The binder over the trochanters, the resuscitation restrictive, the imaging by whether they respond.

When. “If active bleeding is suspected from a pelvic fracture following blunt high‑energy trauma: apply a purpose‑made pelvic binder, or consider an improvised pelvic binder but only if a purpose‑made binder does not fit.” (NG37 1.1.7; word-for-word the same as NG39 1.5.3.)

Where — the practice point NICE leaves out

Neither NG37 nor NG39 says where on the pelvis the binder sits. The near-universal teaching, and the instructions supplied with every purpose-made device, is to centre it over the greater trochanters — the bony points you can feel at the widest part of the hips — not over the iliac crests, where it is most often placed wrongly. A binder over the crests does not close the pelvic ring and can splint it open. This is a technique point from device instructions and standard trauma teaching, not from NICE; it is flagged as such because the rest of this module is national guidance and this is not.

• Straighten and gently bring the legs together, and internally rotate them, before or as the binder is tightened — this helps close the ring. Tie or tape the ankles/knees to hold the position.
• Remove hard objects from pockets under the binder (keys, phones) — they cause pressure necrosis under a binder that may stay on for hours.
• One binder, correctly placed and tightened, is the intervention. It tamponades venous and bony bleeding and reduces the pelvic volume; it does not control arterial bleeding, which is why an arterial bleed still needs interventional radiology or packing.

Restrictive volume resuscitation

• “For patients with active bleeding use a restrictive approach to volume resuscitation until definitive early control of bleeding has been achieved.” (1.5.18)
• In hospital, “move rapidly to haemorrhage control, titrating volume resuscitation to maintain central circulation until control is achieved.” (1.5.20)
• “In hospital settings do not use crystalloids for patients with active bleeding.” (1.5.23)

Blood component ratio

• Adults (16 or over): “use a ratio of 1 unit of plasma to 1 unit of red blood cells to replace fluid volume.” (1.5.24)
• Children (under 16s): “use a ratio of 1 part plasma to 1 part red blood cells, and base the volume on the child's weight.” (1.5.25)
• “For patients with active bleeding, start with a fixed‑ratio protocol for blood components and change to a protocol guided by laboratory coagulation results at the earliest opportunity.” (1.5.27)

Traumatic brain injury alongside the bleed

“For patients who have haemorrhagic shock and a traumatic brain injury: if haemorrhagic shock is the dominant condition, continue restrictive volume resuscitation or if traumatic brain injury is the dominant condition, use a less restrictive volume resuscitation approach to maintain cerebral perfusion.” (1.5.21)

Activating the major haemorrhage protocol

• “Use physiological criteria that include the patient's haemodynamic status and their response to immediate volume resuscitation to activate the major haemorrhage protocol.” (1.5.13)
• “Do not rely on a haemorrhagic risk tool applied at a single time point to determine the need for major haemorrhage protocol activation.” (1.5.14)

• “Use intravenous tranexamic acid as soon as possible in patients with major trauma and active or suspected active bleeding.” (1.5.4)
• “Do not use intravenous tranexamic acid more than 3 hours after injury in patients with major trauma unless there is evidence of hyperfibrinolysis.” (1.5.5)

In February 2016 this was an off-label use of tranexamic acid. NG39 gives no dose; the widely used CRASH-2 regimen is 1 g IV over 10 minutes then 1 g over 8 hours — check your local major haemorrhage protocol, and see the drug monographs.

• Active arterial pelvic bleeding, first-line invasive treatment (NG37 1.2.16): interventional radiology if emergency laparotomy is not needed for abdominal injuries; pelvic packing if emergency laparotomy is needed for abdominal injuries.
• NG39 1.5.40: “Use interventional radiology techniques in patients with active arterial pelvic haemorrhage unless immediate open surgery is needed to control bleeding from other injuries.”
• Damage control surgery (NG39 1.5.37): use it “in patients with haemodynamic instability who are not responding to volume resuscitation.” Consider definitive surgery if responding (1.5.38); use definitive surgery if haemodynamic status is normal (1.5.39).
• Transfer (NG37 1.2.11): “Immediately transfer people with haemodynamic instability from pelvic or acetabular fractures to a major trauma centre for definitive treatment of active bleeding.” Those needing specialist reconstruction go to an MTC or specialist centre within 24 hours (1.2.12).

A pelvic binder controls venous and bony bleeding by tamponade; it does not stop arterial bleeding. A patient who stays unstable with a correctly applied binder has arterial bleeding until proven otherwise — that is the IR/packing decision, made with the trauma team, not delayed for more imaging.

“For people with suspected pelvic fractures and pelvic binders, remove the binder as soon as possible if:” (NG37 1.2.17)

• there is no pelvic fracture, or
• a pelvic fracture is identified as mechanically stable, or
• the binder is not controlling the mechanical stability of the fracture, or
• there is no further bleeding or coagulation is normal.

“Remove all pelvic binders within 24 hours of application.” And before removing it: “Before removing the pelvic binder, agree with a pelvic surgeon how a mechanically unstable fracture should be managed.” (1.2.18)

The 24-hour limit matters in the ED because the binder that saved the patient becomes a pressure-injury risk. Skin necrosis under a binder is a recognised complication; the decision to keep it beyond a few hours is a surgical one, not a default.

Anticoagulation (NG39 1.5.6–1.5.12)

• “Rapidly reverse anticoagulation in patients who have major trauma with haemorrhage” (1.5.6), and “do not reverse anticoagulation in patients who do not have active or suspected bleeding” (1.5.12).
• Adults on a vitamin K antagonist with active bleeding: “use prothrombin complex concentrate immediately” (1.5.8); “do not use plasma to reverse a vitamin K antagonist” (1.5.9).
• Any other anticoagulant in an adult, or any anticoagulant in a child: consult a haematologist immediately (1.5.10, 1.5.11).

The dose calculation and the DOAC agents are in the bleeding & reversal module.

Heat (NG39 1.6.1)

“Minimise ongoing heat loss in patients with major trauma.” Hypothermia, acidosis and coagulopathy are the lethal triad; the exposed, wet, transfused pelvic-trauma patient is the one who gets cold.

Pain (NG39 1.7.4–1.7.6)

“Use intravenous morphine as the first‑line analgesic and adjust the dose as needed to achieve adequate pain relief.” If no IV access, consider intranasal atomised diamorphine or ketamine (off-label in 2016); ketamine in analgesic doses is the named second-line agent. No doses in NG39; use the drug monographs and, for children, the paediatric tool.

• It does not grade the fracture. Young–Burgess and Tile are radiological classifications made after the CT; the ED decisions above do not need them. They are in the classifications tool.
• It does not give drug doses. NG37 and NG39 give none for TXA, morphine or reversal; the drug and paediatric tools do.
• It does not decide the whole major haemorrhage protocol. It points to the physiological trigger NICE names; your trust's MHP is the operational document.
• It does not cover open-book versus lateral-compression management, or open pelvic fractures with perineal wounds, as surgical problems. Those are decisions for the pelvic surgeon at the MTC.
• It does not extend beyond blunt trauma. NICE's pelvic binder and CT-first-line recommendations are written for blunt high-energy mechanisms.

• NICE NG37. Fractures (complex): assessment and management. Published 17 February 2016 (recommendation 1.1.10 amended 2017). The Recommendations chapter was parsed for this module; the pelvic recommendations used here are 1.1.7, 1.1.13 and 1.2.10–1.2.19.
• NICE NG39. Major trauma: assessment and initial management. Published 17 February 2016. The full Recommendations chapter was parsed; the haemorrhage, imaging, heat and pain recommendations used here are in sections 1.5–1.7. Recommendations apply to both children (under 16s) and adults (16 or over) unless otherwise specified.

Every quotation on this page is verbatim from the recommendation named beside it. The one non-NICE element — where to place the binder — is labelled as such wherever it appears.