Written by Rebecca DiFabio
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Where readily available, pelvic angiography +/- embolization (PAE) is an appropriate first-line hemorrhage control intervention (HCI) for the majority of traumatic pelvic ring fractures (PRFs) in shock. Preperitoneal pelvic packing (PPP) can be performed faster and is reserved for more critically injured patients necessitating prompt hemorrhage control.
PAE more frequently, PPP first and faster
We recently covered a review article on managing pelvic fracture bleeding. This takes a deeper look at the interventions. Mortality rates related to hemorrhagic shock in blunt traumatic PRFs remain staggeringly high. Research on the optimal timing of HCIs is barren and requires further investigation.
This prospective, multicenter, observational study across Level I trauma centers explored optimal timing and combination of HCIs to reduce mortality in blunt trauma patients with PRFs in hemorrhagic shock. 524 participants underwent PAE (n=390), PPP (n=68), or both (PPP+PAE, n=66).
PPP and PPP+PAE groups more often underwent laparotomy (67.6%, 65.2% vs. 23.6%,p<0.001) and thoracotomy (20.6%, 7.6% vs. 2.6%,p< 0.001) than PAE alone, since they were comprised of patients who were typically more seriously injured. PPP was associated with 64-fold higher odds of death at 3 hours (95%CI 8.8-465.1), 15-fold at 6 hours (4.4-51.7), and 10-fold at 24 hours (3.7-24.9). Median time to intervention for PAE was longer than PPP (206 min vs. 76.5 min, p<0.001). If undergoing both interventions, PPP was more often performed first, with PAE following if inadequate hemorrhage control.
Besides the limitations inherent in prospective studies, all the study centers also had access to endovascular services within 1 hour. In departments without such rapid access, PPP may need to be performed, even if PAE would have been preferred.
How does this change my practice?
This study was a reminder of the importance of close collaboration with a trauma surgeon and interventional radiology in critically injured PRFs.
Source
To pack or plug: American Association for the Surgery of Trauma multicenter evaluation of hemorrhage control interventions in pelvic fracture management. J Trauma Acute Care Surg. 2026 Jan 12. doi: 10.1097/TA.0000000000004856. Epub ahead of print. PMID: 41533046.
View JournalFeed Critical Appraisal
Critical Appraisal
Study Identification
Background
Study Question
Study Design & Conduct
Prospective / Retrospective: Prospective
Multicenter: Yes
Unit of Allocation: Not applicable
Unit of Analysis: Patients
Randomization Method: Not applicable
Allocation Concealment: Not applicable
Blinding: Not applicable
Follow-up Duration: Not reported
Population
- Radiographic documentation of a pelvic ring fracture from blunt trauma
- Systolic blood pressure ≤90 mm Hg within the first hour of arrival
- Use of a pelvic hemorrhage control intervention or transfusion of ≥4 units of packed red blood cells or 2 units of whole blood within 24 hours
- Arrival in cardiac arrest
- Death in the emergency department
- Isolated pubic rami or acetabular fractures
Number Enrolled: 948
Number Analyzed: 948
Key Baseline Characteristics
Sex: 69.3% male
Disease Severity: Injury Severity Score 34 (24–45)
Care Setting Distribution: Level I trauma centers
Additional Baseline Characteristics
- Admission systolic blood pressure: 98 (80–123) mm Hg
- Admission heart rate: 106 (86–127) bpm
- Admission Glasgow Coma Score: 14 (6–15)
- Admission lactate: 4.8 (3.2–7.5) mmol/L
Exposures / Interventions
Description: Preperitoneal pelvic packing (PPP)
Definition / Dose: Not applicable
Timing: Within 24 hours of admission
Classification Method: Clinical judgment
Protocolized / Discretionary: Discretionary
Description: Pelvic angiography with or without embolization (PAE)
Definition: Not applicable
Outcomes & Results
Primary Outcomes
Definition: Mortality within 3 hours of admission
Time Point: 3 hours
Measurement Method: Clinical assessment
Results: PPP: 27.9%, PAE: 0.5%
Definition: Mortality within 6 hours of admission
Time Point: 6 hours
Measurement Method: Clinical assessment
Results: PPP: 30.9%, PAE: 1.8%
Secondary Outcomes
Definition: Mortality within 24 hours of admission
Time Point: 24 hours
Measurement Method: Clinical assessment
Results: PPP: 38.2%, PAE: 4.1%
Definition: Mortality during hospital stay
Time Point: In-hospital
Measurement Method: Clinical assessment
Results: PPP: 47.1%, PAE: 18.5%
Risk of Bias
Risk of Bias - ROBINS-I
- Confounding (Some concerns): Potential for unmeasured confounding despite multivariable adjustment.
- Selection of participants (Low): Clear inclusion and exclusion criteria with a large multicenter cohort.
- Classification of interventions (Low): Interventions were clearly defined and consistently applied.
- Deviations from intended interventions (Low): Interventions were protocolized and deviations were unlikely.
- Missing data (Low): Minimal missing data with appropriate imputation methods.
- Measurement of outcomes (Low): Outcomes were clearly defined and measured consistently.
- Selection of the reported result (Low): All relevant outcomes were reported.
Transparency
COI Statement Present: TRUE
