The Role of Pelvic Packing for Hemodynamically Unstable Pelvic Ring Injuries

Comparison of Conventional versus Modified Preperitoneal Pelvic Packing in Patients with Bleeding Pelvic Fractures: A Single-Center Retrospective Pilot Study

Background: Bleeding pelvic fractures have high mortality rates, primarily due to severe hemorrhage. Treatment options include mechanical stabilization based on preperitoneal pelvic packing (PPP), resuscitative endovascular balloon occlusion of the aorta, and angioembolization (AE). The bilateral preperitoneal approach, which uses three pads on each side, is the conventional PPP method. We aimed to compare the bilateral preperitoneal approach with a modified approach, involving selectively packing only heavily bleeding areas, in terms of clinical outcomes and mortality risks. Methods: We included patients who underwent PPP and compared the outcomes between conventional (three sponges placed on each side) and modified PPP (selective packing of critical areas). The primary outcome was 30-day mortality; the secondary outcomes included 24 h mortality, pelvic complications, and transfusion requirements. Univariate and multivariate analyses were performed to determine risk factors for 30-day and 24 h mortality. Results: Among the 47 included patients, 19 and 28 underwent conventional and modified PPP, respectively. There were no significant between-group differences in the 24 h (26.3% vs. 42.9%, p = 0.247) and 30-day mortality rates (47.4% vs. 60.7%, p = 0.366). Using univariate and multivariate analyses, initial lactate levels and the decision to perform AE were found to be significant risk factors for mortality. However, the selected PPP method was not a risk factor for 30-day mortality (odds ratio [OR], 2.22; 95% confidence interval [CI], 0.27-18.26; p = 0.457) or 24 hr mortality (OR, 1.77; 95% CI, 0.24-13.19; p = 0.557). Conclusions: The modified PPP method may be considered in patients with bleeding pelvic fractures for effective bleeding control while minimizing potential complications associated with the conventional PPP.

Secondary Angio-Embolization After Emergent Pelvic Stabilization and Pelvic Packing Is a Safe Option for Patients With Persistent Hemorrhage From Unstable Pelvic Ring Injuries

Introduction: In patients with severe pelvic ring injuries, exsanguination still is the leading cause of death in the early post-injury phase. While mechanical pelvic ring stabilization and pre-peritoneal pelvic packing are mainly addressing venous bleeding, angio-embolization aims to control arterial bleeding. The goal of the present study was to evaluate the rate of postoperative angio-embolization after mechanical pelvic ring injury stabilization and pre-peritoneal pelvic packing. Bleeding sources detected in the angiography and the patient's outcome were investigated.

Patients and Methods: Retrospective observational cohort study at a single academic level I trauma center, reviewing all patients with pelvic ring injuries admitted from 01/2010 to 12/2019. Patients with emergent mechanical pelvic ring stabilization (supraacetabular external fixator and/or pelvic C-clamp) and direct pre-peritoneal pelvic packing were further analyzed. Patients that underwent postoperative angio-embolization were compared with those that did not. All postoperative angio-embolizations were evaluated with regards to bleeding sources and type of embolization.

Results: During the study period, a total of 39 patients required immediate mechanical pelvic stabilization and direct pre-peritoneal pelvic packing. Of these, 12 patients (30.8%) underwent a postoperative angio-embolization. The following vessels were identified as bleeding sources: superior gluteal artery (n = 6), obturator artery (n = 2), internal pudendal artery (n = 2), unnamed branches of the internal iliac artery (n = 3). A selective embolization was successful in 11 patients; in 1 patient, an unilateral complete occlusion of the internal iliac artery was performed to control the bleeding. Mean time from hospital admission to the surgical procedure was 52.8 ± 14.7 min and the mean time from admission to angio-embolization was 189.1 ± 55.5 min. The in-hospital mortality rate of patients with angio-embolization was 25.0% (n = 3). Of these, 2 patients died due to multiple organ failure and 1 patient due to severe head injury.

Conclusion: Secondary angio-embolization after external pelvic fixation and pre-peritoneal pelvic packing was effective in controlling ongoing bleeding. The most frequently detected bleeding vessel was the superior gluteal artery, which is difficult to surgically address, further highlighting the importance of angio-embolization in the management algorithm.

Acute Management of the Traumatically Injured Pelvis

Severe pelvic trauma is a challenging condition. The pelvis can create multifocal hemorrhage that is not easily compressible nor managed by traditional surgical methods such as tying off a blood vessel or removing an organ. Its treatment often requires reapproximation of bony structures, damage control resuscitation, assessment for associated injuries, and triage of investigations, as well as multimodality hemorrhage control (external fixation, preperitoneal packing, angioembolization, REBOA [resuscitative endovascular balloon occlusion of the aorta]) by multidisciplinary trauma specialists (general surgeons, orthopedic surgeons, endovascular surgeons/interventional radiologists). This article explores this complex clinical problem and provides a practical approach to its management.