Controlling hemorrhage in exsanguinating pelvic fractures: Utility of extraperitoneal pelvic packing as a damage control procedure

Introduction: Exsanguinating pelvic fractures are still associated with a significant mortality rate of 28-60%. Extraperitoneal pelvic packing (EPP) has been proposed as an optimal method of early haemorrhage control. The aim of this study was to determine the effect of EPP compared with angioembolization as a primary intervention for patients with exsanguinating pelvic fracture.Method: A prospective observational trial was performed at Westmead Hospital between September 2011 and May 2014. Adult patients with exsanguinating pelvic fracture were allocated into one of two treatment groups determined by the primary/initial haemorrhage control technique: 1. EPP followed by angioembolization or 2. Angioembolization alone. The intervention was determined by the on-call surgeon's proficiency with EPP. Demographic, clinical and laboratory data were collected. Univariate analysis of the two groups was performed with Student's t-test, Mann-Whitney-U test and Fisher's exact test.Results: 24 exsanguinating pelvic fracture cases were included. 14 underwent EPP while 10 underwent angioembolization as the primary intervention. Although not statistically significant, the EPP group was more severely injured (Injury Severity Score 32 vs. 23), more acidotic (base deficit 7.9 vs. 6.2), and more hypotensive (Systolic Blood Pressure 74.2 vs. 84.3). Despite these differences, mortality was reduced (7.1% vs. 30%, not significant). Time to EPP compared with angioembolization was reduced (67.6 vs. 130.2 minutes,P= 0.017). Pre-angioembolization transfusion requirement was also reduced with EPP (0.032 vs. 0.052 units/min,P= 0.04). Arterial injury was found in 51% of the EPP group. There were no significant differences in complication rates between the groups.Conclusion: EPP appears to be a safe and efficient technique for primary haemorrhage control in exsanguinating pelvic fractures. Given the high rate of associated arterial injury, EPP should be considered as the first part of a “damage control” approach for exsanguinating pelvic fractures.