Suspected pelvic fracture with bleeding (adult)
High-energy trauma, or a fall in an older adult, with pelvic pain, deformity or shock. Child: use a pediatric trauma protocol.
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Orthopedic SurgeryEmergency
Pelvic Fracture Hemorrhage Management (EAST/WSES)
Pelvic Fracture Hemorrhage Management (EAST/WSES): Suspected pelvic fracture with bleeding (adult) → Check first: child, pregnancy, anticoagulant → Prim...
Pathway Overview
23 steps
Algorithm Steps
23 total
01Start 02Warning Check first: child, pregnancy, anticoagulant
These change the steps below. Never delay the binder, blood or bleeding control.
- Child (<16 y): pediatric trauma team and pediatric doses; the adult doses here do not apply
- Pregnant: binder can be used (legs internally rotated); >20 weeks: manual left uterine displacement; urgent obstetric team; Rh D negative: Kleihauer and anti-D
- Anticoagulant, antiplatelet or age >60: major bleeding can follow a low-energy fall; reverse anticoagulant early
03Action Primary survey: pelvic binder, blood and TXA
Resuscitation bay. Activate the massive transfusion (major hemorrhage) protocol if in shock. No trauma surgery or IR on site: call the retrieval service now. TBI or spinal cord injury: no permissive hypotension.
- Pelvic binder centred on the greater trochanters (not the iliac crests)
- Adult: tranexamic acid 1 g IV over 10 min, then 1 g IV over 8 h; start within 3 h of injury; do not start after 3 h
- Blood products early via the protocol; limit crystalloid; keep the patient warm; keep ionised calcium 1.1-1.3 mmol/L
- Target SBP 80-90 mmHg until bleeding is controlled; not if TBI or spinal cord injury (severe TBI, GCS <=8: MAP >=80 mmHg)
- Do not spring the pelvis; no repeated pelvic examination
- Pelvic X-ray and E-FAST in the resuscitation bay; control other bleeding
04Action If anticoagulated: reverse now
Adult doses. Start with resuscitation; do not delay the binder, blood or bleeding control.
- Warfarin (INR >=1.5): 4F-PCC (Beriplex) 50 IU/kg IV (weight up to 100 kg, max 5000 IU) plus vitamin K 5-10 mg IV
- Dabigatran: idarucizumab 5 g IV (2 x 2.5 g/50 mL)
- Apixaban, rivaroxaban or edoxaban: 4F-PCC 25-50 IU/kg IV (weight up to 100 kg, max 5000 IU); andexanet alfa is not TGA-registered
- Heparin or enoxaparin: protamine per local protocol
- Send coagulation screen and fibrinogen; use viscoelastic testing if available
05Action Check urethra, perineum, rectum and vagina
Primary or secondary survey. Do not delay bleeding control.
- Blood at the meatus or perineal hematoma: no blind urethral catheter; urology review and retrograde urethrogram
- Perineal and rectal examination; vaginal examination in females; proctoscopy if rectal examination is positive
- Open fracture (wound, rectal or vaginal blood): IV antibiotics as soon as possible per local open-fracture protocol; tetanus prophylaxis; surgical review for fecal diversion
06Decision Hemodynamically unstable?
Yes: SBP <90 mmHg; or SBP >90 mmHg only with ongoing blood, fluid boluses or vasopressors; or base deficit >6 mmol/L or shock index >1. Beta-blockers and older age can hide shock.
- If Yes
07Action Unstable: no CT; resuscitation bay or theatre
Aim for the shortest time to bleeding control. Call trauma surgery, orthopedics and interventional radiology now. No trauma surgery or IR on site: call the retrieval service now; do not wait for CT.
- Continue the massive transfusion protocol
- Check binder position on the pelvic X-ray
- Look for other sources: chest (X-ray, E-FAST), abdomen, long bones, external
08Action In extremis only: REBOA or resuscitative thoracotomy
Not routine. UK-REBOA RCT (JAMA 2023): ED REBOA did not reduce and may increase death (90-day mortality 54% vs 42%).
- Only with a trained team, a local protocol and audit; a bridge to packing, embolization or surgery
- Zone III (infrarenal) is for pelvic bleeding only; it does not control abdominal bleeding
- Keep occlusion time as short as possible; consider partial or intermittent occlusion
- Traumatic cardiac arrest: follow the traumatic arrest protocol
09Decision E-FAST positive for abdominal free fluid?
A negative FAST does not rule out abdominal bleeding in a shocked patient.
- If Yes
10Action Unstable, FAST positive: damage-control laparotomy
Abdominal bleeding comes first.
- Laparotomy to control abdominal bleeding
- Pelvic bleeding: preperitoneal packing at the same operation (next step)
- Keep the binder on, or apply an external fixator
11Action Pelvic bleeding: preperitoneal packing (FAST positive or no immediate IR)
Controls venous and bone bleeding. Always with pelvic stabilization.
- Separate suprapubic midline incision; pack the preperitoneal space on both sides of the bladder (3 laparotomy pads each side)
- Apply an external fixator or C-clamp first or at the same operation (next step)
- A needed laparotomy uses a separate, higher incision
- Plan re-look and pack removal in 24-48 h
12Action Pelvic stabilization: external fixator or C-clamp
Gives counter-pressure for packing and reduces pelvic volume.
- No C-clamp in comminuted or transforaminal sacral fractures, iliac wing fractures or LC injuries
- Anterior frame (iliac crest or supra-acetabular) for APC-II/III and LC-II/III
- C-clamp for vertical shear with sacroiliac disruption
13Decision Still bleeding after packing or embolization?
Yes: ongoing transfusion need or shock after extra-pelvic sources are excluded.
- If Yes
14Action Still bleeding: add the other method
Re-check for bleeding outside the pelvis.
- After embolization: preperitoneal packing with stabilization, or repeat angiography
- After packing: angioembolization
15Action Bleeding controlled: monitored care (ICU if unstable)
Continue damage-control resuscitation until physiology recovers.
- Correct coagulopathy, hypothermia and acidosis
- Remove the binder as soon as physiology allows (within 24-48 h); check the skin
- VTE: intermittent pneumatic compression now; add drug prophylaxis within 24 h of bleeding control
- After packing: re-look and remove packs in 24-48 h
16Action Mechanically unstable ring: definitive fixation when physiology allows
Timing depends on physiology, not a fixed day. WSES I (mechanically stable): no fixation; non-operative care.
- Stable or borderline: definitive fixation within 24 h is safe
- Deranged polytrauma: delay until after day 4
- In extremis or coagulopathic: resuscitate first
- Symphysis plating for diastasis >2.5 cm; fix an unstable posterior ring
17Outcome Rehabilitation and follow-up
After a low-energy fracture in an older adult, assess for osteoporosis.
If No- Path rejoins step 15Shared downstream outcome
If No18Action Unstable, FAST negative: treat as pelvic bleeding
Exclude chest, long-bone and external sources.
- Pelvic stabilization plus preperitoneal packing, or angioembolization
- Choose the one that gives bleeding control fastest at your hospital
19Decision Angiography team ready now?
Yes: angioembolization. No: preperitoneal packing with pelvic stabilization.
- If Yes
20Action Arterial bleeding: angioembolization
For unstable patients with IR ready, a CT contrast blush, or high-risk features.
- Keep the binder on during angiography
- Patients with a CT arterial blush may benefit at any hemodynamic status
- Older adults with a pelvic fracture: consider even if stable
- Path rejoins step 13Shared downstream outcome
If No- Path rejoins step 11Shared downstream outcome
If No21Action Stable: CT with IV contrast
Keep the binder on. Recheck vital signs; if shock returns, follow the unstable steps.
- Multiphase CT with IV contrast (arterial phase)
- Look for arterial contrast blush and pelvic hematoma
- Classify: LC, APC, vertical shear or combined; WSES grade I-III
- Look for associated injuries (bladder, urethra, rectum, abdomen)
22Decision Angioembolization needed?
Yes: arterial blush on CT, ongoing bleeding, or age >60 with a major fracture (open book, butterfly or vertical shear).
- If Yes
- Path rejoins step 20Shared downstream outcome
If No23Action No arterial bleeding: manage by ring stability
Pattern alone does not predict bleeding; physiology guides care.
- WSES I (APC-I, LC-I, mechanically stable): remove the binder; non-operative care
- WSES II-III (mechanically unstable): binder, then external fixation or definitive fixation
- Mechanically unstable, no other injuries and CT negative for bleeding: can go straight to definitive fixation
- Path rejoins step 15Shared downstream outcome
Guideline Source
WSES Pelvic Trauma Guidelines 2017 + EAST PMG Pelvic Fracture Hemorrhage 2011
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Adults only. Children need a pediatric trauma protocol and pediatric doses.
- Packing, angioembolization and REBOA depend on local resources and team skill; REBOA is not routine (UK-REBOA 2023).
- WSES 2017 and EAST 2011 predate UK-REBOA; the EAST update is in process.
- A multidisciplinary trauma team (trauma surgery, orthopedics, interventional radiology) is essential.
Contraindicated Populations
Children under 16 years: use a pediatric trauma protocol
Applicable Regions
USEUAU
AU: NBA critical bleeding guideline 2023: use a major haemorrhage protocol; tranexamic acid within 3 h of injury (trauma use is not a listed indication in the AU Cyklokapron PI). Warfarin reversal uses 4F-PCC (Beriplex) per MJA 2025. Rural and remote sites: early retrieval to a major trauma service; call 000 in the field.
Global: WSES 2017 (Fig. 3) and EAST 2011 remain the pelvic-specific guidance. European major-bleeding guideline 6th ed (2023) R20-R21 supports binder, early ring closure, extraperitoneal packing and REBOA only as a bridge; UK-REBOA (JAMA 2023) found no benefit and possible harm from ED REBOA. EAST 2020 practice management guideline (Bugaev, Am J Surg 2020) conditionally recommends preperitoneal packing as part of multimodal care.
Version 2Next review: 2027-09-30
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Related Resources
Frequently Asked Questions
What is the Pelvic Fracture Hemorrhage Management (EAST/WSES)?
The Pelvic Fracture Hemorrhage Management (EAST/WSES) is a emergency clinical algorithm for Orthopedic Surgery. It provides a structured decision tree to guide clinical decision-making, based on WSES Pelvic Trauma Guidelines 2017 + EAST PMG Pelvic Fracture Hemorrhage 2011.
What guideline is the Pelvic Fracture Hemorrhage Management (EAST/WSES) based on?
This algorithm is based on WSES Pelvic Trauma Guidelines 2017 + EAST PMG Pelvic Fracture Hemorrhage 2011 (DOI: 10.1186/s13017-017-0117-6).
What are the limitations of the Pelvic Fracture Hemorrhage Management (EAST/WSES)?
Known limitations include: Adults only. Children need a pediatric trauma protocol and pediatric doses.; Packing, angioembolization and REBOA depend on local resources and team skill; REBOA is not routine (UK-REBOA 2023).; WSES 2017 and EAST 2011 predate UK-REBOA; the EAST update is in process.; A multidisciplinary trauma team (trauma surgery, orthopedics, interventional radiology) is essential.. Individual patient factors may require deviation from these recommendations.
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