Written by Ketan Patel
Spoon Feed
The approach to severe pelvic fracture hemorrhage starts with resuscitation and pelvic binding, then timely patient- and facility-driven selection of angioembolization (AE), preperitoneal pelvic packing (PPP), external fixation, or open internal iliac control.
Pack, pin, or plug: matching pelvic bleeds to your toolbox
Severe pelvic fracture hemorrhage carries a 32% mortality, and management is markedly variable across centers. This expert review synthesizes contemporary evidence and system realities. Key takeaways include:
- Initiate hemostatic resuscitation and massive transfusion protocols; place pelvic binders immediately.
- A parallel hunt for extra-pelvic bleeding is paramount, as they are common in these patients.
- Choose control by physiology and access: PPP, AE, external fixation or open internal iliac ligation/embolization are all options in massive pelvic hemorrhage. Protocols in utilization of each should depend on local systems factors and patient dynamics including stability.
- Early AE has shown mortality benefit, but only 20% of pelvic bleeding from fractures is arterial. Proper patient selection for AE (i.e. clear arterial extravasation) is paramount, and distal embolization should be prioritized when possible.
- PPP has been shown to be more rapidly deployed than AE and affords the opportunity to manage extra-peritoneal bleeds as well. In combination with external fixation, rapid hemorrhage control can be achieved with subsequent positive patient outcomes.
- In edge cases, massive multi-site bleeds should proceed to PPP first. When local capabilities are limited, damage-control options (i.e. REBOA) may be needed first.
Recommendations are derived from heterogeneous observational data and expert consensus. Scarce RCTs, variable care environments, and center-dependent practices limit generalizability.
How will this change my practice?
This is a great foundational article exploring the dynamics of fracture-related pelvic bleeding and management. I intend to use this information to ensure a local protocol with agreed-upon “unstable” thresholds and a clear pathway for subsequent interventions.
Source
Pelvic fracture bleeding control: What you need to know. J Trauma Acute Care Surg. 2025 Sep 1;99(3):319-327. doi: 10.1097/TA.0000000000004609. Epub 2025 Apr 2. PMID: 40170225.
