Pelvic Fracture Hemorrhage Management (EAST/WSES)

Algorithm Steps

1. ▶

   Start

   Suspected Pelvic Fracture

   High-energy trauma with pelvic pain/instability

   1. ●

      Action

      ATLS Primary Survey + Pelvic Binder

      Immediate stabilization

      • ABCDE assessment
      • Apply pelvic binder at level of greater trochanters
      • Do NOT spring pelvis (one exam only)
      • Massive transfusion protocol if indicated
      • Control other hemorrhage sources
      1. ◆

         Decision

         Hemodynamic Status?

         SBP <90 or HR >120 or not responding to resuscitation

         1. ●

            Action

            Hemodynamically Stable

            Proceed to CT imaging

            • CT pelvis with IV contrast
            • Assess fracture pattern (Young-Burgess/Tile)
            • Identify contrast blush (arterial bleeding)
            • Assess for associated injuries
            • Keep binder in place
            1. ●

               Action

               Classify Fracture Pattern

               Young-Burgess / Tile Classification

               • LC (Lateral Compression): Most common, lower mortality
               • APC (Anterior-Posterior Compression): Open book, high mortality
               • VS (Vertical Shear): Highest mortality
               • Combined mechanisms
               • Pattern predicts bleeding severity
               1. ●

                  Action

                  Definitive Fixation

                  Staged approach when stable

                  • ORIF when hemodynamically stable
                  • Timing: 5-14 days post-injury typically
                  • Anterior plating for symphysis/rami
                  • Posterior fixation (SI screws, plate)
                  • May convert ex-fix to internal
                  1. ✓

                     Outcome

                     Hemorrhage Controlled

                     Proceed to definitive care

                  2. ⚠

                     Warning

                     High Mortality Risk

                     Pelvic fracture mortality 10-50% if unstable

            2. ⚠

               Warning

               ⚠️ High-Risk Factors for Angiography

               EAST recommendations

               • Age >60 with major pelvic fracture
               • Arterial contrast extravasation on CT
               • Hemodynamic instability with negative FAST
               • Open book, butterfly, or vertical shear pattern
               • Consider angio even if transiently stable
               1. ●

                  Action

                  Angioembolization

                  For arterial bleeding

                  • If arterial blush on CT or ongoing hemorrhage
                  • EAST: Consider in age >60 with major fracture regardless of HD status
                  • Selective embolization preferred
                  • May need after PPP if still bleeding
                  • Requires IR availability
         2. ●

            Action

            Hemodynamically Unstable

            Do NOT go to CT - direct intervention

            • Keep in resuscitation bay or go to OR
            • Massive transfusion protocol
            • Confirm pelvic binder properly placed
            • FAST/E-FAST to rule out other sources
            1. ◆

               Decision

               FAST Positive?

               Intraperitoneal hemorrhage present?

               1. ●

                  Action

                  FAST Positive - Laparotomy

                  Intraperitoneal hemorrhage takes priority

                  • Emergent exploratory laparotomy
                  • Address abdominal bleeding
                  • Consider preperitoneal pelvic packing at same time
                  • External fixation if available
                  1. ●

                     Action

                     Preperitoneal Pelvic Packing (PPP)

                     Rapid surgical hemorrhage control

                     • Suprapubic incision, extraperitoneal approach
                     • Pack bilateral preperitoneal space with laparotomy pads
                     • Addresses venous/bony bleeding
                     • Combine with pelvic stabilization (C-clamp or ex-fix)
                     • Particularly if no angio available
                     • Return to OR in 24-48h for pack removal
                     1. ●

                        Action

                        External Fixation / C-Clamp

                        Mechanical stabilization

                        • Reduces pelvic volume
                        • C-clamp for posterior ring injuries
                        • Anterior external fixator for APC injuries
                        • Combine with PPP for best effect
               2. ●

                  Action

                  FAST Negative - Pelvic Source

                  Bleeding likely retroperitoneal/pelvic

                  • Pelvic hemorrhage is primary source
                  • Proceed to hemorrhage control
                  • Options: PPP, angioembolization, REBOA
                  1. ●

                     Action

                     REBOA (Zone III)

                     Bridge to definitive treatment

                     • Resuscitative Endovascular Balloon Occlusion of Aorta
                     • Infrarenal (Zone III) for pelvic hemorrhage
                     • Provides temporary hemorrhage control
                     • Bridge to OR or angio suite
                     • Limited occlusion time (<60 min)