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Preperitoneal Packing for Pelvic Fracture Hemorrhage2017

Type: Update Practice Management Guideline (PMG)
Existing PMG/EBR: Pelvic Fracture Hemorrhage-Update and Systematic Review
Category: Trauma
Committee Liaison: John J. Como, MD, MPH


Team leader(s)

Pelvic fractures are encountered in 9% of all blunt trauma patients. In 5% of these patients, it causes significant hemodynamic instability due to bleeding from the pelvic vessels. Uncontrolled pelvic hemorrhage is responsible for 39% of deaths in patients with pelvic fractures. The Eastern Trauma Association for the Surgery of Trauma (EAST) published its first Practice Management Guidelines (PMG) addressing management of pelvic hemorrhage in 2001. A systematic review and update of the 2001 PMG was done in 2011. Both PMGs utilized non-GRADE methodology. The 2011 Pelvic Fracture Hemorrhage PMG, made the following Level 1 (the highest level) recommendation: to perform emergent angiography/embolization in patients with pelvic fracture and 1) arterial extravasation of intravenous contrast on CT scan of pelvis and 2) hemodynamically compromised patients when signs of ongoing bleeding from non-pelvic sources have been ruled out. The remaining recommendations were lower level and addressed the following topics: methods of diagnosis of pelvic hemorrhage, pelvic fracture patterns and risk of significant bleeding, effectiveness of pelvic orthotic devices, temporary external fixation devices, indications for preperitoneal packing, and laparotomy. A few changes have taken place over the last 6 years. First, EAST has adopted GRADE as the methodology to be used in its PMGs. This methodology asks specific clinically relevant questions and through a rigorous process develops practical recommendations. Second, a large number of scientific reports were published addressing “grey” areas in the management of patients with hemorrhage related to pelvic fractures. The Trauma Force of the EAST guideline committee is planning to update the 2011 PMG. A working group consisting of EAST members will be created. This group will discuss areas for potential updates. These areas may include the following: methods of diagnosis of pelvic hemorrhage, pelvic fracture patterns and risk of significant bleeding, effectiveness of pelvic orthotic devices and temporary external fixation devices, indications for preperitoneal packing, the utility of laparotomy in the control of hemorrhage related to pelvic fractures, and indications for Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA). The working group will utilize the GRADE methodology for this PMG update.

PICO 1
In blunt trauma patients who are unstable due to their pelvic fractures (pelvic binder is on), should initial preperitoneal packing vs. initial angiography be performed to decrease transfusion requirements and mortality.

PICO 2
In blunt trauma patients who are unstable due to their pelvic fractures (pelvic binder is on) and angiography is not immediately available, should preperitoneal packing vs external orthopedic fixation be performed prior to angiography to decrease transfusion requirements and mortality.

PICO 3
In blunt trauma patients who are unstable due to their pelvic fractures (pelvic binder is on), and angiography is not immediately available, should preperitoneal packing vs resuscitation alone be performed prior to angiography to decrease transfusion requirements and mortality.

PICO 4
In blunt trauma patients with pelvic fractures who underwent PPP, is routine post-PPP angiography required vs no routine angiography" to decrease transfusion requirements and mortality.

Workgroup Members
James Bogert, MD
John Como, MD
Chasen Croft, MD
Mathew (Josie) Edavettal, MD, PhD
Tanya Egodage, MD
Paul Engels, MD
Michael Goodman, MD
Vijay Jayaraman, MD
Kosar Khwaja, MD, MBA, MSc
Dennis Kim, MD
Ryan A. Lawless, MD
Jeff Litt, DO
Rebecca Maine, MD, MPH
Amy McDonald, MD
Caleb Mentzer, DO
Kaushik Mukherjee, MD, MSCI
Rishi Rattan, MD
Bryce Robinson, MD, MS
Mary Elizabeth "Libby" Schroeder, MD
Rebecca W. Schroll, MD




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