Management of hemodynamically unstable pelvic trauma: results of the first Italian consensus conference (cooperative guidelines of the Italian Society of Surgery, the Italian Association of Hospital Surgeons, the Multi-specialist Italian Society of Young Surgeons, the Italian Society of Emergency Surgery and Trauma, the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care, the Italian Society of Orthopaedics and Traumatology, the Italian Society of Emergency Medicine, the Italian Society of Medical Radiology -Section of Vascular and Interventional Radiology- and the World Society of Emergency Surgery)
Hemodynamically Unstable Pelvic Trauma is a major problem in blunt traumatic injury. No cosensus has been reached in literature on the optimal treatment of this condition. We present the results of the First Italian Consensus Conference on Pelvic Trauma which took place in Bergamo on April 13 2013. An extensive review of the literature has been undertaken by the Organizing Committee (OC) and forwarded to the Scientific Committee (SC) and the Panel (JP). Members of them were appointed by surgery, critical care, radiology, emergency medicine and orthopedics Italian and International societies: the Italian Society of Surgery, the Italian Association of Hospital Surgeons, the Multi-specialist Italian Society of Young Surgeons, the Italian Society of Emergency Surgery and Trauma, the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care, the Italian Society of Orthopaedics and Traumatology, the Italian Society of Emergency Medicine, the Italian Society of Medical Radiology, Section of Vascular and Interventional Radiology and the World Society of Emergency Surgery. From November 2012 to January 2013 the SC undertook the critical revision and prepared the presentation to the audience and the Panel on the day of the Conference. Then 3 recommendations were presented according to the 3 submitted questions. The Panel voted the recommendations after discussion and amendments with the audience. Later on a email debate took place until December 2013 to reach a unanimous consent. We present results on the 3 following questions: which hemodynamically unstable patient needs an extraperitoneal pelvic packing? Which hemodynamically unstable patient needs an external fixation? Which hemodynamically unstable patient needs emergent angiography? No longer angiography is considered the first therapeutic maneuver in such a patient. Preperitoneal pelvic packing and external fixation, preceded by pelvic binder have a pivotal role in the management of these patients.
Hemodynamically Unstable Pelvic Trauma is a frequent death cause among people who sustain blunt trauma. We present the results of the First Italian Consensus Conference.
Hemodynamically unstable pelvic trauma is a major problem in trauma surgery and even in the most experienced Trauma Centers. A long living debate in the literature, with plenty of classifications and protocols, has not still established the best treatment strategy for these patients [1–6].
In recent years the EAST (Eastern American Society for Trauma) published the Management Guidelines on Hemorrhage from Pelvic Trauma which were developed by a named group of leading surgeons and physicians . As in Italy this topic has never been faced in a public scientific debate, a National Consensus Conference (CC) was held in Bergamo on April 13th, 2013.
An Organizing Committee (OC) from the Papa Giovanni XXIII Hospital of Bergamo [Italy] was established to organize a National Consensus Conference on Unstable Pelvic Trauma. Regulations in order to conduct the CC were adopted from “The Methodological Manual – How to Organize a Consensus Conference”, edited by the Higher Health Institute . Levels of evidence (LoE) and grade of recommendations (GoR) come from Center for Evaluation of the Efficacy of Health Treatment (CeVEAS), Modena, Italy: six levels of evidence and five grade of recommendations have been defined (Table 1) . A systematic review of the literature from 1990 to November 2012, commissioned by the OC, was undertaken by two reference librarians in December 2012. The electronic search was undertaken in following databases: MedLine, Embase, Cochrane, Tripdatabase, National Guidelines Clearinghouse, NHS Evidence, Trauma.org, Uptodate. In the meantime 9 Scientific Societies, both Italian and International, identified by the OC as among those interested in this topic, were asked to appoint 2 members each to participate in the CC organization. The following societies appointed the two requested members in December 2012: the Italian Society of Surgery (Società Italiana di Chirurgia, SIC), the Italian Association of Hospital Surgeons (Associazione dei Chirurghi Ospedalieri Italiani, ACOI), the Multi-specialist Italian Society of Young Surgeons (Società Polispecialistica Italiana dei Giovani Chirurghi, SPIGC), the Italian Society of Emergency Surgery and Trauma (Società Italiana di Chirurgia d’Urgenza e del Trauma, SICUT), the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (Società Italiana di Anestesia, Analgesia, Rianimazione e Terapia Intensiva, SIAARTI), the Italian Society of Orthopaedics and Traumatology (Società Italiana di Ortopedia e Traumatologia, SIOT), the Italian Society of Emergency Medicine (Società Italiana di Medicina d’Emergenza-Urgenza, SIMEU), the Italian Society of Medical Radiology, Section of Vascular and Interventional Radiology (Società Italiana di Radiologia Medica, SIRM, Sezione di Radiologia Interventistica e Vascolare) and the World Society of Emergency Surgery (WSES).
Levels of evidence and grade of recommendations
Levels of evidence
RCTs and/or systematic review or metanalysis of RCTs
A single well designed RCT
Cohort studies with concurrent or historical controls or their metanalysis
Case control studies or their metanalysis
Case series without controls
Expert opinion, guidelines, documents coming from consensus conference
Grade of recommendations
Highly recommended. From good quality level, even if not level I-II
Not always recommended but must be taken in consideration
Substantial uncertainty in favour or against
Highly not recommended
Among these societies’ delegates, the OC named the Scientific Committee (SC, 9 members) and the Jury Panel (JP, 9 members) in which each society was represented. The SC had the responsibility of creating 3 presentations according to the retrieved literature to answer the 3 questions selected by the OC.
The three questions were:
Which hemodynamically unstable patient needs a preperitoneal pelvic packing (PPP)?
Which hemodynamically unstable patient needs an external fixation (EF)?
Which hemodynamically unstable patient needs emergent angiography (AG)?
The OC reviewed the retrieved papers and selected the most appropriated as related to the three topics. Studies not directly addressing the management of hemodynamically unstable pelvic trauma were excluded (elective procedures, stable patients, reviews studies). Manual cross-reference search of the relevant studies was performed by the OC and the related relevant papers were also retrieved. The selected papers were subsequently sent to the members of the SC in late December 2012, helping in the review of the literature. The SC and the OC shared the presentation in late February and completed the work in early March 2013. At the conference was also invited a representative of a voluntary association the Italian Association of Blood Volunteers (Associazione Volontari Italiani del Sangue, AVIS), as a representative of the civil society. During the day of the conference (April 13 th 2013) the SC presented in the morning the whole review of the literature and in the afternoon the statements for each of the three questions. The JP, who was previously aware of the content of presentations and statements, discussed with the audience the results and formally approved the statements. Furthermore an algorithm for the whole management of hemodynamically unstable pelvic trauma was proposed during the conference. In the subsequent months the discussion took place by email and the overall content of the conference was definitely approved by all the members of the three committees. The Scientific Societies gave the last approval and permission for submission and publication.
Results and discussion
The electronic search (Figure 1) gave 1391 abstracts. Of these 1203 were excluded (not directly related topic, stable patients, mixed population, elective procedures). Among the 198 remaining papers, 162 were excluded (elective procedures, overlapping data, stable patients, expert opinion, review). Finally 36 papers were considered (Table 2). No randomized controlled trials were found, but only case series and case-control studies. The SC presented this revision of the literature trying to answer the three previously decided topics at the conference day. This public conference was attended by 160 scientists and experts. Each revision was focused to answer one of the three questions and was followed by a public debate. During the lunch meeting the SC and the JP discussed the statements reaching an informal consensus and in the afternoon the statements were presented to the audience. The conference was closed after a public debate which strengthened the statements and produced a draft for an algorithm for the whole management of hemodynamically unstable pelvic trauma. Later on the SC and the JP, with the OC, discussed the algorithm via email and finally approved it. For the purposes of the CC we define hemodynamically unstable a patient which needs ongoing appropriate resuscitation without reaching a target systolic blood pressure of 90 mmHg and pelvic trauma is, together or not with other traumatic lesions, responsible for this hemodynamic status. Patient in extremis is a “bleeding to death” one, with profound refractory shock despite a timely and correct resuscitation. Pelvic mechanical stability is defined according to AO/OTA classification .
4 groups with either external fixation only, together with angio, laparotomy or angio before external fixation
Statements were approved as follow:
Preperitoneal pelvic packing (PPP)
In the last 10 years PPP has gained popularity as a tool to control venous bleeding in pelvic trauma. Since the first report from Pohlemann in 1994  and Ertel in 2001  many papers demonstrated this is a feasible, quick and easy procedure. PPP has been already adopted in some centers as a key maneuver for unstable patients . It can be accomplished both in the emergency department (ED) and the operating room (OR). Our CC agreed that PPP can be quickly done both in the shock room in the ED or in the OR, according to local organization. In a mechanically unstable pelvic fracture PPP has to be done together with fixation of the pelvis with EF, when feasible and possibile, as indicated by Pohlemann , Ertel  and Cothren  as well as others authors [3, 4, 15, 25, 41, 45]. In conclusion PPP is a pivotal procedure, as well as external stabilization, in the emergency setting, both in the OR and the ED. When patient is in extremis PPP, together with external stabilization can be life saving.
PPP is effective in controlling hemorrhage when used as part of a multidisciplinary clinical pathway including AG and EF. [GoR B, LoE IV]
PPP is effective in controlling hemorrhage when used as a salvage technique. [GoR B, LoE IV]
The volume of the pelvis increases after a mechanically unstable pelvic fracture. EF has always been the mainstay of emergency treatment in order to reduce the volume of the pelvis and control hemorrhage [46, 48–50]. Two main techniques are available to externally fix the unstable pelvic ring: external fixator and C-Clamp. While the external fixator is indicated in type B fractures, the pelvic C-clamp is used in unstable C type injuries, according to AO/OTA classification .
Temporary binders are used to control the hemorrhage from the pelvic fractures. These devices are very simple and quick to apply, and they can reduce the pelvic volume. However pelvic binders (PB) are not external fixator because they do not provide mechanical stabilization of the pelvis and they must be removed within 24 hours to avoid pressure sores on the patient. The data confirming efficacy of pelvic binders in controlling hemorrhage from pelvic fracture remain unclear because of conflicting studies in the literature [28, 29, 51, 52].
The Consensus Conference considered EF a pivotal procedure in presence of a mechanically unstable pelvic fracture and agreed that EF can be performed both in the shock room in the ED or in the OR, according to the local facilities. PB is a valid tool, mainly if applied in the prehospital setting, as a bridge to fixation. It can provide an external stabilization that could be life saving in patients in extremis. When EF is not possible (ie orthopedic surgeon is on call during night hours) PB is a valid alternative, provided EF is accomplished as soon as possible or the patient transferred to another facility.
PB should be applied as soon as pelvic mechanic instability is assessed, better in the prehospital setting [GoR A, LoE III]
Anterior or posterior EF must be accomplished in unstable fractures as soon as possible in substitution of PB [GoR B, LoE III]
EF can be accomplished in the ED or in the OR and appear to be a quick tool to reduce venous and bony bleeding [GoR A, LoE IV]
EF, whenever possible, can be the first maneuver to be done in patients with hemodynamic instability and a mechanically unstable pelvic fracture [GoR A, LoE IV]
AG emerged in the ‘80s as a valid tool to control arterial bleeding [53–55] and for many years has been regarded in the vast majority of trauma centers as the first-line treatment in unstable patients. On the other hand it has long activation time, as teams are often on call and they are not present in the hospital on a 24 hours basis. In the last years improvement of technology allowed for portable instruments [32, 36] that can lower the threshold for indication towards this method.
After non-pelvic sources of blood loss have been ruled out, patients with pelvic fractures and hemodynamic instability or signs of ongoing bleeding should be considered for pelvic AG/embolization. [GoR A, LoE III]
Patients with CT-scan demonstrating arterial intravenous contrast extravasation in the pelvis, may require pelvic AG and embolization regardless of hemodynamic status. [GoR A, LoE III]
After non pelvic sources of blood loss have been ruled out, patients with pelvic fractures who have undergone pelvic AG with or without embolization, with persisting signs of ongoing bleeding, should be considered for repeat pelvic AG/embolization [GoR B, LoE IV]
The decisional algorithm
During the Conference, after debating the statements, a draft for an algorithm was proposed to the SC, the JP and the audience (Figure 2). A formal consensus was reached on the use of PPP, as a first maneuver only, in mechanically stable fractures of the pelvis. In mechanically unstable fractures EF should be applied as a substitution of the PB as soon as possible even in the ED or in the OR according to local protocols. PPP without any kind of mechanical stabilization is not adequate, because it needs a stable frame for packing to be effective.
In the last few months the algorithm was written in detail and conducted to a double pathway according to the local expertise/availability of trauma surgeons/orthopedics. In the unstable patient EF can be done in the ED or the OR. The unanimous consent in the Conference regards the fact that AG is no more considered the first maneuver in the unstable patient, but is considered only for patients who remains unstable after EF and PPP.
Hemodynamically unstable pelvic trauma is a challenging task in most Trauma Centers. No unanimous consent is present in the literature regarding the best treatment for these patients. The First Italian Consensus Conference on this topic extensively reviewed the current available knowledge and proposed a readily available algorithm for different level and experience hospitals.
Special thanks to Franca Boschini (Ospedale Papa Giovanni XXIII, Bergamo, Italy) and Chiara Bassi (Regione Emilia-Romagna, Bologna/Modena, Italy) for their great bibliographical work and to Dr Walter Biffl who took part to the Conference presenting Denver experience and revised the manuscript.
First General Surgery Unit, Ospedale Papa Giovanni XXIII
Interventional Radiology, Ospedale Papa Giovanni XXIII
Emergency Medicine Unit, Ospedale Papa Giovanni XXIII
Second General Surgery, Ospedale Santa Chiara
Orthopedics and Traumatology, Presidio Ospedaliero di Ravenna
Intensive Care Unit, Ospedali Riuniti di Trieste
Professor of Surgery University of Colorado, Denver Health Medical Center
Orthopedics and Traumatology, Ospedale Papa Giovanni XXIII
Papakostidis C, Giannoudis PV: Pelvic ring injuries with haemodynamic instability: efficacy of pelvic packing, a systematic review.Injury 2009,40(Suppl 4):S53-S61.PubMedView Article
Papakostidis C, Kanakaris NK, Kontakis G, Giannoudis PV: Pelvic ring disruptions: treatment modalities and analysis of outcomes.Int Orthop 2009,33(2):329–338.PubMed CentralPubMedView Article
Cullinane DC, Schiller HJ, Zielinski MD, Bilaniuk JW, Collier BR, Como J, Holevar M, Sabater EA, Sems SA, Vassy WM, Wynne JL: Eastern Association for the Surgery of Trauma practice management guidelines for hemorrhage in pelvic fracture–update and systematic review.J Trauma 2011,71(6):1850–1868.PubMedView Article
Flint L, Babikian G, Anders M, Rodriguez J, Steinberg S: Definitive control of mortality from severe pelvic fracture.Ann Surg 1990, 211:703–706.PubMed CentralPubMedView Article
Latenser BA, Gentilello LM, Tarver AA, Thalgott JS, Batdorf JW: Improved outcome with early fixation of skeletally unstable pelvic fractures.J Trauma 1991,31(1):28–31.PubMedView Article
Broos P, Vanderschot P, Craninx L, Rommens P: The operative treatment of unstable pelvic ring fractures.Int Surg 1992,77(4):303–308.PubMed
Gruen GS, Leit ME, Gruen RJ, Peitzman AB: The acute management of hemodynamically unstable multiple trauma patients with pelvic ring fractures.J Trauma 1994,36(5):706–711. discussion 711–3PubMedView Article
van Veen IH, van Leeuwen AA, van Popta T, van Luyt PA, Bode PJ, van Vugt AB: Unstable pelvic fractures: a retrospective analysis.Injury 1995,26(2):81–85.PubMedView Article
Heini PF, Witt J, Ganz R: The pelvic C-clamp for the emergency treatment of unstable pelvic ring injuries. A report on clinical experience of 30 cases.Injury 1996,27(1):A38-A45.View Article
Bassam D, Cephas GA, Ferguson KA, Beard LN, Young JS: A protocol for the initial management of unstable pelvic fractures.Am Surg 1998,64(9):862–867.PubMed
Velmahos GC, Chahwan S, Falabella A, Hanks SE, Demetriades D: Angiographic embolization for intraperitoneal and retroperitoneal injuries.World J Surg 2000, 24:539–545.PubMedView Article
Wong YC, Wang LJ, Ng CJ, Tseng IC, See LC: Mortality after successful transcatheter arterial embolization in patients with unstable pelvic fractures: rate of blood transfusion as a predictive factor.J Trauma 2000, 49:71–75.PubMedView Article
Biffl WL, Smith WR, Moore EE, Gonzalez RJ, Morgan SJ, Hennessey T, Offner PJ, Ray CE Jr, Franciose RJ, Burch JM: Evolution of a multidisciplinary clinical pathway for the management of unstable patients with pelvic fractures.Ann Surg 2001, 233:843–850.PubMed CentralPubMedView Article
Ertel W, Keel M, Eid K, Platz A, Trentz O: Control of severe hemorrhage using C-clamp and pelvic packing in multiply injured patients with pelvic ring disruption.J Orthop Trauma 2001, 15:468–474.PubMedView Article
Cook RE, Keating JF, Gillespie I: The role of angiography in the management of haemorrhage from major fractures of the pelvis.J Bone Joint Surg 2002, 84B:178–182.View Article
Kushimoto S, Arai M, Aiboshi J, Harada N, Tosaka N, Koido Y, Yoshida R, Yamamoto Y, Kumazaki T: The role of interventional radiology in patients requiring damage control laparotomy.J Trauma 2003,54(1):171–176.PubMedView Article
Miller PR, Moore PS, Mansell E, Meredith JW, Chang MC: External fixation or arteriogram in bleeding pelvic fracture.J Trauma 2003, 54:437–443.PubMedView Article
Hagiwara A, Minakawa K, Fukushima H, Murata A, Masuda H, Shimazaki S: Predictors of death in patients with life-threatening pelvic hemorrhage after successful transcatheter arterial embolization.J Trauma 2003, 55:696–703.PubMedView Article
Ruchholtz S, Waydhas C, Lewan U, Pehle B, Taeger G, Kühne C, Nast-Kolb D: Free abdominal fluid on ultrasound in unstable pelvic ring fracture: is laparotomy always necessary?J Trauma 2004,57(2):278–285. discussion 285–7PubMedView Article
Fangio P, Asehnoune K, Edouard A, Smail N, Benhamou D: Early embolization and vasopressor administration for management of life-threatening hemorrhage from pelvic fracture.J Trauma 2005, 58:978–984.PubMedView Article
Sadri H, Nguyen-Tang T, Stern R, Hoffmeyer P, Peter R: Control of severe hemorrhage using C-clamp and arterial embolization in hemodynamically unstable patients with pelvic ring disruption.Arch Orthop Trauma Surg 2005, 125:443–447.PubMedView Article
Krieg JC, Mohr M, Ellis TJ, Simpson TS, Madey SM, Bottlang M: Emergent stabilization of pelvic ring injuries by controlled circumferential compression: a clinical trial.J Trauma 2005, 59:659–664.PubMedView Article
Croce MA, Magnotti LJ, Savage SA, Wood GW 2nd, Fabian TC: Emergent pelvic fixation in patients with exsanguinating pelvic fractures.J Am Coll Surg 2007, 204:935–942.PubMedView Article
Lai C, Kam CW: Bleeding pelvic fractures: updates and controversies in acute phase management.Hong Kong J Emerg Med 2008,15(1):36–42.
Richard MJ, Tornetta P: Emergent management of APC-2 pelvic ring injuries with an anteriorly placed C-Clamp.J Orthop Trauma 2009, 23:322–326.PubMedView Article
Morozumi J, Homma H, Ohta S, Noda M, Oda J, Mishima S, Yukioka T: Impact of mobile angiography in the emergency department for controlling pelvic fracture hemorrhage with hemodynamic instability.J Trauma 2010,68(1):90–95.PubMedView Article
Jeske HC, Larndorfer R, Krappinger D, Attal R, Klingensmith M, Lottersberger C, Dünser MW, Blauth M, Falle ST, Dallapozza C: Management of hemorrhage in severe pelvic injuries.J Trauma 2010, 68:415–420.PubMedView Article
Enninghorst N, Toth L, King KL, McDougall D, Mackenzie S, Balogh ZJ: Acute definitive internal fixation of pelvic ring fractures in polytrauma patients: a feasible option.J Trauma 2010,68(4):935–941.PubMedView Article
Tan EC, van Stigt S, van Vugt A: Effect of a new pelvic stabilizer [T-POD®] on reduction of pelvic volume and haemodynamic stability in unstable pelvic fractures.Injury 2010, 41:1239–1243.PubMedView Article
Cherry RA, Goodspeed DC, Lynch FC, Delgado J, Reid SJ: Intraoperative angioembolization in the management of pelvic-fracture related hemodynamic instability.J Trauma Manag Outcomes 2011, 5:6.PubMed CentralPubMedView Article
Karadimas EJ, Nicolson T, Kakagia DD, Matthews SJ, Richards PJ, Giannoudis PV: Angiographic embolisation of pelvic ring injuries. Treatment algorithm and review of the literature.Int Orthop 2011,35(9):1381–1390.PubMed CentralPubMedView Article
Hornez E, Maurin O, Bourgouin S, Cotte J, Monchal T, de Roulhac J, Meyrat L, Platel JP, Delort G, Meaudre E, Thouard H: Management of exsanguinating pelvic trauma: do we still need the radiologist?J Visc Surg 2011,148(5):e379-e384.PubMedView Article
Fang JF, Shih LY, Wong YC, Lin BC, Hsu YP: Angioembolization and laparotomy for patients with concomitant pelvic arterial hemorrhage and blunt abdominal trauma.Langenbecks Arch Surg 2011,396(2):243–250.PubMedView Article
Tai DK, Li WH, Lee KY, Cheng M, Lee KB, Tang LF, Lai AK, Ho HF, Cheung MT: Retroperitoneal pelvic packing in the management of hemodynamically unstable pelvic fractures: a level I trauma center experience.J Trauma 2011,71(4):E79-E86.PubMedView Article
Burlew CC, Moore EE, Smith WR, Johnson JL, Biffl WL, Barnett CC, Stahel PF: Preperitoneal pelvic packing/external fixation with secondary angioembolization: optimal care for life-threatening hemorrhage from unstable pelvic fractures.J Am Coll Surg 2011,212(4):628–635. discussion 635–7PubMedView Article
Fu CY, Wang YC, Wu SC, Chen RJ, Hsieh CH, Huang HC, Huang JC, Lu CW, Huang YC: Angioembolization provides benefits in patients with concomitant unstable pelvic fracture and unstable hemodynamics.Am J Emerg Med 2012,30(1):207–213.PubMedView Article
Hu P, Zhang YZ: Surgical hemostatic options for damage control of pelvic fractures.Chin Med J (Engl) 2013,126(12):2384–2389.
Metsemakers WJ, Vanderschot P, Jennes E, Nijs S, Heye S, Maleux G: Transcatheter embolotherapy after external surgical stabilization is a valuable treatment algorithm for patients with persistent haemorrhage from unstable pelvic fractures: outcomes of a single centre experience.Injury 2013,44(7):964–968.PubMedView Article
Abrassart S, Stern R, Peter R: Unstable pelvic ring injury with hemodynamic instability: what seems the best procedure choice and sequence in the initial management?Orthop Traumatol Surg Res 2013,99(2):175–182.PubMedView Article
Pohlemann T, Gansslen A, Bosch U, Tschern H: The technique of packing for control of hemorrhage in complex pelvic fractures.Tech Orthop 1994, 9:267–270.View Article
Cothren CC, Moore EE, Johnson JL, Moore JB: Outcomes in surgical versus medical patients with the secondary abdominal compartment syndrome.Am J Surg 2007,194(6):804–807.PubMedView Article
Ganz R, Krushell RJ, Jakob RP, Küffer J: The antishock pelvic clamp.Clin Orthop 1991, 267:71–78.PubMed
Bonner TJ, Eardley WG, Newell N, Masouros S, Matthews JJ, Gibb I, Clasper JC: Accurate placement of a pelvic binder improves reduction of unstable fractures of the pelvic ring.J Bone Joint Surg (Br) 2011,93(11):1524–1528.View Article
Köhler D, Sellei RM, Sop A, Tarkin IS, Pfeifer R, Garrison RL, Pohlemann T, Pape HC: Effects of pelvic volume changes on retroperitoneal and intra-abdominal pressure in the injured pelvic ring: a cadaveric model.J Trauma 2011,71(3):585–590.PubMedView Article
Ghaemmaghami V, Sperry J, Gunst M, Friese R, Starr A, Frankel H, Gentilello LM, Shafi S: Effects of early use of external pelvic compression on transfusion requirements and mortality in pelvic fractures.Am J Surg 2007,194(6):720–723.PubMedView Article
Spanjersberg WR, Knops SP, Schep NW, van Lieshout EM, Patka P, Schipper IB: Effectiveness and complications of pelvic circumferential compression devices in patients with unstable pelvic fractures: a systematic review of literature.Injury 2009,40(10):1031–1035.PubMedView Article
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