supine
• Palpate greater Trochanters
• If difficult to locate, estimated as:
• Medial to the wrists, arms by patient’s sides
• Lateral to the top of the symphysis pubis

Medication

Consider pre-procedure pain relief adjusted to haemodynamic status:

• Ketamine IV 10-20mg
• Morphine IV 5-10mg

Sequence (T-Pod binder application)

• Remove clothing (in major trauma) and bring legs together
• If clothes are left on, ensure any belt and all objects are removed from pocket’s
• Place T-Pod belt orange side down and insert belt under the curve of back or above the patients knees
• Manoeuvre belt under pelvis until positioned with greater trochanters at the middle of the belt
• Fold or cut each side of T-Pod belt mid-thigh allowing 15 to 20 cm space between the two edges (cut for smaller patients)
• Apply the Velcro-backed Pulley System to the Belt on each side of the gap.
• Slowly apply tension on “pull tab”, until space between edges of belt is opposed (circumferential pressure)
• Wrap the cord around the Pulley System hooks and secure the Velcro-backed Pull Tab to the Pulley System fabric
• Ensure that two fingers can fit between the device and the patient
• Place padding between ankles and knees secure legs with triangular bandage

TO REMOVE

• Lift the Velcro pull tab off belt and slowly release tension in the mechanical advantage system allowing binder to loosen

Sequence (SAM Sling application)

• Remove clothing (in major trauma) and bring legs together
• If clothes are left on, ensure any belt and all objects are removed from pocket’s
• Place padding between ankles and knees secure legs with triangular bandage
• Place SAM sling under the curve of back or above the patient’s knees
• Manoeuvre belt under pelvis until positioned with greater trochanters at the middle of the belt
• Position the buckle in the midline and pull the strap through the buckle
• Firmly pull the orange and black straps in opposite directions until you feel the buckle click
• Maintaining tension press the black strap onto the surface of the pelvic sling to secure it
• Ensure that two fingers can fit between the device and the patient

TO REMOVE

• Lift the black strap up by pulling upwards, maintain tension and slowly allow the sling to loosen

Sequence (Sheet application)

• Remove clothing (in major trauma) and bring legs together
• If clothes are left on, ensure any belt and all objects are removed from pocket’s
• Narrowly folded sheet to the distance from pubic symphysis to iliac crest (approx. 20 cm)
• Place sheet under the curve of back or above the patient’s knees
• Manoeuvre sheet under pelvis until positioned with greater trochanters at the middle of the belt
• Pass sheet to partner opposite and pull sheet as tight as possible (the sheet may be twisted)
• Apply clamps (this will require a third person) laterally and tape to prevent loosening
• Place padding between ankles and knees secure legs with triangular bandage

Post procedure care

• Confirm pelvic at the level of greater trochanters
• Record the date and time of application
• Periodically re-check tension

Tips

• Avoid compression (‘springing’) of the pelvis in suspected injury (risk of clot disruption and haemorrhage)
• Clinical assessment of pelvic injury is unreliable, if in doubt treat patients with a pelvic binder
• Misplacement pelvic binders can lead to inadequate compression of the pelvis (regularly check position)
• Consider positioning an open binder on the bed prior to patient transfer (minimising patient movement)

Discussion

The role of pelvic binders in hemodynamically unstable patients with pelvic fractures is to aid in controlling small venous and cancellous bone bleeding. It does this by reducing the volume of the pelvis thereby promoting pelvic tamponade and clot formation. External stabilisation does not control arterial bleeding.

Consensus opinion suggests that a pelvic binder is not indicated for hemodynamically stable patients (Systolic BP >90mmHg and Heart Rate <100bpm) without pelvic pain, reduced GCS or distracting injury.

There is no specific evidence to suggest superiority of one type of pelvic binder device over another (including pelvic sheeting) and if pelvic sheeting has been correctly positioned, it should be left in place until pelvic ring injury has been definitively excluded. If a pelvic binder becomes loose tension should be readjusted, but the binder should not be removed.

References

• Ambulance Service of NSW. NSW Ambulance Protocol 106.14 (Pelvic sheeting)
• Ambulance Service of NSW. NSW Ambulance Protocol 106.15 (Pelvic Splint T-Pod)
• Ambulance Service of NSW. Traumatic cardiac arrest. Report HELI.CLI.07. Sydney: ASNSW; 2013. 6pp. Available from: https://sydneyhems.com/resources/policies-and-procedures/
• SAM pelvic sling II instructional guide, two-person application. Available: https://www.sammedical.com/blogs/training/sam-pelvic-sling-ii
• Arrow® T-POD™ Pelvic Stabilization Device: Instructional guide. Available: https://learn.teleflex-academy.com/learn
• Roberts JR, Custalow CB, Thomsen TW. Roberts and Hedges’ clinical procedures in emergency medicine and acute care. 7th ed. Philadelphia, PA: Elsevier; 2019.
• Heetveld MJ, Harris I, Schlaphoff G, Sugrue M. Guidelines for the management of haemodynamically unstable pelvic fracture patients. ANZ J Surg. 2004 Jul;74(7):520-9. 
• Scott I, Porter K, Laird C, Greaves I, Bloch M. The prehospital management of pelvic fractures: initial consensus statement. Emerg Med J. 2013 Dec;30(12):1070-2.
• Cullinane DC, Schiller HJ, Zielinski MD, Bilaniuk JW, Collier BR, Como J, Holevar M, Sabater EA, Sems SA, Vassy WM, Wynne JL. Eastern Association for the Surgery of Trauma practice management guidelines for hemorrhage in pelvic fracture–update and systematic review. J Trauma. 2011 Dec;71(6):1850-68. 

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