Pelvic Fracture Hemorrhage-Update and Systematic Review (UPDATE IN PROCESS)

Level 1

There are no Level I recommendations.

Level 2

1. Fracture pattern on pelvic X-ray does not single-handedly predict mortality, hemorrhage or the need for angiography.
2. Presence/location of hematoma does not predict or exclude the need for angiography and possible embolization.
3. CT of the pelvis is an excellent screening tool to exclude pelvic hemorrhage.
4. Absence of contrast extravasation on CT does not always exclude active hemorrhage.
5. Pelvic hematoma >500cc in size has an increased incidence of arterial injury and need for angiography.

Level 3

1. Isolated acetabular fractures are as likely to require angiography as pelvic rim fractures.
2. If a retrograde urethrocystogram (RUG) is required, it should be performed after CT with intravenous contrast.

Level 1

1. Focused Assessment with Sonography for Trauma (FAST) is not sensitive enough to exclude intra-peritoneal bleeding in the presence of pelvic fracture. 
2. FAST has adequate specificity in patients with unstable vital signs and pelvis fracture to recommend laparotomy to control hemorrhage. 

Level 2

1. Diagnostic Peritoneal Tap/Lavage is the best test to exclude intra-abdominal bleeding in the hemodynamically unstable patient.

1. In the hemodynamically stable patient with a pelvic fracture, CT of the abdomen and pelvis with intravenous contrast is recommended to evaluate for intra-abdominal bleeding regardless of FAST results. 

Level 3

There are no Level 3 recommendations.

Level 1

There are no Level I recommendations.

Level 2

There are no Level 2 recommendations.

Level 3

1. Temporary pelvic binders effectively reduce unstable pelvic fractures as well as definitive stabilization, and decrease pelvic volume
2. Temporary pelvic binders may limit pelvic hemorrhage but do not appear to affect mortality
3. Temporary pelvic binders work as well or better than emergent external pelvic fixation in controlling hemorrhage

Level 1

1. Patients with pelvic fractures and hemodynamic instability or signs of ongoing bleeding after non-pelvic sources of blood loss have been ruled out should be considered for pelvic angiography/embolization.
2. Patients with evidence of arterial intravenous contrast extravasation (ICE) in the pelvis by computed tomography may require pelvic angiography and embolization regardless of hemodynamic status.

Level 2

1. Patients with pelvic fractures who have undergone pelvic angiography with or without embolization who have signs of ongoing bleeding after non-pelvic sources of blood loss have been ruled out should be considered for repeat pelvic angiography and possible embolization.
2. Patients age > 60 with major pelvic fracture (open book, butterfly segment or vertical shear) should be considered for pelvic angiography without regard for hemodynamic status.

Level 3

1. While fracture pattern or type does not predict arterial injury or need for angiography, anterior fractures are more highly associated with anterior vascular injuries, while posterior fractures are more highly associated with posterior vascular injuries.
2. Pelvic angiography with bilateral embolization appears safe with few major complications. Gluteal muscle ischemia/necrosis has been reported in patients with hemodynamic instability and prolonged immobilization or primary trauma to the gluteal region as the possible cause, rather than a direct complication of angioembolization.
3. Sexual function in males does not appear to be impaired after bilateral internal iliac arterial embolization. 

Level 1

There are no Level 1 recommendations.

Level 2

There are no Level 2 recommendations.

Level 3

1. Retroperitoneal pelvic packing is effective in controlling hemorrhage when used as a salvage technique following angiographic embolization
2. Retroperitoneal pelvic packing is effective in controlling hemorrhage when used as part of a multidisciplinary clinical pathway including a Pelvic Orthotic Device (POD)/C-clamp

Level 1

There are no Level 1 recommendations.

Level 2

There are no Level 2 recommendations.

Level 3

1. Use of a pelvic orthotic device does not appear to limit blood loss in patients with pelvic hemorrhage.
2. Use of a pelvic orthotic device effectively reduces fracture displacement and decreases pelvic volume.