The ideal management option for unstable pelvic injuries with haemorrhage is still being debated. The 2004 guidelines (Heetveld et al) call for urgent surgical fixation, followed by angioembolisation if the bleeding cannot be controlled. This paper was the contemporary of Question 5 from the first paper of 2004, which asked directly about a comparison of surgery and angiography. Subsequently, technology moved on (the 2004 guidelines also asked for a DPL). The more recent 2010 guidelines (Cullinane et al) makes stronger recommendations for the use of angiography early.
Specific statements from these recent guidelines include the following Level I and II recommendations, regarding who should have urgent angioembolisation after a pelvic fracture:
- Patients who are haemodynamicaly unstable and in whom non-pelvic sources of bleeding have been excluded
- Patients in whom a "blush" of contrast is seen on a CT angio
- Patients who are older than 60 with major pelvic fractures
More recently, authors have been swayed yet further towards angioembolisation as the primary method of control. In 2013, Abrassart et al have recommended that angioembolisation be the first approach, and laparotomy with pelvic packing only resorted to if there is no other option. Even more recently, the Italian Consensus Conference (Magnone et al, 2014) has come up with a sort of agreement among themselves. Again the guidelines were similar to the above, putting angiography in the role of primary therapy, and reserving pelvic packing for salvage procedures when all else has failed.
Question 21 from the first paper of 2012 asks the candidate to discuss the management of haemorrhagic shock due to pelvic fractures, in an unfocused what-would-you-do sort of way. This would not be very different to the emergency management of any severe trauma, until things came to the actual pelvis (and at that stage the choice of angio vs. surgery would again come up). Thus, that question is not dealt with here.
Other interesting options which are not mentioned in the table below are resuscitative endovascular balloon occlusion of the aorta (REBOA); this is dealt with well in the LITFL CCC entry of the same name.