Preperitoneal pelvic packing/external fixation with secondary angioembolization: optimal care for life-threatening hemorrhage from unstable pelvic fractures

J Am Coll Surg. 2011 Apr;212(4):628-35; discussion 635-7. doi: 10.1016/j.jamcollsurg.2010.12.020.


Background: Preperitoneal pelvic packing/external fixation (PPP/EF) for controlling life-threatening hemorrhage from pelvic fractures is used widely in Europe but has not been adopted in North America. We hypothesized that PPP/EF arrests hemorrhage rapidly, facilitates emergent operative procedures, and ensures efficient use of angioembolization (AE).

Study design: In 2004 we initiated a PPP/EF guideline for pelvic fracture patients with refractory shock requiring ongoing blood transfusion at our regional trauma center.

Results: Among 1,245 patients admitted with pelvic fractures, 75 consecutive patients underwent PPP/EF (age 42 ± 2 years and injury severity score 52 ± 1.5). Emergency department systolic blood pressure was 76 ± 2 mmHg and heart rate 119 ± 2 beats/min. Time to operation was 66 ± 7 minutes, and 65 patients (87%) underwent 3 ± 0.3 additional procedures. Blood transfusion before PPP/EF compared with the first postoperative 24 hours was 10 ± 0.8 units versus 4 ± 0.5 units (p < 0.05). The fresh frozen plasma-red blood cell ratio was 1:2. After PPP/EF, 10 patients (13%) underwent angioembolization with a documented blush; time to angioembolization was 10.6 ± 2.4 hours (range 1 to 38 hours). Mortality for all pelvic fractures was 8%, with 21% mortality in this high-risk group. There were no deaths due to acute hemorrhage.

Conclusions: PPP/EF was effective in controlling hemorrhage from unstable pelvic fractures. None of these high-risk patients died due to pelvic bleeding. Secondary angioembolization was needed in a minority, permitting selective use of this resource-demanding intervention. Additionally, PPP/EF temporizes arterial hemorrhage, providing valuable transfer time for facilities without angiography. With other urgent operative interventions required in >85% of patients, combining these procedures with PPP/EF for operative pelvic hemorrhage control appears to optimize patient care.

MeSH terms

  • Adult
  • Clinical Protocols
  • Cohort Studies
  • Embolization, Therapeutic*
  • Female
  • Fracture Fixation*
  • Fractures, Bone / complications*
  • Fractures, Bone / surgery*
  • Hemorrhage / diagnosis
  • Hemorrhage / etiology
  • Hemorrhage / therapy*
  • Humans
  • Male
  • Pelvic Bones / injuries*
  • Retrospective Studies