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Western Trauma Association
Management of Pelvic Fracture with Hemodynamic Instability
Annotation for Point F
In patients with
hemodynamic instability and refractory hemorrhagic shock, an alternative option,
is direct transport to the operating room for preperitoneal packing. This
approach should be used if the surgical team has the appropriate knowledge and
experience to perform preperitoneal packing as described.3
If the pelvic hematoma is expanding or the patient remains unstable, exploration
and preperitoneal packing should be rapidly performed.3,31
Preperitoneal packing is performed by opening the retroperitoneal hematoma
anteriorly, and evacuating the blood and clot. The bladder is retracted
laterally with a malleable retractor and the pelvic brim is carefully palpated
and manually dissected. Care should be taken to avoid avulsing any vascular
connections between the iliac and obturator vessels. After the pelvic brim is
palpated as posteriorly as the surgeon can reach (it is not visualized), three
laparotomy packs are placed sequentially deep to the pelvic brim. The first is
placed posteriorly just below the sacro-iliac joint, the second sponge is placed
anteriorly to the first (in the middle of the pelvic brim), and the third sponge
is placed in the retropubic space, deep, and lateral to the bladder. When one
side is completed, the bladder is retracted laterally toward that side and the
other side is packed.31
If there is continued bright red hemorrhage indicative of arterial bleeding,
emergency angiography with embolization should be performed. Removal or exchange
of the packs (if bleeding persists after pack removal) should be performed in 24
to 48 hours.
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