The Journal of TRAUMA Injury, Infection, and Critical Care

Extraperitoneal Pelvic Packing: A Salvage Procedure to

Control Massive Traumatic Pelvic Hemorrhage
Anna Totterman, MD, Jan Erik Madsen, MD, PhD, Nils Oddvar Skaga, MD, and Olav Rise, MD, PhD
Objective: To describe the method of
extraperitoneal pelvic packing (EPP), and
to assess the impact of EPP on outcome in
severely hemodynamically unstable patients after blunt pelvic trauma.
Methods: Of 661 patients treated for
pelvic trauma, 18 underwent EPP as part
of our protocol with the intent to control
massive pelvic bleeding and constituted
the study population. Data retrospectively
collected from the medical records and
from the Ullevl Trauma Registry included
demographics, fracture classification,
additional injuries, blood transfusions,

surgical interventions, angiographic

procedure, physiologic parameters, and
survival.
Results: Survival rate within 30 days
was 72% (13/18), and correlated inversely
to the age of the patient ( p 0.038). Only
one of the nonsurvivors died of exsanguination. A significant increase in systolic
blood pressure (BP) ( p 0.002) was observed immediately after EPP. Angiography performed after EPP was positive
for arterial injury in 80% of patients.
All types of pelvic ring fractures were
represented.

Conclusions: EPP as part of a

multi-interventional resuscitation protocol might be life saving in patients with
life-threatening pelvic injury who are
exsanguinating. However, the high rate
of arterial injuries seen after EPP indicates that the procedure should be supplemented with angiography once the
patient is sufficiently stabilized to tolerate transportation to the angiography
suite.
Key Words: Pelvis, Hemorrhage,
Outcome, Damage control, Transfusion,
Trauma.
J Trauma. 2007;62:843 852.

ortality after severe pelvic injury is a consequence of

continuous hemorrhage within the first 24 hours of
hospitalization,1,2 whereas coexisting cerebral injuries, thromboembolism, and multiple organ failure (MOF)
explain most of the mortality after this period.3,4 Vascular
injuries in association with pelvic trauma may be difficult to
address because of the abundant collateral blood supply of the
pelvis, and several different techniques of attaining bleeding
control have been described, such as ligation of the iliac
artery or vein, application of local hemostatic therapies, attachment of sterile thumbtacks to the sacrum, cautery, and
bone wax.5 8 None of these techniques have, however,
proven successful because of anatomic reasons.9 In the past
years emergent angiographic embolization has been advocated
in the control of life-threatening pelvic hemorrhage.10,11 However, the angiographic procedure (AP) may be time-consuming,
with reported procedure times of 90 minutes12 and this might
not be tolerated by the severely hemodynamically unstable
patient. Furthermore, angiographic services may not be available in all hospital settings. In these patients there is a need
for supplementary life-saving procedures.

The technique of pelvic packing as a means of controlling massive pelvic bleeding was described already in 1926
by Logothetopulos.13 Today, several different techniques of
pelvic packing are used,14,15 but very little has been published
on the effect of pelvic packing on bleeding control. In 1994
the senior author (O.R.) introduced the technique of extraperitoneal pelvic packing (EPP), as first described by Pohlemann et al.,16 in our institution. The procedure has been
employed as a salvage procedure as part of the initial treatment protocol in patients with life-threatening traumatic pelvic bleeding who demonstrate continued signs of massive
pelvic bleeding after AP, and in patients who are not transportable to the angiography suite because of profound hemorrhagic shock.
In the following we describe the use and outcome of EPP
in patients with exsanguinating pelvic bleeding. The aim of
the study was to assess survival rate after EPP in hemodynamically unstable patients subjected to blunt pelvic injury,
and to study the changes in physiologic parameters and transfusion requirements at the time of the procedure.

MATERIALS AND METHODS

Patient Selection
Submitted for publication August 31, 2005.
Accepted for publication March 16, 2006.
Copyright 2007 by Lippincott Williams & Wilkins, Inc.
From the Orthopedic Centre (A.T., J.E.M., O.R.), and the Department
of Anesthesiology (N.O.S.) at Ullevl University Hospital, Oslo, Norway.
Supported by the Norwegian Air Ambulance Foundation.
Address for reprints: Anna Totterman, Orthopaedic Center, Ullevl
University Hospital, Kirkeveien 166, 0407 Oslo, Norway; email: anna.
totterman@ulleval.no.
DOI: 10.1097/01.ta.0000221673.98117.c9

Volume 62 Number 4

Eighteen of 661 prospectively registered patients admitted to our regional trauma center between August 1, 2000 and
March 31, 2004 because of pelvic, sacral, or acetabular injury
underwent EPP with the intent to control massive pelvic
bleeding. These patients constituted the study population.
According to the predefined protocol for the initial
treatment of patients with pelvic hemorrhage (Fig. 1), angiography was performed in patients with continuous pelvic
bleeding who were estimated to tolerate transportation to the
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The Journal of TRAUMA Injury, Infection, and Critical Care

packing (BP, pulse frequency, base excess (BE), hemoglobin
(Hb) count). Data from the hospital-based trauma registry
(The Ullevl Trauma Registry) included age, gender, additional injuries, patients outcome (alive/ dead), and time/
cause of death in nonsurvivors. Injuries were coded according
to the Abbreviated Injury Scale (AIS)18 for calculation of
Injury Severity Score (ISS), according to convention.19 Probability of survival was calculated according to Trauma and Injury
Severity Score (TRISS) methodology20 with coefficients revised
according to AIS 90 as published by Champion et al. in 1995.21
Physiologic derangements were classified according to Revised
Trauma Score (RTS). Fracture characteristics (type, classification according to AO-OTA22) were obtained from an institutionspecific prospective registration of pelvic injuries.
EPP was considered primarily effective when the patient
survived the first 30 days after injury. The procedure was
considered secondarily effective when time-adjusted transfusion requirements decreased after EPP, or when the tested
physiologic parameters improved after EPP.
Fig. 1. Flow-sheet for the initial treatment of patients pelvic ring
fractures and clinical signs of hemorrhage.

angiography suite. Indication for EPP was severe hemodynamic instability corresponding to class III to IV hemorrhage
according to Advanced Trauma Life Support17 in patients
who were assessed to exsanguinate before or during angiography. EPP was further indicated in patients who continued to
show signs of severe ongoing massive bleeding despite the
AP. Common to all included patients were the presence of
more than one of the following clinical signs before EPP:
systolic blood pressure (BP) 90 mm Hg; central venous
pressure (CVP) 5 cm H2O, and pulse frequency 100
beats/min. Seven patients arrived in the emergency department
(ED) with nonobtainable systolic BP. Of the remaining patients,
six were in hemorrhagic shock at admission (BP 90 mm Hg),
and five patients were initially described as circulatory stable,
but decompensated within the first hours from admission despite
ongoing fluid resuscitation. In three of the five initially stable
patients, EPP was performed after angiography.
Seven patients with pelvic injury as part of their injury
panorama were dead on arrival and thus excluded from the
study. The criteria for dead on arrival was absence of pulse,
spontaneous movement, respiratory effort, or effective cardiac electrical activity and prehospital cardiopulmonary resuscitation 5 minutes after blunt trauma with no response to
resuscitation.

Baseline Assessment
Data retrospectively collected from the medical records
included time of injury, arrival time at ED, blood transfusions
(units of red blood cells [RBCs]), surgical interventions,
initial pelvic stabilization, AP (embolization, findings), physiologic parameters plotted immediately around the time of
844

Management Algorithm for Blunt Pelvic Trauma

The algorithm for the initial treatment of patients with
blunt pelvic trauma employed at our regional trauma hospital
is summarized in Figure 1.
Initial Resuscitation
Patients suffering from high-energy injuries are managed
according to the ATLS (Advanced Trauma Life Support)
algorithm.17 Until the sources of bleeding are identified and
controlled, the patients are resuscitated according to the principle of deliberate hypotensive fluid resuscitation. Depending
on circulatory state and hemodynamic response to initial fluid
resuscitation with up to 2 L of warmed Ringers acetate, the
patients are assessed to be one of the following:
1. Hemodynamically normal with estimated blood loss by
admission of less than 1,500 mL (30%). These patients
receive a continued fluid resuscitation with Ringers acetate and/or colloid solutions. Blood transfusions are initiated if signs of ongoing hemorrhage are observed or initial
Hb count is 8 g/dL in younger patients, or 9 g/dL in
patients older than 65 years, or
2. In hypovolemic shock with estimated blood loss by admission of more than 1,500 mL (30%), and signs of hemodynamic instability judged by presence of tachycardia,
delayed capillary refill 2 seconds, hypotension 90 mm
Hg, or decreased pulse pressure. In these patients aggressive fluid resuscitation is continued with crystalloids, colloids, and concentrated RBCs (one unit 300 mL). In
cases of gross hemodynamic instability, indicating lifethreatening hemorrhage, massive transfusion efforts are
commenced before initial Hb count is obtained, and administered until the Hb count is above 9 g/dL, BE tends to
improve, and clinical signs of hemodynamic normalization are observed.
April 2007

Extraperitoneal Pelvic Packing

Fig. 2. Lower-midline incision. The peritoneum is visible.

Initial Stabilization of Pelvic Injury

The use of a temporary external fixator as a means to
stabilize the pelvis has at our hospital been substituted with
the more rapid method of pelvic sheeting.23,24 In our modification a folded 20-cm-wide sheet is positioned in a circumferential manner around the trochanteric region after the pelvic
fracture is reduced by traction and internal rotation of the
hips. The ends of the sheet are crossed, pulled taut, and
secured with clamps. Pelvic sheeting is kept until the patient
is judged hemodynamically normal and transfusion requirements have ceased, usually 1 to 2 days.
The Technique of EPP
EPP is performed in the emergency room in cases of
patients in extremis, who are obviously unable to survive
transferal to the angiography suite. With the patient positioned supine, the abdomen is draped from the pubic area to
the upper clavicular margins for direct access to emergency
thoracotomy and laparotomy, when needed. A lower midline
incision from the umbilicus to the symphysis is used. Linea
alba is incised and the peritoneum is left intact. The peritoneum is manually pushed free from the inner aspect of the
osseous pubic symphysis and the pelvic ring (Fig. 2). The
linea terminalis is followed by palpation to the sacroiliac (SI)
joint, exposing the inner aspect of the quadrilateral plate. The
obturatory nerve with vessels is usually not searched for, but
if identified pushed laterally. The internal oblique muscle,
which drapes the inner surface of the quadrilateral plate, is
left uninterrupted and no attempts to free the peritoneum from
the sacrum are attempted. In cases where laparotomy is performed before the pelvic packing, the peritoneum is left intact
distally to facilitate packing in the extraperitoneal space. A
minimum of three large radio-opaque swabs are placed in the
pelvis in the interspace between the bony pelvic ring and the
peritoneum, starting posteriorly from the SI joint and advancing anteriorly to the retropubic area (Figs. 3 and 4). The
swabs are directed toward branches of the internal iliac artery
Volume 62 Number 4

Fig. 3. Pelvic anteroposterior view showing a combined pelvic (bilateral, Type B3.2) and acetabular fracture ( left). Bilateral radioopaque swabs are seen compressing the contrast-filled bladder.
Bilateral embolization coils are seen posteriorly.

and the pelvic venous plexus situated in the retroperitoneal

space lateral to the sacrum. The procedure is repeated on the
contralateral side to achieve sufficient tamponade. In unstable
pelvic fractures the levator muscles, as well as the sacrotuberal and ischial ligaments may be torn. This increases the
volume of the true pelvis and 3 to 10 more swabs might be
needed. When the pelvic fracture is associated with a perineal
tear, additional swabs are placed in the open wound cavity.
After completing pelvic packing the linea alba is closed with
continuous sutures to achieve additional tamponading effect.
No wound drains are left. In cases where a coinciding intraabdominal injury has necessitated damage control surgery
intra-abdominally, the upper part of the laparotomy incision
may be left open according to the abdominal vacuum
principle25 to reduce the risk of abdominal compartment

Fig. 4. Computed tomography scan demonstrating the position of

the radio-opaque swabs in the pelvis. The peritoneum is pushed
medially (same patient as in Fig. 3).

845

The Journal of TRAUMA Injury, Infection, and Critical Care

syndrome (ACS). The swabs are carefully removed in a
second look operation after 2 days. If bleeding is still encountered, a repeated packing is performed. In stabilized
patients without signs of re-bleeding, definite orthopedic stabilization is performed if the general condition of the patient
allows for it. At our hospital the in-house surgical trauma
team leaders perform EPP on a 24-hour basis.
Additional Hemostatic Procedures
Percutaneous pelvic angiography is performed in patients who have sustained blunt high-energy injuries to the
pelvic ring when the predefined transfusion criteria for angiography are met. In our institution these are (1) initial
hemorrhage necessitating more than five units of RBCs
within the first 24 hours, or (2) protracted hemorrhage after
initial stabilization necessitating more than four units RBCs
within the following 24 hours. All patients subjected to EPP
undergo angiography after successful initial resuscitation.
The interventional angiography team provides 24-hour coverage. In the present study, angiography was performed in all
patients, and 15 (83%) had signs of arterial injury. Three
patients were interpreted as sufficiently hemodynamically
stable to tolerate an AP as the primary measure for control of
continuing hemorrhage, but EPP later proved necessary because of persistent hemorrhagic shock after angiography.
Two of these patients survived.
Emergent left-sided thoracotomy as a salvage procedure
is performed parallel to crash laparotomy and/or pelvic packing in patients with no measurable BP at admission who do
not respond to aggressive fluid resuscitation. If successful
resuscitation is obtained, the procedure is continued and gradually terminated when damage control surgery has been performed and the anesthesiologists have caught up with the
administration of transfusions. In the present study, aortic
clamping was performed before EPP in five patients. In the
remaining two patients who arrived to the ED with nonobtainable BPs, a measurable BP was observed after initial fluid
resuscitation.
In the present study, a combined emergency laparotomy
and EPP was performed in 14 patients, 8 of whom were found
to have concomitant gastrointestinal lesions, none of which,
however, significantly contributed to the hemorrhage. The
remaining four patients underwent a diagnostic peritoneal
lavage to exclude abdominal bleeding, all of which were
negative. Thirteen patients underwent internal fixation of the
pelvic fracture on mean day 3 (range, 1 6); two of whom
later died from unrelated causes. Five of the injuries were
open fractures (Gustillo III). Conservative treatment was
scheduled for the remaining patients.
Pelvic sheeting as a means to achieve initial stabilization
was applied to all patients with pelvic fractures excluding the
three patients with acetabular fractures and one patient who
had an external fixator applied at the referring hospital. The
pelvic sheeting was converted to an external fixator in two
patients who were not eligible to early definitive surgery
846

because of additional injuries. A C-clamp was not used in any

of these patients.

Statistical Analysis
Statistical analysis was performed using SPSS 12.0 software (SPSS Inc., Chicago, IL). To study the association
between continuous variables the Spearmans correlation coefficient was used. A comparison between means was calculated using the paired samples t test, except for variables with
a markedly skewed distribution, where a MannWhitney U test
was used. An independent samples t test was used to compare
means between survivors and nonsurvivors. A 5% significance
level was used.
The Regional Committee for Research Ethics approved
the study.

RESULTS
Results are given as mean values and range if not stated
otherwise.

Background Data
All but one patient had been involved in high-energy
injuries. Traffic crashes accounted for 15 of the included
cases (83%), falls from height for 2 (11%), and fall from
standing position for 1 (6%). All patients with high-energy
injuries were severely injured as measured by ISS (48; range,
9 66 for all). Associated injuries occurred in 17 patients
(94%) (Table 1). The most frequent concomitant injuries
were orthopedic (n 17, 94%), pulmonary (n 14, 78%),
cerebral (n 9, 50%), and gastrointestinal tract injuries (n
8, 44%). Injuries to three or more organ systems occurred in
15 cases (83%). Seventeen patients (94%) filled the criteria
for polytrauma, defined as injury to two or more organ
systems and ISS 15. Seventeen patients (94%) underwent
surgery for associated injuries.
Median transferal time from injury to the ED was 98
minutes (9 1,520 minutes). Only five patients arrived within
an hour after injury. Twelve of the patients (67%) were
admitted directly from the site of injury, and the remaining
via a referring hospital. Patients arriving directly from the site
of the crash arrived within a median of 63 minutes (9 68
minutes). Transferring a patient via a referring hospital increased the transferal time from injury to ED by a median of
417 minutes (100 1,450 minutes). The transferal time was

Table 1 Patient Characteristics (n 18)

Age at accident
Proportion male patients
Associated injuries
Injury Severity Score (ISS)
ISS 15
Revised Trauma Score (RTS)
Glasgow Coma Scale (GCS)
Probability of survival (Ps)

44 (1680) years*
71% (14:4)
17 (94%)
47 (966)
17 (94%)
10 (412)
12 (315)
57% (6% to 97%)

* Mean (Range).

April 2007

Extraperitoneal Pelvic Packing

longer for the 13 survivors (252 minutes, 9 1,520 minutes),
as compared with the five nonsurvivors (73 minutes, 10 170
minutes), but the difference was not statistically significant
( p 0.149).
EPP was performed within 41 minutes of arrival in the
13 patients presenting with manifest signs of hemorrhagic
shock at admission. The corresponding time for all patients
was 134 minutes (5720 minutes), including the three patients who underwent EPP after angiography. Removal of
swabs was possible within 48 hours in 14 of the 15 (93%)
early survivors. Repacking was necessary in two survivors
because of significant bleeding at the time of the second look
surgery.
In the 15 patients who had angiography performed after
EPP, 12 (80%) had positive findings for arterial injury.
A total of 59 transfusions (RBC) (12191) were administered to each patient during the whole hospitalization period
(27 days; range, 1102 days). Patients were administered 12
RBC transfusions (0 58) from injury to EPP, and an additional 17 (0 43) within 24 hours of completed EPP. An
insignificant increase in total transfusion requirements was
seen with higher injury scores, as measured by ISS ( p
0.097). In all patients, the mean transfusion rate decreased
from 0.1 (0.00 0.92) unit/min before EPP, to 0.012 (0.003
0.030) units/min within 24 hours after completed EPP ( p
0.044). Nonsurvivors were administered more transfusions
before EPP (0.38 units/min, 0.00 0.92), compared with survivors (0.07 units/min, 0.00 0.32), but the difference was
nonsignificant ( p 0.155).

Pulse frequency at admission (119 bpm, 40 165) had not

changed markedly by the time of EPP (105 bpm, 70 140)
despite aggressive fluid resuscitation. A slight decrease in
pulse frequency was seen after completion of EPP (102 bpm,
55150), but the reduction in pulse frequency plotted around
EPP was not significant ( p 0.541).
BE at the time of arrival was 6.6 mmol/L (2 to 23.6
mmol/L). At the time of pelvic packing acidosis had increased to 7.9 mmol/L, (0 to 16.7 mmol/L), and persisted
after completed EPP (BE 9.0 mmol/L; range, 2.5 to
21.9 mmol/L). The impact of EPP on BE before and after
the procedure was not significant ( p 0.259). An improvement of BE after completed EPP was, however, seen more
often in survivors compared with nonsurvivors, but the difference was not significant ( p 0.088). Admission delay
was found to increase the level of acidosis, but the difference
was not significant ( p 0.413).
Mean Hb count at admission was 8.8 g/dL (6.512.9
g/dL). Immediately before EPP a reduction of Hb to 8.0 g/dL
(4.4 11.9 g/dL) was observed despite blood transfusions.
After completed damage control surgery Hb had risen to 9.4
g/dL (6.113.6 g/dL), probably as a consequence of the
anesthesiologists catching up with transfusions. The improvement in Hb before and after EPP was significant ( p
0.012), but the improvement did not differ significantly in
survivors (0.7 g/dL), and nonsurvivors (2 g/dL) ( p 0.138).
Lower Hb at the time of EPP tended to increase the risk of
later mortality, but not to a statistically significant extent
( p 0.627).

Physiologic Parameters

Mortality

Mean systolic BP at arrival was 60 mm Hg (0 130 mm

Hg). All seven patients with nonobtainable BP at arrival
(patients in extremis) survived, two of who were resuscitated from cardiac arrest that occurred during resuscitation.
At the time of EPP all patients had a measurable BP (80
mm Hg, 60 120 mm Hg) because of initial fluid resuscitation, pelvic sheeting, and aortic clamping (n 5). There was
a statistically significant increase in BP measured immediately after EPP (99 mm Hg, 70 130 mm Hg), as compared
with BP measured before EPP (80 mm Hg) ( p 0.002). A
summary of the physiologic findings and transfusion requirements plotted around the time of EPP is given in Table 2.

Overall mortality rate after EPP, defined as death within

30 days of injury, was 28% (n 5). Characteristics of the
five nonsurvivors are summarized in Tables 3 and 4. All five
nonsurvivors had sustained multiple associated injuries. The
cause of death was verified by autopsy in four of the five
patients. Two of the nonsurvivors died within 24 hours of
injury; in these cases the primary cause of death was multifocal hemorrhage from pelvic, liver, and pulmonary injuries
(n 1), and cerebral injury (n 1). MOF accounted for
death in the remaining three nonsurvivors on days 2, 9, and
28, respectively. Thus, only one patient died of ongoing
hemorrhage. Nevertheless, pelvic injury was interpreted as a

Table 2 Physiological Parameters and Transfusion Rate at Time of EPP

Systolic blood pressure (mm Hg)

Pulse frequency (beats/min)
Base excess (mmol/L)
Hemoglobin (g/dL)
Time adjusted RBCs (units/min)

Prior to EPP

After EPP

Level of
Significance

80
105
7.9
8.0
0.1

99
102
9.0
9.4
0.012

p 0.001*
p 0.541
p 0.259
p 0.012*
p 0.044

* Significant with a 95% level of confidence.

RBCs, packed red blood cells. One unit 300 mL.

Volume 62 Number 4

847

The Journal of TRAUMA Injury, Infection, and Critical Care

Table 3 Fracture Classification* and Mortality Rate

Pelvic fractures
Type A
Type B1
Type B2
Type B3
Type C
Sacral fracture
Acetabular fracture
Total

All Patients
(n 18)

Overall Mortality

14 (77%)
1
2
2
2
7
1 (6%)
3 (17%)
18

5 (100%)
1
1
1
0
2
0
0
5

found in the assigned trauma scores between survivors and

nonsurvivors. An insignificantly shorter delay between admission and the packing procedure was observed in survivors
(123 minutes; range, 5720), compared with the nonsurvivors
(162 minutes; range, 5 660), ( p 0.519).

Complications

* Classification according to AO-OTA.21

major contributor to death in four of five nonsurvivors. Significant comorbidity (systemic lupus erythematosus with ongoing immunosuppressive therapy) contributed to the death
in one of the nonsurvivors who died as a result of MOF and
septicemia on day 28.
When comparing survivors and nonsurvivors, survivors
were younger (37 years), compared with nonsurvivors (59
years) ( p 0.038) (Table 5). There was no significant difference in ISS or the number of administered transfusions in
the different ages. Furthermore, no significant difference was

Pelvic infection necessitating wound revisions occurred

in six patients (33%), five of whom had routine revisions
performed because of severe open pelvic fractures (Gustillo
III). In one patient, swabs were not removed until day 3
because of logistic problems, this patient later died of MOF
on day 9. One patient developed septicemia after transfer
from Ullevl to the local hospital and was found to have a
swab accidentally left in the pelvis. The swab was removed
and the patient survived.

DISCUSSION
The initial management of traumatic pelvic bleeding is
dependent on hemodynamic stability of the patient at admission. In the majority of cases, bleedings stop after pelvic
stabilization and adequate initial resuscitation. However, a
small percentage of patients present with life-threatening

Table 4 Characteristics of the Nonsurvivors (n 5)

Age (years)
Time of death
Primary cause of death
Pelvic injury primary cause
of death
Injury Severity Score
Comorbidity
Fracture type

Patient A

Patient B

Patient C

Patient D

Patient E

80
Day 1 (13 h)
Cerebral injury and
multiple fractures
Yes

39
Day 9
MOF

51
Day 1 (2 h)
Multiple hemorrhage

72
Day 2
MOF

No

54
Day 28
MOF, cerebral abscess,
septicemia
No

Yes

Yes

59
Unknown
B2

45
No
B1

38
SLE, vasculitis
C2

57
No
C2

43
Unknown
A2

Multiple organ failure.

Table 5 Comparison Between Survivors and Nonsurvivors

Age
Injury Severity Score
New Injury Severity Score
Revised Trauma Score
Probability of Survival Score (%)
Time from injury to admission (min)
Time from injury to EPP (min)
Time from admission to EPP (min)
Physiological variables prior to
EPP
Systolic blood pressure (mm Hg)
Hemoglobin (g/dL)
Base excess (mmol/L)
Pulse frequency (beats/min)
RBCs

Survivors (n 13)

Nonsurvivors (n 5)

38 years (1680)
47 (966)
50 (1866)
10 (412)
63 (1897)
252
360
123

59 years (3980)
48 (3859)
52 (4366)
9 (512)
43 (694)
67
221
162

p
p
p
p
p
p
p
p

0.0038 (41.8 to 1.4)

0.84 (16.8 to 13.8)
0.750 (15.9 to 11.7)
0.340 (1.5 to 1.1)
0.203 (11.9 to 51.9)
0.352 (217 to 576)
0.626 (452 to 730)
0.744 (286 to 209)

84
8.6
5.5
102
9.4

p
p
p
p
p

0.411
0.587
0.263
0.715
0.908

76
7.9
8.7
107
12.6

Level of Significance*

(25.8 to 11.2)
(3.4 to 2.0)
(8.9 to 2.6)
(22.9 to 32.6)
(16.5 to 14.8)

* Independent samples test (95% confidence interval), difference in means.

RBCs, packed red blood cells. One unit 300 mL.

848

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Extraperitoneal Pelvic Packing

hemorrhage. Most of these patients may successfully be
treated with arterial embolization for definite arterial control.
However, a subgroup of patients will not tolerate transportation to the angiography suite because of life-threatening
hemorrhage. In these cases damage control surgery is
indicated.26
The present study describes the method of extraperitoneal packing as a damage control procedure in the treatment
of patients with severe hemorrhage after pelvic ring injury,
and looks at the effects of the procedure on survival, transfusion requirements, and physiologic parameters. Of the 661
patients admitted with pelvic, acetabular, or sacral fractures
during the study period, 18 patients (2.7%) had clinical signs
of massive pelvic hemorrhage necessitating pelvic packing to
control pelvic bleeding. In the present study, the success rate,
defined as 30-day survival, of EPP as part of a multidisciplinary approach, was 72%. This corresponds to a previous
report by Ertel et al.14 who described a 71% survival rate in
10 of 14 patients with hemorrhagic shock after retroperitoneal
pelvic packing and application of a C-clamp.
To test the efficacy of a treatment that goes beyond the
conventional morbidity parameters, a variety of resuscitative
end points have been proposed. Previous studies have demonstrated that high lactate and base deficit levels are important predictors of mortality in pelvic trauma,14,27,28 and that
pelvic fracture patients with a base deficit 5 mmol/L are
significantly more likely to die compared with patients with
normal values.29 In the present study we defined the efficacy
of EPP secondary as improvement of physiologic parameters
plotted around the time of EPP, or a reduced need for transfusions after EPP. We observed metabolic acidosis measured
by BE in all patients at admission, but the acidosis did not
significantly differ between survivors and nonsurvivors, or
improve with the procedure. However, in the majority of
patients an immediate increase in systolic BP immediately
after EPP was observed, together with a decrease in timeadjusted transfusion requirements. This improvement in
physiologic parameters, combined with reduced transfusion
requirements may indicate that EPP, as part of a multidisciplinary resuscitative approach, reduces the rate of pelvic bleeding, thereby enabling the anesthesiologist to catch up with
fluid resuscitation and transfusions before definite control of
arterial bleeding by angiographic embolization is achieved.
As simple resuscitative measures suffice in the majority
of patients with pelvic ring fractures, it is assumed that the
majority of pelvic bleedings are caused by injury to small
pelvic vessels.12,30 However, in the hemodynamically unstable patient with pelvic trauma little is known regarding the
precise anatomic site of bleeding. Several authors implicate
venous injury as the main cause of bleeding in severe pelvic
hemorrhage,14,31,32 and foremost injury to the presacral venous plexus.14 Nevertheless, as few studies have formally
examined the prevalence of pelvic venous injuries, the rate of
significant venous injury in pelvic trauma is largely unknown. Kataoka et al.33 found venous injury on transfemoral
Volume 62 Number 4

venography after angiography in 9 of 11 hypotensive patients. The veins involved were the common iliac vein (n
5), the internal iliac vein (n 3), and the external iliac vein
(n 1). The researchers recommended venography to be
performed immediately after arteriography in patients who
remained in shock, and venous stenting performed when
major venous injury was diagnosed.
Information about the rate of arterial injury in pelvic
trauma has primarily been derived from angiographic studies,
with reported rates ranging from 0.01% to 2.3%12,34,35 for all
pelvic trauma, and from 9% to 80% in unstable pelvic
injuries.11,12,32,36 38 In the present study, consisting only of
patients with severe traumatic pelvic hemorrhage, a high rate
(80%) of arterial injury was observed on angiography after
EPP. The combination of improvement in systolic BP and the
positive findings on angiography after the procedure may
indicate that the hemostatic effect of packing is mainly attributed to control of venous bleeding. Our results may therefore indicate that in patients subjected to high-energy pelvic
trauma with massive pelvic bleeding, a combined injury to
both intrapelvic veins and arteries is common. Therefore, to
control arterial bleeding, EPP needs to be complemented with
angiography once sufficient hemodynamic stability has been
attained. We think that in the three unstable patients who
underwent EPP after negative angiography, EPP may either
have controlled arterial bleeding or, more probably, that
bleeding was mainly caused by significant venous injury.
At our hospital the method for pelvic packing is extraperitoneal, but several different techniques for pelvic packing
have been described.14,16,39 41 In the intraperitoneal techniques the pelvis is approached through an abdominal midline
incision. The abdominal peritoneal cavity is opened and the
intestines are pushed deep into the upper abdomen before
placing the swabs in the lower abdomen.41,42 In the EPP or
retroperitoneal pelvic packing techniques swabs are placed in
the space formed by the pelvic peritoneum and the bony
pelvic side walls to access directly the extraperitoneally situated vessels. Ertel described a technique of retroperitoneal
pelvic packing through a laparotomy incision.43 In this technique the retroperitoneum is entered after bilateral colonic
mobilization and direct manual access down to the sacrum
and the SI joints, and swabs are placed in the presacral and
prevesical regions bilaterally. To minimize the risk of ACS,
the abdominal cavity is left open. In the technique of EPP
described by Pohlemann et al.,16 and slightly modified by us,
the extraperitoneal pelvic space is entered from a lower midline incision and the swabs are placed in the space formed by
the peritoneum and the true pelvis. As the peritoneum is
loosely attached to the pelvis in these areas, it is frequently
already dissected from the osseous pelvis by the fracture
hematoma. Contrary to Pohlemann et al., we do not attempt
to identify the bleeding sources when profuse extraperitoneal
bleeding is encountered at the time of packing. In our modification the SI joints form the most posterior border of
dissection and the presacral retroperitoneal space is not en849

The Journal of TRAUMA Injury, Infection, and Critical Care

tered. By detaching the tightly attached pelvic fascia from the
sacrum we think that the tamponading effect on injured presacral veins would be lost. Furthermore, as the presacral veins
are easily lacerated during blunt mobilization, dissection may
in itself result in life-threatening bleeding.7,8 We attempt
wound closure of the lower midline incision as an intact
abdominal wall has been shown to contribute to decreased
pelvic volume and increased stability.44 Midline fascial closure may further limit the decompression of hematoma and
assist with pelvic tamponade.
The potential advantage of the extraperitoneal packing
technique is that it is quick and easy to perform. By placing
the swabs extraperitoneally, they remain in the pelvis and do
not dislocate intra-abdominally. In the intra-abdominal techniques, the swabs might migrate cranially as there are no
natural cranial boundaries in the true pelvis. Because of the
large intra-abdominal cavity, sufficient pressure directed to
the true pelvis may be difficult to obtain unless larger
amounts of swabs are used. These swabs may interfere with
intra-abdominal circulation by compression of the vena cava,
increasing the risk of ACS with secondary impact on the
cardiopulmonary system.45 By placing the swabs extraperitoneally, the risk of swabs interfering with intra-abdominal
circulation or pulmonary function may be reduced, keeping
the risk of ACS to a minimum.
As hemostatic packing is performed on severely hemodynamically unstable patients, the rate of complications will
be high. Sharp and Locicero46 reported a 27% complication
rate in 22 survivors after intra-abdominal packing; 5 abdominal abscesses, 2 wound dehiscence, and 2 enterocutaneous
fistulae. In patients treated with intra-abdominal packing for
liver injury the rate of perihepatic infection has been shown
to be independently associated with increasing abdominal
trauma indices and transfusion requirements,47 but the incidence of infection has not been shown to significantly increase by the packing as such.30 Mild transient neuropathy
involving the obturator and the sciatic nerves has been reported after intraperitoneal pelvic packing secondary to massive intra-operative hemorrhage in gynecological surgery.39
The overall incidence of ACS after damage control laparotomy for severe abdominal or pelvic trauma has been reported
to be 5.5%,45 and Ertel et al. reported a 36% ACS rate (5 of
14) in patients treated with retroperitoneal pelvic packing and
C-clamp after pelvic trauma.14 In the present study intrapelvic infection necessitating surgical revision occurred in six
patients (33%), but five of these patients had severe open
pelvic fractures necessitating wound revisions as part of their
routine wound management. As abdominal compartment
pressures were not registered routinely during the whole
study period, the association between abdominal pressure and
extraperitoneal packing as performed in our unit needs to be
systematically addressed in further studies.
The strength of this study is the use of a strictly defined
population of patients from a single trauma center with an
established protocol for the initial treatment of pelvic trauma.
850

Continuous data capture of all patients admitted and treated

for pelvic trauma provides reliable data.
The limitations obviously constitute the small and heterogeneous study population, and statistical analysis should
therefore be interpreted with caution. When assessing the
effect of the procedure we used two outcome measures;
30-day survival, and improvement of physiologic parameters.
We found that the mortality rate after pelvic packing was
similar to those published by Ertel et al.14 However, a comparison of mortality rates between centers, or between different
hemostatic procedures, is difficult as most of the mortalities
in pelvic trauma cases are related to additional injuries. In
addition, the indication for different hemostatic procedures
may differ, as is the case in our institution where angiography
is the primary choice of bleeding control in patients with
significant pelvic bleeding, and EPP is used as a supplementary salvage procedure in patients who would not survive the
AP.3,48 51 As a prolonged time to achieve hemostasis has
been shown to have an adverse effect on survival,52 the
relatively long time interval observed in our study from injury
to EPP in the severely unstable patients (41 minutes) indicates that greater efficiency is needed to further reduce late
mortality.
To evaluate the isolated impact of EPP on physiologic
parameters as a measure of effect will remain problematic for
two reasons. First, as the majority of patients with massive
pelvic bleeding have multiple bleeding sites, several interventions are performed simultaneously. Second, the reduction in
transfusion rate observed in our study may also partly be explained by the natural hemostasis that occurs in most patients.
EPP as part of a multidisciplinary approach is performed
in the severely hypovolemic pelvic trauma patient who would
not otherwise survive transferal to the angiography suite,
disregarding type of pelvic ring fracture. Temporary pelvic
packing can control hemorrhage and provide crucial time to
correct physiologic derangements. The technique is easy,
quick to perform, and associated with a high survival rate. In
the present study pelvic packing was performed in 18 hemodynamically unstable patients as a life-saving emergency
procedure. Initial bleeding control was achieved in all but one
patient who died of uncontrollable multiple hemorrhages. In
the remaining patients an increase in systolic BP was observed after the initial resuscitation and damage control surgery, which enabled transferal to the intensive care unit or to
the angiography suite for further stabilization and arterial
bleeding control. The higher age observed in nonsurvivors
corresponds to previous studies on mortality after pelvic
trauma.53 Life-threatening pelvic hemorrhages were observed
in all types of pelvic fractures, and also in isolated acetabular
and sacral fractures. This emphasizes the need for alertness in
the treatment of all pelvic traumas. The high proportion of
arterial injuries observed indicates that arterial injuries play
an important role in massive pelvic bleeding. Consequently,
we think that EPP should be complemented with angiography
in all patients once transferable to the angiography suite.
April 2007

Extraperitoneal Pelvic Packing

However, in a minority of cases significant venous injury is
the primary cause of bleeding and these patients may be
successfully treated with EPP as a means to achieve definite
bleeding control. Furthermore, in hospitals without angiographic facilities, pelvic packing may be the only option in
patients with massive hemorrhage after pelvic trauma.

17.

ACKNOWLEDGMENTS

20.

We wish to thank nurse anesthetists/trauma registrar Morten Hestnes,

certified AIS registrar, for his kind assistance in acquiring data from the
Ullevl Trauma Registry.

18.
19.

21.
22.

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April 2007