Overview of EMS Pelvic Binders
Pelvic fractures, or broken bones in the area of the hips and lower abdomen, are seen in about 10% of people who have had a severe physical impact. People who get these fractures are usually young and have seriously damaged other parts of their body as well. In some cases (1-4%), a pelvic fracture can cause dangerous bleeding that can sometimes result in death (in up to 60% of cases).
In a healthy person, the pelvis naturally helps to stop bleeding by acting as a plug or tamponade. However, in a person with a pelvic fracture, this function can be lost due to the instability of the pelvic bone and damage to the surrounding muscle and organs. The bleeding comes from multiple sources like the broken bones, blood vessels and organs in the pelvis.
A key part of initial treatment for pelvic fractures is to use a tool called a pelvic binder. This device, used like a belt around the hips, helps recreate the body’s natural ability to stop bleeding. It does this by pulling the pelvic bones back together and applying pressure in the pelvic area, which helps blood clots form. This can help limit the amount of blood transfusions the patient may need.
Pelvic binders are widely taught as part of pre-hospital and emergency room trauma care and are part of the Advanced Trauma Life Support (ATLS) protocols. However, detecting a pelvic fracture just by physical examination is tough. So, in cases where there might be a pelvic injury, ATLS guidelines recommend using pelvic binders as a precaution.
One of the challenges in using pelvic binders is making sure they are applied correctly, as studies have shown that they are often used improperly in major trauma centers. Therefore, it’s important to teach medical professionals how to properly use this essential tool.
Anatomy and Physiology of EMS Pelvic Binders
The pelvis is a complex structure in your body which can sustain serious damage in the event of a trauma like a car accident. When this happens, bleeding can occur. In up to 85% of these cases, the bleeding comes from veins rather than arteries, and this can be life-threatening because the pelvic area can hold a lot of blood. This type of bleeding usually occurs due to injury to the network of veins located in the pelvis.
The pelvis is made up of the sacrum (the bone at the base of the spine), and two bones called the innominate bones. Each of these bones is made up of three parts: the ischium, ilium, and pubis. These bones come together at the front to form the pubic symphysis, and at the back to form the sacroiliac joints. The pelvis is designed to be very strong and stable, thanks to the work of various ligaments.
Just as the skeleton system provides structure and support, the circulatory system provides the vital function of circulating blood throughout the body. The internal iliac artery, a significant blood vessel in the pelvis, splits off from the common iliac artery and enters the pelvic region, where it’s divided into two sections. Direct injuries to this artery are rare, but can be fatal. Because of its location, branches of the artery that are located near the back of the pelvis can be accidentally damaged, which can cause abnormal bleeding.
The iliac artery also has an anterior division that supplies blood to the internal organs of the pelvis. Several other arteries are also located nearby, and they can be injured by fractures, which can lead to bleeding. There’s also a network of veins surrounding the pelvic organs that can be damaged and lead to bleeding when a fracture occurs in the pelvis.
Given the complexity of the pelvis and the high risk of bleeding following pelvic injury, proper care and treatment are crucial. So, understanding the anatomy of the pelvis and the potential sources of bleeding is essential to manage such injuries effectively.
Why do People Need EMS Pelvic Binders
It can be hard to identify a broken pelvis before getting to the hospital. This is because there may not be any visible signs of injury to the pelvis, and patients often have other distracting injuries. Even when specialist doctors providing emergency services from a helicopter assess a patient, they are only able to correctly identify a serious pelvic injury about half the time.
If a person involved in an accident is unstable and experiencing pelvic pain, or if the situation of the accident suggests a significant pelvic injury, a pelvic binder should be used. This is a device that wraps around the hips to help keep the pelvis stable.
Older methods of checking for a stable pelvis, like pushing on the pelvis to see if it springs back, are no longer recommended. These methods don’t always correctly show if there’s a problem, and could potentially interfere with the body’s initial attempts to clot the blood around the area and start healing the injury.
When a Person Should Avoid EMS Pelvic Binders
There are differing opinions on the use of pelvic binders, especially when applied by first responders or in emergency situations without using diagnostic imaging to see the exact injuries. Some critics say that these binders might be used more than necessary. Pelvic binders are not recommended for people with certain types of injuries, like broken hips or legs, because these injuries are incredibly difficult to diagnose without a proper medical examination or an image scan.
Some research suggests that pelvic binders can actually cause harm instead of helping when they are used on certain types of fractures in the pelvis. These fractures, called lateral compression fractures, are particularly complicated and unstable. But, since it’s hard to identify these fractures without an image scan, emergency care guidelines still include the use of pelvic binders.
One more factor to consider is the likelihood of injuring the skin and underlying tissue if the binder is too tight or left on for too long. In some cases, skin death (necrosis) and ulcers can occur within just 3 hours of using the binder. To avoid this, the binders should ideally be removed within 24 hours. Some research also suggests that patients with multiple injuries may have a higher chance of skin problems due to the body’s stressed response to the injuries.
How is EMS Pelvic Binders performed
Pelvic compression devices are tools designed to quickly stabilize and control bleeding from a pelvic injury. Some popular brands include the SAM Sling, T-POD splint, Prometheus pelvic splint, and field expedient pelvic splint, which are commonly carried by emergency medical teams. If these specific devices aren’t available, something as simple as a tightly wrapped sheet can also be used.
Studies have suggested that two brands, the T-POD sling and SAM pelvic sling, perform the best at maintaining tension, although there’s no clinical evidence yet to show that one device is significantly better than another.
To be effective, pelvic binders need to be situated correctly. The best position is centered over the part of the hip called the greater trochanters, which are knobs of bone at the top of the thigh bones. Applying a binder in this position allows for controlled reduction of unstable fractures with less tension. Positioning the binder too high, over the iliac crests (the large wing-shaped parts of the pelvis), could lead to overtightening and potential damage to soft tissues.
Placement can affect how well a pelvic binder works. Some research has suggested that if the device is placed under the lower back and slid downwards, it often ends up too high on the hips. Instead, the better process is to position the binder under the knees without moving the legs significantly. Any clothing covering the hip and thigh regions should be removed to prevent pressure damage. The knees should also be kept together, and the legs should be internally rotated before the binder is placed and tightened according to the manufacturer’s instructions. In some cases, binding the patient’s knees and ankles together may help with rotation at the hips.
If there is also a thigh (femur) fracture causing the leg to be shorter, a bandage can be tied in a “figure-eight” around the foot and ankle to stabilize both the pelvis and thigh bones.
What Else Should I Know About EMS Pelvic Binders?
When someone has a pelvic fracture, it’s sometimes hard to detect it using a simple X-ray. That’s where a Computerized tomography, or CT scan, comes in. It’s basically a more advanced X-ray and is really useful in spotting these fractures. Generally, after patients are stabilized in the emergency room, they undergo a CT scan to identify any other issues or injuries.
During the scan, doctors usually keep a pelvic binder (basically a tight wrap around the hip area) in place. This helps in preventing any possible clot from dislodging and causing more bleeding. However, doctors have to be careful because this binder can also hide signs of a fracture. In fact, up to 47% of injuries can be missed at first glance with a binder in place. Hence, it’s important to conduct further checks or imaging with the binder removed to ensure no fractures are hidden.
Pelvic binders can be really beneficial when used early on patients with suspected pelvic trauma. They can improve the overall patient outcome, reduce the need for blood transfusion, and shorten the time spent in the Intensive Care Unit (ICU) and hospital. The main benefit of these binders is to stop bleeding in the veins around the injury. However, they don’t provide enough pressure to stop an arterial bleed. Thankfully, there’s a way to spot active arterial bleeds: a CT scan with a special dye (or contrast) can successfully identify this in up to 84% of cases, making it a very good tool.
If an active arterial bleed is present, doctors could use procedures like angiography (a kind of X-ray using a special dye to view the arteries) and embolization (a procedure to block a blood vessel) to manage it.
However, if a patient with a pelvic fracture is not stable enough for angiography, doctors may use a technique known as pelvic packing. In this technique, special bandages are packed into the pelvic area to stop the bleeding. At this stage, the pelvic binder is usually exchanged for a different piece of equipment called an anterior-based external fixator. But, recent studies show that keeping the binder on and performing the packing with the binder in place is just as effective.
Pelvic binders are therefore a critical tool in managing pelvic injuries. They provide stability, stop bleeding, are cost-effective, and are easy to use. They are a key tool in emergency care, providing support to the patient until they can be transferred to a place where they can receive more definitive treatment. It’s important that emergency care providers understand how to use these binders correctly.
