Pelvic Packing Research Articles

External iliac artery thrombosis after hypogastric artery ligation and pelvic packing for placenta previa percreta

Placenta previa percreta is a serious pregnancy condition that may cause massive bleeding. Life-threatening hemorrhage is commonly managed via cesarean hysterectomy or vascular ligations in order to preserve fertility. We present a case of bilateral external iliac artery thrombosis after pelvic compression and uterine devascularization due to placenta previa percreta. The patient had cesarean section due to ultrasonography and magnetic resonance imaging-diagnosed placenta previa percreta, and stated that she preferred a conservative approach rather than hysterectomy in a case of massive bleeding. Spontaneous hemorrhage was recognized during the operation. Pelvic compression and bilateral uterine and internal iliac artery ligations were performed. The left external iliac artery was accidentally held and bonded as the left internal iliac artery, which was turned loose within a minute after distinguishing the vessels. Emergency angiography that was applied because of patient’s leg pain showed bilateral external iliac artery thrombosis. Angioplasty was performed by a cardiologist for bilateral occlusions. Placenta invasion abnormalities may be managed by pelvic compression or vascular ligations, which have their own serious complications that the surgeon must manage immediately.

Optimal sequence of surgical procedures for hemodynamically unstable patients with pelvic fracture: A network meta-analysis

BackgroundThe mortality rate of patients with hemodynamic instability due to severe pelvic fracture remains substantial and massive transfusion happens frequently. Angio-embolization, external fixation and preperitoneal pelvic packing of the pelvis are the main managements used to control bleeding in these patients. In this paper, we aimed at characterizing the rationale of these surgical managements, and placed them in optimal management algorithm to compose a new guideline. MethodsWe selected controlled trials, assessing safety of management for the intervention of hemorrhagic shock from mortality data, and assessing efficacy from volume of first 24 h blood transfusion following hospitalization. Six single and combined managements were extracted as comparison. A pairwise meta-analysis was conducted using a random effect model, and then the analysis was extended to a network meta-analysis. Pooled effect sizes were ranked and demonstrated the probability of being the best treatments for safety and efficacy. Results13 clinical trials and 24,396 participants were identified for this analysis. The assessment of rank probability indicated that pelvic packing presented the greatest likelihood of improving safety, while external fixation was indicated most efficient among the interventions for controlling hemorrhage. ConclusionsClinical protocols for guidelines of hemodynamically unstable pelvic fracture patients have been multidirectionally developed. We strongly support the initial application of an external fixator. Provided that patients remain hemodynamically unstable after application of an external fixation, pelvic packing is the next procedure to consider. Angio-embolization is the complementary but not alternative method of choice subsequently.

Bilateral distal ureteral transection in the setting of blunt trauma

A 69-year-old obese man was involved in a high-speed head-on motor vehicle collision. He was tachycardic and normotensive on arrival. He subsequently developed hemodynamic instability requiring blood transfusion. On examination...

The focused abdominal sonography for trauma examination can reliably identify patients with significant intra-abdominal hemorrhage in life-threatening pelvic fractures.

The focused abdominal sonography for trauma (FAST) examination has been reported to be unreliable in pelvic fracture patients. Additionally, given the advent of new therapeutic interventions, such as resuscitative endovascular balloon occlusion of the aorta (REBOA), rapid identification of intra-abdominal hemorrhage compared with Zone III hemorrhage may guide different therapeutic strategies. We hypothesized that FAST is reliable for detecting clinically significant intra-abdominal hemorrhage in the face of complex pelvic fractures. Our pelvic fracture database of all hemodynamically unstable patients requiring intervention from January 1, 2005, to July 1, 2015, was reviewed. The FAST examination was compared with operative and computed tomography (CT) scan findings. Confirmatory evaluation for FAST(-) patients was considered positive if therapeutic intervention was required. During the study period, 81 patients in refractory shock with FAST imaging in our emergency department (ED) underwent pelvic packing. Mean age was 45 ± 2 years and Injury Severity Score was 50 ± 1.5. The FAST examination was negative in 53 patients; 52 patients did not require operative intervention for abdominal bleeding while one patient required splenectomy. The FAST examination was positive in 28 patients; 26 had findings confirmed by CT or laparotomy while two patients did not have intra-abdominal hemorrhage on further evaluation. The sensitivity and specificity for FAST in this population was 96% and 96%, respectively, positive predictive value was 93%, and negative predictive value was 98%. The false-negative and -positive rates for FAST were 2% and 7%. Focused abdominal sonography for trauma examination reliably identifies clinically significant hemoperitoneum in life-threatening, pelvic fracture related hemorrhage. The incidence of a false-negative FAST in this unstable pelvic fracture population was 2%. FAST results may be used when determining the role of REBOA in these multisystem trauma patients and requires further study. REBOA placement should be considered in hemodynamically unstable pelvic fracture patients who are FAST(-), while laparotomy should be used in FAST(+) patients. Therapeutic, level IV.

A 24-year-old Female Traumatic Patient Following a Car Accident.

A healthy 24-year-old female presented at the emergency department (ED) after a car accident with ambulance while injured severely after the bus got run over her lower limb. As the trauma team was activated, her primary survey was started: Ac (Airway and cervical collar): She was awake and could talk. Cervical collar was fixed, oxygenation with face mask was started. B (Breathing): Her chest rising was symmetrical without any laceration or abrasion. Chest auscultation was clear and there was no tenderness or crepitation on palpation. No tracheal shift was found. She had normal respiratory rate and O2 saturation of 94% at ambient air. C (Circulation): Two large bore IV lines were inserted and blood samples were obtained. Her vital signs were BP = 60/40 mmHg, PR = 130/min, RR = 12. E-FAST was performed which was negative for free fluid in abdomen, pelvis and thorax, tamponade, and hemopneumothorax. Her pelvis was unstable on examination and pelvic wrapping was performed with sheath. IV fluid therapy with normal saline was started followed by 3 units of packed RBC transfusion. More pack cells and FFP were also requested. D (Disability): She had Glasgow coma scale of 15/15 with normal size and reactive pupil. No neurologic deficit was found except disability of lower extremities due to crush injury. E (Exposure): She had no midline spinal tenderness with normal sphincter anal tone, but there was a laceration in the perineum which extended to the vagina. Portable chest and pelvic x-ray as an adjutant to primary survey were performed which showed type C pelvic fracture. On her secondary survey, she had abrasion on her scalp, 1.5 cm laceration on her right tibia, deformity of her right thigh, and laceration in her genitalia with some vaginal bleeding. Direct pressure was applied and all lacerations were packed. According to negative e-FAST and pelvic fracture and shock, since the angiography was not available, it was decided to fix the pelvis with external fixator in the operation room. After the fixation, and because shock persisted, operative pelvic packing was undertaken. Unfortunately, she suffered cardiorespiratory arrest in the operating room and died.

Effect of abdominal negative-pressure wound therapy on the measurement of intra-abdominal pressure

BackgroundIn critically ill surgical patients undergoing abdominal negative-pressure wound therapy (NPWT), it remains uncertain whether or not intra-abdominal pressure (IAP) measurements should be obtained when NPWT is activated. We aimed to determine agreement between IAP measured with and without NPWT. MethodsIn this analytic cross-sectional study, critically ill surgical adults (≥18 y) requiring abdominal NPWT for temporary abdominal closure after a damage control laparotomy were selected. Patients with urinary tract injuries or with pelvic packing were excluded. Paired IAP measures were performed in the same patient, with and without NPWT; two different operators performed the measures unaware of the other's result. Bland-Altman methods assessed the agreement between the two measures. Subgroup analyses (trauma and nontrauma) were performed. ResultsThere were 198 IAP measures (99 pairs) in 38 patients. Mean IAP with and without NPWT were 8.33 (standard deviation 4.01) and 8.65 (standard deviation 4.04), respectively. Mean IAP difference was −0.323 (95% confidence interval −0.748 to 0.101), and reference range for difference was −4.579 to 3.932 (P = 0.864). From 112 IAP measures (56 pairs) in 21 trauma patients, mean IAP difference was −0.268 (95% confidence interval −0.867 to 0.331), and reference range for the difference was −4.740 to 4.204 (P = 0.427). ConclusionsThere was no statistically significant disagreement in IAP measures. IAP could be measured with or without NPWT. In critically ill surgical patients with abdominal NPWT for temporary abdominal closure, monitoring and management of IAP either with or without NPWT is recommended.

Pelvic Packing for Intractable Obstetric Hemorrhage After Emergency Peripartum Hysterectomy: A Review.

Postpartum hemorrhage (PPH) is the leading cause of maternal mortality worldwide. Even after emergency peripartum hysterectomy (EPH), bleeding may occur in the setting of acquired coagulopathy. This type of bleeding resistant to clipping, ligating, or suturing could be successfully controlled with a pelvic packing. This review provides an overview of the different pelvic packing techniques used after the failure of an EPH to control severe PPH. It aims to highlight the outcome of patients after packing, the morbidity and complications of packing, the timing and indications of packing, and finally the optimal duration of packing. Literature relating to pelvic packing after EPH in a PPH setting was reviewed. Packing techniques can be divided into 2 types: pads or roller gauze and balloon pack. The overall success rate was as high as 78.8% with a mortality rate of 12.5%. No major morbidity related to the pelvic packing was documented. The optimal duration of packing is in the range of 36 to 72 hours. Pelvic packing should be part of the armamentarium available to the obstetrician whenever intractable pelvic hemorrhage is encountered. It is quite simple and quick to perform and requires no special medical materials, the rate of complications is very low, and the success rate is high. The pelvic packing should be particularly useful in developing countries where more advanced technologies such as selective arterial embolization are not always available. In developed countries, the pelvic packing may be a valuable temporary measure pending transport to a tertiary care facility.

Severe Bleeding in Pelvic Fractures: Considerations in Planning Damage Control

Severe bleeding due to pelvic fractures may require damage control procedures, such as preperitoneal packing. In many cases, preperitoneal packing is performed without full abdominal exploration. There are concerns that such an approach may miss major iliac vascular injuries or other intraabdominal injuries. This analysis assessed the incidence of iliac vascular and intraabdominal injuries in patients with pelvic fractures. The National Trauma Data Bank was queried for blunt trauma patients. Patients with severe pelvic fractures were observed. Common or external iliac vascular lacerations (CEIVL) and associated intraabdominal injuries were recorded. The study comprised 42,122 patients with pelvic fractures, of which 3,221 (7.6%) were severe pelvic fractures. The incidence of CEIVL in patients with severe pelvic fractures was 10.7 per cent. Patient age greater than or equal to 65 years was an independent predictor of CEIVL. A total of 34.3 per cent of severe pelvic fracture patients had severe associated intraabdominal injuries, including injuries to the bladder (26.5%) and bowel (16.7%). Severe pelvic fractures are associated with a high incidence of iliac vascular and intraabdominal injuries. Preperitoneal pelvic packing without abdominal exploration may miss these injuries.

Angiography and Embolization in the Management of Bleeding Pelvic Fractures.

The use, timing, and priority of angioembolization in the management of bleeding pelvic fractures remain ambiguous. The most common vessels for angioembolization are, in decreasing order, the internal iliac artery and its branches, the superior gluteal artery, the obturator artery, and the internal pudendal artery. Technical success rates for this treatment option range from 74% to 100%. The fracture patterns most commonly requiring angioembolization are the Young and Burgess lateral compression and anterior-posterior compression types and Tile type C. Mortality rates after angioembolization of 16% to 50% have been reported, but deaths are usually related to concomitant injuries. The sensitivity and specificity of contrast-enhanced CT in detecting the need for angioembolization range from 60% to 90% and 92% to 100%, respectively. Angioembolization can be effective in the management of bleeding pelvic fractures, but as with any treatment, the risks of complications must be considered. Availability of angioembolization and institutional expertise/preference for the alternative strategy of pelvic packing influence its use.

Effects of the establishment of a trauma center and a new protocol on patients with hemodynamically unstable pelvic fractures at a single institution in Korea.

The aim of this study was to determine whether the outcomes of patients with hemodynamically unstable pelvic bone fractures changed after the introduction of a protocol including extraperitoneal pelvic packing (EPP) and the establishment of a trauma center. We analyzed data of adult patients (≥ 18years old) with hemodynamically unstable pelvic bone fractures who visited a single trauma center from February 2009 to October 2016. In July 2014, a new protocol for pelvic fractures was implemented, and a trauma center was established. Therefore, patient outcomes were compared by period (period I: pre-protocol vs. period II: post-protocol). Seventy-nine patients with hemodynamically unstable pelvic bone fractures were recruited. The time to angiographic embolization after arrival at the emergency room decreased significantly in period II when compared to period I (182.9 vs. 268.9min, respectively, p < 0.001). The time required to intervention, including EPP, also decreased, from 268.9 ± 132.4min in period I to 141.9 ± 79.9min in period II (p < 0.001). The overall mortality rate decreased from 47.2% in period I to 23.3% in period II (p = 0.033), and mortality related to hemorrhagic shock in particular, was significantly lowered, from 27.8% in period I to 4.7% in period II (p = 0.009). The establishment of a trauma center and the implementation of a new protocol that included EPP were effective in the treatment of patients with hemodynamically unstable pelvic fractures.

Effect of angioembolisation versus surgical packing on mortality in traumatic pelvic haemorrhage: A systematic review and meta-analysis.

The management of complex pattern of bleeding associated with pelvic trauma remains a big challenge for trauma surgeons. We aimed to conduct a comprehensive meta-analysis to compare the outcomes of angioembolisation and pelvic packing in patients with pelvic trauma. We conducted a systematic search of electronic information sources, including MEDLINE; EMBASE; CINAHL; the CENTRAL; the World Health Organization International Clinical Trials Registry; ClinicalTrials.gov; ISRCTN Register, and bibliographic reference lists. The primary outcome was defined as mortality. Combined overall effect sizes were calculated using random-effects models. Results are reported as the odds ratio (OR) and 95% confidence interval (CI). We identified 3 observational studies reporting a total of 120 patients undergoing angioembolisation (n=60) or pelvic packing (n=60) for pelvic trauma. Reporting of the Injury Severity Score (ISS) was variable, with higher ISS in the pelvic packing group. The risk of bias was low in two studies, and moderate in one. The pooled analysis demonstrated that angioembolisation did not significantly reduce mortality in patients with pelvic trauma compared to surgery (OR=1.99; 95% CI= 0.83-4.78, P=0.12). There was mild between-study heterogeneity (I2=0%, P=0.65). Our analysis found no significant difference in mortality between angioembolisation and pelvic packing in patients with traumatic pelvic haemorrhage. The current level of evidence in this context is very limited and insufficient to support the superiority of a treatment modality. Future research is required.

Haemodynamically unstable pelvic trauma: initial validation of a dedicated protocol by a retrospective cohort study with historical controls

Background: We present our experience after the introduction of Advanced Trauma Life Support (ATLS)©, Trauma Team (TT) and Preperitoneal Pelvic Packing (PPP) protocols for the treatment of hemodynamically unstable pelvic blunt trauma.Methods: This is a retrospective study with historical controls: before (Control Group, CG) and after (Study Group SG) the introduction of the protocol. A single physician managed the CG and angiography was the emergency manoeuvre. A team with ATLS guidelines and PPP as an emergency manoeuvre managed the SG. Data were collected retrospectively. Patients were divided into two groups: before and after the introduction of protocols.Results: From January 2007 to October 2014, 36 patients were treated at our Centre. We consider patients from January 2007 to August 2011 (19 patients, CG) and from September 2011 to October 2014 (17 patients, SG). Median age was 54 years (43–69) in the CG vs. 47 (40–63) in the SG (p = 0.43), median initial SBP 90 mmHg (85–103) in the CG 94 (69–103) in the SG, (p = 0.60), heart rate was 90 (80–110) in the G and 110 (95–130) in the SG, (p = 0.09). Median Injury Severity Score was 33 (21–41) in the CG and 34 (26–41) in the SG (p = 0.29). Time from arrival in the Emergency Department to first therapeutic manoeuvre was 132 minutes (109–180) in the CG and 87 minutes (51–204) in the SG (p = 0.4). The difference in mortality was statistically significant: 64.7% (11/17) in the CG and 23.5% (4/17) in the SG (p = 0.02).Conclusions: The introduction of protocols changed our approach in hemodynamically unstable pelvic trauma, achieving a remarkable improvement in early mortality.

Improvement of outcomes in patients with pelvic fractures and hemodynamic instability after the establishment of a Korean regional trauma center

Despite using a multidisciplinary treatment approach, the mortality rate of patients with hemodynamic instability from severe pelvic fractures is still 40-60%. We evaluated the improvement of outcomes in this patient population after the establishment of a regional trauma center in Korea. We retrospectively reviewed the medical charts of 50 patients with hemodynamic instability due to pelvic fractures between March 2011 and November 2016. Patients were divided into two groups: the pre-trauma center (PTC) group (n = 23) and trauma center (TC) group (n = 27). Sixteen (32.0%) patients died of exsanguination. Patients in the TC group had shorter trauma resuscitation room stay (101 vs 273min, p < 0.001) and underwent preperitoneal pelvic packing (PPP) more frequently (88.9 vs 8.7%, p < 0.001) than those in the PTC group. During the TC period, emergent procedures such as PPP and pelvic angiography were performed more frequently (92.6 vs 39.1%, p < 0.001). Although there was no statistical difference in the overall mortality rate between groups, patients in the TC group had less mortality due to hemorrhage (18.5 vs 47.8%, p = 0.027). Logistic regression analysis demonstrated that initial systolic blood pressure and establishment of trauma center were independent protective factors of mortality from hemorrhage [odds ratio (OR) 0.957, 95% confidence interval (CI) 0.926-0.988, p = 0.007; OR 0.134, 95% CI 0.028-0.633, p = 0.011]. Since the regional trauma center was established, emergent procedures such as pelvic angiography and PPP were performed more frequently, and mortality due to exsanguination was significantly decreased.

Interventional and operative procedures in complex and poly-trauma

Previously any general surgeon could practice trauma as the approaches to even complex trauma were straightforward: open the appropriate body cavity, identify the bleeding organ, and repair the damage. The high morbidity and mortality associated with this approach has given way to new concepts and techniques. Resuscitative thoracotomy has in part been replaced by resuscitative endovascular balloon occlusion of the aorta (REBOA). The approach to hemorrhage associated with complex pelvic fractures has evolved with the addition of REBOA, and preperitoneal pelvic packing (PPP). Damage control laparotomy (DCL) has been utilized less frequently thanks to better resuscitation. The evolution of these techniques has guided trauma surgery to becoming a distinct specialty.

Current trends in the management of hemodynamically unstable pelvic ring injuries

Complex traumatic pelvic ring disruptions are associated with a high mortality rate due to associated retroperitoneal hemorrhage, traumatic-hemorrhagic shock, and postinjury coagulopathy. The present review provides an update on current management strategies to improve survival rates form hemodynamically unstable pelvic ring injuries. Recently published international consensus guidelines have attempted to standardize the classification of hemodynamically unstable pelvic ring injuries and provided classification-based management algorithms for acute resuscitation and pelvic ring stabilization. Acute management strategies for pelvic ring disruptions with associated hemorrhagic shock include resuscitative endovascular balloon occlusion of the aorta for patients 'in extremis' in conjunction with point-of-care guided resuscitation for postinjury coagulopathy. Recent data indicate that a protocol of early pelvic external fixation in conjunction with direct preperitoneal pelvic packing and subsequent angioembolization in patients with ongoing hemorrhage results in significantly improved survival from retroperitoneal exsanguinating hemorrhage in at-risk patients with historic mortality rates as high as 50-60%.

Preperitoneal pelvic packing is effective for hemorrhage control in open pelvic fractures

BackgroundOpen pelvic fractures are life-threatening injuries. Preperitoneal pelvic packing (PPP) has been suggested to be ineffective for hemorrhage control in open pelvic fractures. We hypothesize that PPP is effective at hemorrhage control in patients with open pelvic fractures and reduces mortality. MethodsPatients undergoing PPP from 2005 to 2015 were analyzed. Patients with open pelvic fractures were defined as direct communication of the bony injury with overlying soft tissue, vagina, or rectum. ResultsDuring the 10-year study, 126 patients underwent PPP; 14 (11%) sustained an open pelvic fracture. After PPP, 1 patient (7%) underwent angioembolization with a documented arterial blush. PPP controlled pelvic hemorrhage in all patients. Overall mortality rate was 7% with one death due to traumatic brain injury. ConclusionsPPP is effective for hemorrhage control in patients with open pelvic fractures. PPP should be used in a standard protocol for hemodynamically unstable patients with pelvic fractures regardless of associated perineal injuries.

Effect of Retroperitoneal Pelvic Packing on Pelvic Cavity Pressure: A Cadaveric Study.

Limited clinical evidence demonstrates the effectiveness of direct retroperitoneal pelvic packing for hemorrhage control in pelvic fractures due to the difficulty in measuring pressure on the pelvic walls within the pelvic cavity after retroperitoneal pelvic packing. Using a cadaver model, the authors aimed to assess whether retroperitoneal pelvic packing generates pressure that exceeds the venous return and arterial pressure in the pelvis. The pressure on the pelvic wall was measured in 5 fresh Japanese cadavers. Sensors were placed at 4 points on the pelvic wall, and the pressure at each point was measured after the insertion of each of 3 sponges, per the procedure originally described for direct retroperitoneal pelvic packing. In each specimen, the average pressure across all 4 points on the pelvic wall increased with the addition of each sponge, reaching 12.3±4.5 mm Hg when all 3 sponges were inserted. Furthermore, the pressure at the pelvic floor and posterior pelvic brim increased significantly, whereas the pressure at the anterior and middle pelvic brim increased nonsignificantly. The results of this study suggest that retroperitoneal pelvic packing provides pressure on the pelvic wall that exceeds the venous pressure and is thus effective for the control of venous hemorrhage in pelvic fractures. Currently, the recommended procedure combines external fixation for venous bleeding, transcatheter arterial embolization, and pelvic packing; however, the authors' results suggest that pelvic packing alone may be effective for controlling venous hemorrhage in pelvic fracture. [Orthopedics. 2017; 40(6);e947-e951.].

Experience of application of extraperitoneal pelvic packing in unstable pelvic ring injuries

OBJECTIVE. Clinical efficacy of extraperitoneal pelvic packing for hemostasis was assessed in patients with unstable pelvic ring injuries and signs of unstable hemodynamics. MATERIAL AND METHODS. The results of treatment were analyzed in 19 patients with hemodynamically unstable pelvic ring injuries. Extraperitoneal pelvic packing was applied in order to stop bleeding after mechanical pelvic stabilization. The evaluation of hemostasis efficacy was performed by using computerized helical tomography with intravenous contrast. RESULTS. The extraperitoneal pelvic packing allowed doctors to achieve stop of bleeding in 14 (73,7 %) patients. CONCLUSIONS. Complex of mechanical stabilization and extraperitoneal pelvic packing of damaged pelvic ring could be actively used in cases of severe injuries for victims in critical conditions.

Management of hemodynamically unstable patients with fracture pelvis Mafraq Hospital experience, UAE

Background: Multidisciplinary team and multiple approaches were introduced to improve the outcome after significant pelvic trauma. In present study, we are evaluating our institutional management modalities for unstable patients with unstable pelvic fractures using angio-embolization, pelvic packing with or without angio-embolization and conservative management with surgical intensive care unit (SICU) admission.Methods: We reviewed 108 patients admitted with pelvic fractures from January 2013 to September 2014, 19 patients (17.5%) were hemodynamically unstable with pelvic fracture. Massive transfusion protocol was activated in all patients. FAST scan was done. Level 1 trauma CT for the responder and transient responder patients.Results: Out of 19 patients, 7 patients (36.8%) were good responders to resuscitation with maintaining of their hemoglobin stable, with no extravasation of dye, admitted to SICU for conservative management. 4 patients (21%) were responders with CT trauma revealed dye leak so they underwent angio-embolization, SICU admission. 8 patients (42.1%) were non-responders underwent preperitoneal packing, one of them had additional angio-embolization.Conclusions: Preperitoneal packing is an excellent choice for non-responder patients, while angio-embolization can be done for responder and transient responder patients with evident dye extravasation. This study needs more evaluation on a wider clinical scale.

Basic Management of Pelvic Fractures

The management and treatment of complex pelvic fractures require knowledge of the initial evaluation of a trauma patient, pertinent anatomy, and techniques available for hemorrhage control. Trauma patients with complex pelvic fractures are at high risk for hemorrhage and require thoughtful and expeditious management. A multidisciplinary team including a trauma surgeon, an orthopedic surgeon, and an interventional radiologist is required for optimal treatment of these complex injuries. The team must be managed by the trauma surgeon to guide ongoing resuscitation as the patient may travel throughout the hospital to undergo several interventions to control hemorrhage. A number of techniques can be emergently implemented for fracture stabilization and hemorrhage control, including temporary application of a pelvic binder, preperitoneal pelvic packing, external fixation, and angioembolization. The patient’s clinical status, fracture pattern, and bleeding source must be considered when deciding which hemorrhage control techniques should be performed. New temporary hemorrhage control interventions, such as resuscitative endovascular balloon occlusion of the aorta, have shown early success in control of pelvic fracture–related hemorrhage and require further investigation. Pelvic fractures are associated with a number of neurovascular and genitourinary injuries, which can carry long-term morbidity. This review discusses the diagnosis, management, and treatment of complex pelvic fracture and associated hemorrhage. This review contains 5 figures, and 55 references. Key words: angioembolization, pelvic fixation, pelvic fracture, preperitoneal packing, resuscitative endovascular balloon occlusion of the aorta