Background A 2015 AAST trial reported a 32% mortality for pelvic fracture patients in shock. Angioembolization (AE) is the most common intervention; the Maryland group revealed time to AE averaged 5 hours. The goal of this study was to evaluate the time to intervention and outcomes of an alternative approach for pelvic hemorrhage. We hypothesized preperitoneal pelvic packing (PPP) results in a shorter time to intervention and lower mortality. Methods In 2004 we initiated a PPP protocol for pelvic fracture hemorrhage. Results During the 11-year study, 2293 patients were admitted with pelvic fractures; 128 (6%) patients underwent PPP (mean age 44 ± 2 years and ISS 48 ± 1.2). The lowest emergency department SBP was 74 mmHg and highest heart rate was 120. Median time to operation was 44 minutes and 3 additional operations were performed in 109 (85%) patients. Median RBC transfusions prior to SICU admission compared to the 24 postoperative hours were 8 versus 3 units (p<0.05). After PPP, 16 (13%) patients underwent AE with a documented arterial blush. Mortality in this high-risk group was 21%. Death was due to brain injury (9), multiple organ failure (4), pulmonary or cardiac failure (6), withdrawal of support (4), adverse physiology (3), and Mucor infection (1). Of those patients with physiologic exhaustion, 2 died in the OR at 89 and 100 minutes after arrival while 1 died 9 hours after arrival. Conclusions PPP results in a shorter time to intervention and lower mortality compared to modern series utilizing AE. Examining mortality, only 3 (2%) deaths were attributed to the immediate sequelae of bleeding with physiologic failure. With time to death under 100 minutes in 2 patients, AE is unlikely to have been feasible. PPP should be employed for pelvic fracture related bleeding in the patient who remains unstable despite initial transfusion.

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