Pelvic trauma frequently is associated with other injuries from the high force required to break the pelvis. Management is focused on stabilizing the pelvis and stopping the bleeding. Due to other injuries requiring emergent surgical stabilization, pelvic trauma is primarily managed surgically with pre-peritoneal packing and external fixation, followed by angioembolization for continued bleeding. Emergency physicians must quickly resuscitate patients while gathering vital information to direct the correct definitive bleeding control strategy. New endovascular techniques such as REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta) may change future emergency department strategies and improve mortality in severe pelvic trauma.
How do I know the pelvis is fractured?
- History
- If awake, complains of pain – more sensitive then physical exam1,2
- Pelvic, low back, groin, or hip pain
- Physical exam
- Gentle palpation
- NO pelvis ROCKING – does not provide any more evidence of unstable pelvic fracture and potentially increases bleeding1,3,4
- Perineal bruising
- Blood at rectum or urethra
- Lower limb asymmetry
- Gentle palpation
- Imaging
- Hemodynamically unstable: Obtain pelvis x-ray (PXR), because not able to obtain CT5,6
- Hemodynamically stable: Obtain CT
- PXR has low sensitivity and high false negative rate in stable patients7,8
When to suspect significant pelvic bleeding that needs intervention?
- Fracture patterns are NOT predictive.8–10
- More likely predictive with at least one finding of:
- Sacroiliac joint disruption
- Pubic symphysis diastasis >2.5 cm
- Displaced obturator ring fracture
- More likely predictive with at least one finding of:
- Findings on CT obtained with IV contrast ARE predictive.5,6
- “Blush” on CT = active contrast extravasation
- Hematoma size ≥500 cm3
- Other predictive findings
- Hemodynamically unstable + pelvic fracture on PXR
- Age >60 years: These patients have an increased risk of need for angioembolization regardless of initial hemodynamic stability11
Key ED resuscitation points for patients with major pelvic trauma
- Check for alternative sources for significant thoracic or abdominal bleeding.
- E-FAST
- Chest x-ray (CXR)
- Pelvis x-ray vs CT scan
- Start early massive transfusion protocol if hemodynamically unstable and not expected to be stabilized after 2 units of packed red blood cells.
- Obtain IV/IO access above the pelvis (e.g. central line access in the subclavian vein or IO access in the humerus)
Pelvic binder positioning
- Place a temporary pelvic binder, which is also called a Pelvic Orthotic Device (POD)5,6
- Important to position this correctly: Over greater trochanters and pubic symphysis
- Only for 24-48 hours
- Safe but less effective in elderly
- Safe in pregnancy
- Reduced transfusion requirements with few complications12–14
- Commercial device better than sheet, but sheet is has some benefit if it is the only thing available.
- Avoid initial foley placement if any the following (high incidence of genitourinary and anorectal injuries):5,6
- Unable to urinate
- Blood at meatus
- Gross hematuria
- Perineal bruising
How to treat significant pelvic bleeding?
- Best current options to stop significant pelvic bleeding are with either or both:
-
Angioembolization (AE)
- A pelvic binder or POD should be adequate stabilization in the first 24 hours.
- Fewer transfusion requirements in first 24 hours when AE directly compared to pelvic external fixation likely due to delay in definitive control of bleeding.12
- Very effective for ARTERIAL bleeding (85-100%) and unlikely to control VENOUS bleeding. 15–20
- CT findings (active IV contrast extravasation, hematoma size ≥500 cm3) are good indicators for AE.15
-
Angioembolization (AE)
Preperitoneal pelvic packing diagram
-
-
Pre-peritoneal pelvic packing (PPP)
- Pelvic External (EF) fixation should be done in conjunction with PPP.5
- PPP + EF can effectively control venous bleeding and may stabilize arterial bleeding until subsequent AE.15
-
Pre-peritoneal pelvic packing (PPP)
How do I decide which first: Surgical (PPP+EF) or endovascular (AE)?
- Most patients (up to 90%) will have significant associated intrathoracic, intrabdominal, and/or extremity injuries that will require surgical treatment. This will direct the primary course of treatment for pelvic bleeding towards a surgical approach — that is PPP + EF.
- For HEMODYNAMICALLY STABLE or stabilized patients, a CT scan should be done first.
- If a therapeutic thoracotomy or laparotomy is needed based on the CT scan, then PPP + EF should be done to control active pelvic bleeding, followed by AE if needed for continued pelvic bleeding.
- If isolated pelvic bleeding, CT findings are used to guide the decision for AE or PPP + EP.
- AE is indicated if CT findings demonstrate active IV contrast extravasation or hematoma size ≥500 cm3.
- For HEMODYNAMICALLY UNSTABLE patients, a FAST exam should be performed early.21–33
- FAST positive: PPP + EF should be performed first, because of the need to address concurrent intraabdominal injuries.
-
FAST negative: Either AE or PPP + EF can be performed first, assuming AE is readily available
- Traditionally, these patients have been directed to AE first, but delays to bleeding control have raised concerns.
- Because PPP + EF can be completed within 30 minutes, some algorithms recommend AE as the first-line approach, if available in <30 minutes.
- 2011 study: PPP + EF is a reasonable first-line approach for pelvic fractures with hemodynamic instability. 31
- Overall mortality rate: 21% (Past reports have reported higher mortality rates ranging 29-35% but with varied treatment strategies so it is difficult to interpret.)
- Secondary AE needed for continued bleeding: 13%
- Pelvic infections after packing: 15%
- 2016 study: PPP or AE are equally effective with similar mortality rates as the first-line approach for hemodynamically unstable patients with a negative FAST.33
- Patient were randomized to either (PPP then AE) or (AE then PPP, with AE being readily available).
- This study did not answer the question about whether hemorrhage control could be obtained using solely PPP or AE.
- Traditionally, these patients have been directed to AE first, but delays to bleeding control have raised concerns.
- General rule of thumb: Continued hemodynamic instability from pelvic bleeding despite a first-line approach (AE or PPP + EF) warrants performing the alternative approach.
What are new techniques being used with severe pelvic trauma?
- Endovascular strategies to control bleeding in pelvic trauma are being developed and currently being utilized in emergency department management.34–44
Resuscitative Endovascular Balloon Occlusion of the Aorta
-
Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA)
- Alternative to resuscitative thoracotomy (cross clamping the aorta as a bridge to definitive surgical management)5
- 2015 study: Patients who were hemodynamically unstable with below-diaphragm trauma showed an overall improved survival rate with ED REBOA.38
- Resuscitative thoracotomy survival rate: 9.7%
- REBOA survival rate: 37.5%
- Requires common femoral artery access
- Concern for ischemia-reperfusion organ injury
- Intermittent or partial REBOA may improve outcomes5
Take Home Points
- In patients with major pelvic trauma, pelvis CT imaging is extremely valuable to help determine need for intervention (CT contrast extravasation or pelvic hematoma size ≥500 cm3)
- Angioembolization is primarily effective for arterial bleeding control in the pelvis.
- There are 2 general approaches to hemorrhage control in major pelvic trauma: angioembolization (interventional radiology) and preperitoneal pelvic packing with external fixation (operating room). Deciding on the first-line approach relies on multifactorial variables including:
-
- Hemodynamic stability of the patient
- Availability of the angiography/interventional radiology suite within 30 minutes
- Capabilities of the angiography suite
- Concurrent injuries which require emergent operative stabilization
1.
Lee C, Porter K. The prehospital management of pelvic fractures. Emerg Med J. 2007;24(2):130-133. [PubMed]
2.
Gonzalez R, Fried P, Bukhalo M. The utility of clinical examination in screening for pelvic fractures in blunt trauma. J Am Coll Surg. 2002;194(2):121-125. [PubMed]
3.
White C, Hsu J, Holcomb J. Haemodynamically unstable pelvic fractures. Injury. 2009;40(10):1023-1030. [PubMed]
4.
Shlamovitz G, Mower W, Bergman J, et al. How (un)useful is the pelvic ring stability examination in diagnosing mechanically unstable pelvic fractures in blunt trauma patients? J Trauma. 2009;66(3):815-820. [PubMed]
5.
Coccolini F, Stahel P, Montori G, et al. Pelvic trauma: WSES classification and guidelines. World J Emerg Surg. 2017;12:5. [PubMed]
6.
Cullinane D, Schiller H, Zielinski M, et al. Eastern Association for the Surgery of Trauma practice management guidelines for hemorrhage in pelvic fracture–update and systematic review. J Trauma. 2011;71(6):1850-1868. [PubMed]
7.
Paydar S, Ghaffarpasand F, Foroughi M, et al. Role of routine pelvic radiography in initial evaluation of stable, high-energy, blunt trauma patients. Emerg Med J. 2012;30(9):724-727. doi: 10.1136/emermed-2012-201445
8.
Guillamondegui O, Pryor J, Gracias V, Gupta R, Reilly P, Schwab C. Pelvic radiography in blunt trauma resuscitation: a diminishing role. J Trauma. 2002;53(6):1043-1047. [PubMed]
9.
Blackmore C, Cummings P, Jurkovich G, Linnau K, Hoffer E, Rivara F. Predicting major hemorrhage in patients with pelvic fracture. J Trauma. 2006;61(2):346-352. [PubMed]
10.
Marzi I, Lustenberger T. Management of Bleeding Pelvic Fractures. Scand J Surg. 2014;103(2):104-111. [PubMed]
11.
Kimbrell B, Velmahos G, Chan L, Demetriades D. Angiographic embolization for pelvic fractures in older patients. Arch Surg. 2004;139(7):728-32; discussion 732-3. [PubMed]
12.
Croce M, Magnotti L, Savage S, Wood G, Fabian T. Emergent pelvic fixation in patients with exsanguinating pelvic fractures. J Am Coll Surg. 2007;204(5):935-9; discussion 940-2. [PubMed]
13.
Ghaemmaghami V, Sperry J, Gunst M, et al. Effects of early use of external pelvic compression on transfusion requirements and mortality in pelvic fractures. Am J Surg. 2007;194(6):720-3; discussion 723. [PubMed]
14.
Fu C, Wu Y, Liao C, et al. Pelvic circumferential compression devices benefit patients with pelvic fractures who need transfers. Am J Emerg Med. 2013;31(10):1432-1436. [PubMed]
15.
Miller P, Moore P, Mansell E, Meredith J, Chang M. External fixation or arteriogram in bleeding pelvic fracture: initial therapy guided by markers of arterial hemorrhage. J Trauma. 2003;54(3):437-443. [PubMed]
16.
Agolini S, Shah K, Jaffe J, Newcomb J, Rhodes M, Reed J. Arterial embolization is a rapid and effective technique for controlling pelvic fracture hemorrhage. J Trauma. 1997;43(3):395-399. [PubMed]
17.
Velmahos G, Toutouzas K, Vassiliu P, et al. A prospective study on the safety and efficacy of angiographic embolization for pelvic and visceral injuries. J Trauma. 2002;53(2):303-8; discussion 308. [PubMed]
18.
Rossaint R, Duranteau J, Stahel P, Spahn D. Nonsurgical treatment of major bleeding. Anesthesiol Clin. 2007;25(1):35-48, viii. [PubMed]
19.
Metsemakers W, Vanderschot P, Jennes E, Nijs S, Heye S, Maleux G. Transcatheter embolotherapy after external surgical stabilization is a valuable treatment algorithm for patients with persistent haemorrhage from unstable pelvic fractures: outcomes of a single centre experience. Injury. 2013;44(7):964-968. [PubMed]
20.
Panetta T, Sclafani S, Goldstein A, Phillips T, Shaftan G. Percutaneous transcatheter embolization for massive bleeding from pelvic fractures. J Trauma. 1985;25(11):1021-1029. [PubMed]
21.
Verbeek D, Zijlstra I, van der, Ponsen K, van D, Goslings J. Predicting the need for abdominal hemorrhage control in major pelvic fracture patients: the importance of quantifying the amount of free fluid. J Trauma Acute Care Surg. 2014;76(5):1259-1263. [PubMed]
22.
Gänsslen A, Hildebrand F, Pohlemann T. Management of hemodynamic unstable patients “in extremis” with pelvic ring fractures. Acta Chir Orthop Traumatol Cech. 2012;79(3):193-202. [PubMed]
23.
Costantini T, Coimbra R, Holcomb J, et al. Current management of hemorrhage from severe pelvic fractures: Results of an American Association for the Surgery of Trauma multi-institutional trial. J Trauma Acute Care Surg. 2016;80(5):717-23; discussion 723-5. [PubMed]
24.
Verbeek D, Sugrue M, Balogh Z, et al. Acute management of hemodynamically unstable pelvic trauma patients: time for a change? Multicenter review of recent practice. World J Surg. 2008;32(8):1874-1882. [PubMed]
25.
Abrassart S, Stern R, Peter R. Unstable pelvic ring injury with hemodynamic instability: what seems the best procedure choice and sequence in the initial management? Orthop Traumatol Surg Res. 2013;99(2):175-182. [PubMed]
26.
Suzuki T, Smith W, Moore E. Pelvic packing or angiography: competitive or complementary? Injury. 2009;40(4):343-353. [PubMed]
27.
Agnew S. Hemodynamically unstable pelvic fractures. Orthop Clin North Am. 1994;25(4):715-721. [PubMed]
28.
Hou Z, Smith W, Strohecker K, et al. Hemodynamically unstable pelvic fracture management by advanced trauma life support guidelines results in high mortality. Orthopedics. 2012;35(3):e319-24. [PubMed]
29.
Perkins Z, Maytham G, Koers L, Bates P, Brohi K, Tai N. Impact on outcome of a targeted performance improvement programme in haemodynamically unstable patients with a pelvic fracture. Bone Joint J. 2014;96-B(8):1090-1097. [PubMed]
30.
Osborn P, Smith W, Moore E, et al. Direct retroperitoneal pelvic packing versus pelvic angiography: A comparison of two management protocols for haemodynamically unstable pelvic fractures. Injury. 2009;40(1):54-60. [PubMed]
31.
Burlew C, Moore E, Smith W, et al. Preperitoneal pelvic packing/external fixation with secondary angioembolization: optimal care for life-threatening hemorrhage from unstable pelvic fractures. J Am Coll Surg. 2011;212(4):628-35; discussion 635-7. [PubMed]
32.
Cothren C, Osborn P, Moore E, Morgan S, Johnson J, Smith W. Preperitonal pelvic packing for hemodynamically unstable pelvic fractures: a paradigm shift. J Trauma. 2007;62(4):834-9; discussion 839-42. [PubMed]
33.
Li Q, Dong J, Yang Y, et al. Retroperitoneal packing or angioembolization for haemorrhage control of pelvic fractures–Quasi-randomized clinical trial of 56 haemodynamically unstable patients with Injury Severity Score ≥33. Injury. 2016;47(2):395-401. [PubMed]
34.
Stannard A, Eliason J, Rasmussen T. Resuscitative endovascular balloon occlusion of the aorta (REBOA) as an adjunct for hemorrhagic shock. J Trauma. 2011;71(6):1869-1872. [PubMed]
35.
Morrison J, Galgon R, Jansen J, Cannon J, Rasmussen T, Eliason J. A systematic review of the use of resuscitative endovascular balloon occlusion of the aorta in the management of hemorrhagic shock. J Trauma Acute Care Surg. 2016;80(2):324-334. [PubMed]
36.
Biffl W, Fox C, Moore E. The role of REBOA in the control of exsanguinating torso hemorrhage. J Trauma Acute Care Surg. 2015;78(5):1054-1058. [PubMed]
37.
Delamare L, Crognier L, Conil J, Rousseau H, Georges B, Ruiz S. Treatment of intra-abdominal haemorrhagic shock by Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA). Anaesth Crit Care Pain Med. 2015;34(1):53-55. [PubMed]
38.
Moore L, Brenner M, Kozar R, et al. Implementation of resuscitative endovascular balloon occlusion of the aorta as an alternative to resuscitative thoracotomy for noncompressible truncal hemorrhage. J Trauma Acute Care Surg. 2015;79(4):523-30; discussion 530-2. [PubMed]
39.
Moore L, Martin C, Harvin J, Wade C, Holcomb J. Resuscitative endovascular balloon occlusion of the aorta for control of noncompressible truncal hemorrhage in the abdomen and pelvis. Am J Surg. 2016;212(6):1222-1230. [PubMed]
40.
Hörer T, Skoog P, Pirouzram A, Nilsson K, Larzon T. A small case series of aortic balloon occlusion in trauma: lessons learned from its use in ruptured abdominal aortic aneurysms and a brief review. Eur J Trauma Emerg Surg. 2016;42(5):585-592. [PubMed]
41.
Ogura T, Lefor A, Nakano M, Izawa Y, Morita H. Nonoperative management of hemodynamically unstable abdominal trauma patients with angioembolization and resuscitative endovascular balloon occlusion of the aorta. J Trauma Acute Care Surg. 2015;78(1):132-135. [PubMed]
42.
DuBose J, Scalea T, Brenner M, et al. The AAST prospective Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) registry: Data on contemporary utilization and outcomes of aortic occlusion and resuscitative balloon occlusion of the aorta (REBOA). J Trauma Acute Care Surg. 2016;81(3):409-419. [PubMed]
43.
Johnson M, Neff L, Williams T, DuBose J, EVAC S. Partial resuscitative balloon occlusion of the aorta (P-REBOA): Clinical technique and rationale. J Trauma Acute Care Surg. 2016;81(5 Suppl 2 Proceedings of the 2015 Military Health System Research Symposium):S133-S137. [PubMed]
44.
Hörer TM, Cajander P, Jans A, Nilsson KF. A case of partial aortic balloon occlusion in an unstable multi-trauma patient. Trauma. 2016;18(2):150-154. doi: 10.1177/1460408615624727
Author information
The post Management of Major Pelvic Trauma appeared first on ALiEM.
