In what percentage of pelvic trauma cases is pelvic packing required?

Pelvic Packing in Pelvic Trauma

Pelvic packing is required in approximately 10-20% of all pelvic trauma cases, primarily in hemodynamically unstable patients with pelvic ring disruptions where the main source of bleeding is venous (80-90% of cases) rather than arterial (10-20% of cases). 1

Indications for Pelvic Packing

Pelvic packing should be considered in the following scenarios:

• Patients with pelvic fracture-related hemodynamic instability, especially in hospitals with no angiography service 1
• Hypotensive patients with bleeding pelvic ring disruptions 1
• Patients with persistent bleeding after angiography 1
• Patients with hemodynamic instability despite adequate pelvic stabilization 1
• Patients with open pelvic fractures 2

Rationale for Pelvic Packing

The decision to perform pelvic packing is based on several key factors:

• Venous bleeding is the predominant source (80-90%) in pelvic trauma, which is inadequately managed by angio-embolization alone 1
• Traditional management with angio-embolization alone results in poor outcomes with mortality rates exceeding 40% 1
• Pre-peritoneal pelvic packing (PPP) is a quick procedure that can be completed in less than 20 minutes in experienced hands 1
• PPP can be performed in both emergency departments and operating rooms 1

Timing of Pelvic Packing

Time is critical in managing pelvic trauma with active bleeding:

• Bleeding control procedures should be performed as soon as possible 1
• The time between hospital admission and bleeding control procedures should not exceed 60 minutes 1
• Mortality increases from 16% to 64% if embolization requires more than 60 minutes 1
• Mortality increases by approximately 1% for every additional 3 minutes required for embolization 1

Technique of Pelvic Packing

The modern approach to pelvic packing involves:

• Direct preperitoneal pelvic packing (PPP) via a separate suprapubic midline incision 1
• This approach allows direct access to the retroperitoneal space of Retzius 1
• Typically three laparotomy pads are placed on each side of the bladder in the retroperitoneal space, packed below the pelvic brim toward the iliac vessels 1
• A separate midline laparotomy can be performed if indicated for associated intra-abdominal injuries 1
• PPP revision should be done within 48-72 hours 1

Effectiveness and Outcomes

Evidence supports the efficacy of pelvic packing:

• Implementation of standardized protocols including early PPP has led to decreased transfusion requirements and reduced mortality 1
• PPP controls pelvic hemorrhage effectively even in patients with open pelvic fractures (100% effectiveness in one study) 2
• PPP can reduce the need for angiography in many cases 3
• Blood transfusion requirements are significantly reduced after PPP 3

Important Considerations and Pitfalls

Several important caveats should be noted:

• Pelvic packing should be performed in conjunction with pelvic stabilization to maximize bleeding control effectiveness 1
• Approximately 34.3% of severe pelvic fracture patients have associated intra-abdominal injuries that may be missed if preperitoneal packing is performed without abdominal exploration 4
• The incidence of common or external iliac vascular lacerations in severe pelvic fractures is about 10.7%, which may require additional interventions 4
• Angiography may still be required after pelvic packing in cases with arterial bleeding sources 5
• Patient age ≥65 years is an independent predictor of iliac vascular injuries 4

Algorithm for Management

1. Immediate pelvic stabilization with external compression devices (pelvic binder) 6
2. Assess hemodynamic status and perform CT with contrast if stable
3. For hemodynamically unstable patients:
   • Proceed directly to pre-peritoneal pelvic packing if angiography is not immediately available
   • Complete procedure within 60 minutes of admission
   • Consider angiography after packing if arterial bleeding is suspected or if patient remains unstable
4. Perform packing revision within 48-72 hours

In conclusion, pelvic packing represents a critical intervention in approximately 10-20% of pelvic trauma cases, particularly those with hemodynamic instability, and should be performed promptly as part of a comprehensive management strategy.