Management of Major Pelvic Trauma

2017-07-19T21:58:25+00:00

pelvic trauma fracturePelvic 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
  • 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
  • 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

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

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.
    • 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

  1. 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)
  2. Angioembolization is primarily effective for arterial bleeding control in the pelvis.
  3. 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
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Heather Mahoney, MD MA

Heather Mahoney, MD MA

Associate Clinical Professor
Department of Emergency Medicine
University of California, San Francisco
Zuckerberg San Francisco General Hospital
Heather Mahoney, MD MA

Latest posts by Heather Mahoney, MD MA (see all)

  • Zanther

    Isn’t pelvic binding only appropriate for certain fracture patterns?
    I don’t even remember what the latest is on this, but last time I visited the topic, i was warned about the lack of data on it and possible harmful effects if we don’t take fracture type into account…?

    • Heather Mahoney

      Sorry for delay in response
      No there is no danger if applied correctly (not too high). There was past discussion in literature about potentially causing worsening bleeding with certain fracture patterns (vertical) but not proven and not clinically relevant to consider during initial stabilization- you would never know in an unstable patient until the xray. The benefit is clearly there to place one in unstable patients.

    • Heather Mahoney

      Sorry for delay in response
      No there is no danger if applied correctly (not too high). There was past discussion in literature about potentially causing worsening bleeding with certain fracture patterns (vertical) but not proven and not clinically relevant to consider during initial stabilization- you would never know in an unstable patient until the xray. The benefit is clearly there to place one in unstable patients.