What are the indications for pelvic packing in trauma?

Indications for Pelvic Packing in Trauma

Preperitoneal pelvic packing (PPP) should be performed in hemodynamically unstable pelvic fracture patients when the patient cannot be transferred to CT/angiography or when angioembolization cannot be performed within 60 minutes of diagnosis. 1

Primary Indications

Hemodynamic Instability with Limited Access to Angiography

PPP is indicated when:

• The patient is too unstable to transfer to CT scan or angiography suite 1
• Angioembolization cannot be performed within 60 minutes once diagnosis is made 1
• The patient is exsanguinating and requires immediate hemorrhage control 1, 2

This represents a critical time-based decision point. The 60-minute threshold reflects the reality that severely unstable patients cannot wait for interventional radiology mobilization, particularly in centers where IR staff is not in-house 24/7. 3, 2

Mechanically Unstable Pelvic Ring Injuries

PPP must be performed in conjunction with external fixation for hemodynamically unstable patients with mechanically unstable pelvic fractures (APC-II/III, LC-II/III, vertical shear patterns). 1 The external fixation provides essential counterpressure for effective packing—without this rigid stabilization, packing is ineffective. 1

Technical Requirements

Mandatory Combination with External Fixation

• External fixation is a required adjunct to PPP to provide stable counterpressure 1
• Packing without adequate posterior pelvic element stabilization fails to control hemorrhage 1
• For APC-II/III and LC-II/III injuries: use anterior resuscitation frames (iliac crest or supra-acetabular pins) 1
• For vertical shear injuries with sacroiliac disruption: posterior C-clamp may be indicated 1

Contraindications to C-Clamp

Do not use C-clamp in:

• Comminuted sacral fractures 1
• Transforaminal sacral fractures 1
• Iliac wing fractures 1
• Lateral compression (LC-type) disruptions 1

Relationship to Angioembolization

PPP as Bridge, Not Substitute

Critical concept: PPP is a complementary procedure to achieve temporary hemostasis, not a replacement for angioembolization. 1 The evidence shows:

• 13-20% of patients require subsequent angioembolization after PPP 1
• One study found 80% had arterial injury on angiography post-PPP 1, 4
• PPP primarily controls venous hemorrhage (85% of pelvic bleeding), while arterial bleeding often persists 2

When to Proceed to Angiography After PPP

Angioembolization is indicated after PPP when:

• Ongoing hemorrhage despite packing 1
• Continued transfusion requirements 1
• Hemodynamic instability persists after stabilization measures 1

The French Society of Anaesthesia guidelines emphasize that extensive injury assessment must follow PPP, with readiness to proceed to angiography once the patient is sufficiently stabilized. 1, 4

Clinical Context and Outcomes

Patient Population

Typical candidates have:

• Mean systolic BP ~77 mmHg in emergency department 2
• Mean base deficit ~13 mmol/L 2
• Injury Severity Score ≥33 to 55 3, 2

Time Advantages

PPP offers significant time savings:

• Time to intervention: 77 minutes (vs 102 minutes for angiography) 3
• Procedure time: 60 minutes (vs 84 minutes for angiography) 3
• This speed advantage is life-saving in exsanguinating patients 3, 2

Survival Data

• Survival rates of 72-75% reported in severely unstable patients 4, 2
• Mortality primarily from multiple organ failure, not exsanguination when PPP used 2
• Significant reduction in blood transfusion requirements after PPP (12 units pre-SICU vs 6 units in 24h post-op) 2

Common Pitfalls

Failure to Combine with External Fixation

The most critical error is performing PPP without external fixation—this renders the packing ineffective as there is no counterpressure against the packed sponges. 1

Assuming PPP Eliminates Need for Angiography

Do not assume hemorrhage control is complete after PPP. Maintain high suspicion for arterial injury requiring subsequent angioembolization, particularly if transfusion requirements continue or hemodynamics remain unstable. 1, 4

Delayed Decision-Making

The 60-minute window is firm—do not delay PPP waiting for angiography availability in unstable patients. 1 The procedure requires surgical training and multidisciplinary discussion beforehand, not during the resuscitation. 1