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)
- Stefano Magnone1Email author,
- Federico Coccolini1,
- Roberto Manfredi1,
- Dario Piazzalunga1,
- Roberto Agazzi2,
- Claudio Arici3,
- Marco Barozzi3,
- Giovanni Bellanova4,
- Alberto Belluati5,
- Giorgio Berlot6,
- Walter Biffl7,
- Stefania Camagni1,
- Luca Campanati1,
- Claudio Carlo Castelli8,
- Fausto Catena9,
- Osvaldo Chiara10,
- Nicola Colaianni1,
- Salvatore De Masi11,
- Salomone Di Saverio12,
- Giuseppe Dodi13,
- Andrea Fabbri14,
- Giovanni Faustinelli1,
- Giorgio Gambale15,
- Michela Giulii Capponi1,
- Marco Lotti1,
- Gian Mariano Marchesi16,
- Alessandro Massè17,
- Tiziana Mastropietro1,
- Giuseppe Nardi18,
- Raffaella Niola19,
- Gabriela Elisa Nita1,
- Michele Pisano1,
- Elia Poiasina1,
- Eugenio Poletti1,
- Antonio Rampoldi20,
- Sergio Ribaldi21,
- Gennaro Rispoli22,
- Luigi Rizzi8,
- Valter Sonzogni23,
- Gregorio Tugnoli24 and
- Luca Ansaloni1
© Magnone et al.; licensee BioMed Central Ltd. 2014
Received: 3 February 2014
Accepted: 24 February 2014
Published: 7 March 2014
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.
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.
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
Revised papers 1990-2013
Acute external fixation and angio
Use of PASG, 37/60 had ORIF within 24 hrs, only 4 ext fix
Prospective with historical controls
Early defined as internal or external fixation within 8 hrs from arrival
44 type B and C fractures
Angio and anterior urgent ORIF [within 2-3 days]
Van Veen 
Peritoneal packing, bilateral ligation of internal iliac artery, EF and/or ORIF within 6 hours
C clamp placement
External fixation first if anterior fracture, angio first if posterior fracture
Bilateral embolization of iliac internal artery
External fixation and angio, either before or after
Observational with historical controls
50/38 systolic blood pressure < 90
Use of angio and early external fixation or C clamp
Use of C clamp and pelvic packing
74 unstable [23 underwent angio]
Exernal fixation and angio
29 mixed population
Angio before and after Damage Control Laparotomy. No pelvic packing or external fixation. High mortality.
Angio and then external fixation. If laparotomy first angio done after external fixation
61 stable and unstable
Angio and then external fixation in the angio suite
Early external fixation in mechanically unstable fractures
Angio first usually. No packing. Laparotomy before or after angio. Some external fixation
C clamp and then angio
Outcomes following pelvic belt
186 [stable and unstable]
Use of External fixation or T-POD® and angio
External fixation and angio
24 APC-2 pelvic injuries [11 unstable]
Anteriorly placed C-clamp [in the ER, angio suite or OR]
Mobile angio first. No packing or fixation
External fixation and angio
Acute ORIF [< 24 hrs]
Application of T-POD®
34 mixed population
External fixation and secondary angio.
Pelvic packing, angio and fixation.
Mixed population [60% unstable fractures]. Angio and/or laparotomy. No packing.
Shift to pelvic packing and external fixation before angio
Preperitoneal pelvic packing and external fixation in emergency. Secondary angiography
Angio [available 24 hrs] directly if negative FAST. Intraperitoneal packing. No fixation.
External fixation first, no pelvic packing for closed fractures. Then angio [13 embolized out of 15 angio done]
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
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.
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