BACKGROUND Hemodynamically unstable pelvic fractures often require a multi-modal approach including both operative and endovascular management. While an important adjunct in hemorrhage control, time to angioembolization even at the most advanced trauma centers may take hours. Extraperitoneal packing (EPP) is a fast and effective procedure that can immediately address pelvic hemorrhage from the retroperitoneal space in severe pelvic injuries. The aim of this study was to evaluate the efficacy of early EPP, looking at 24 hours and overall mortality, and the hemodynamic impact of EPP in unstable blunt pelvic trauma. METHODS All trauma patients admitted to an urban Level I trauma center were evaluated from 2002 to 2018 in a retrospective single-center comparative study. Inclusion criteria were patients 14 years or older who sustained blunt trauma with pelvic fractures and hemodynamic instability. Exclusion criteria were a concomitant head injury (Abbreviated Injury Scale >3) and patients who underwent resuscitative thoracotomy. The patient population was divided into two groups: an EPP group and a no-EPP group. Propensity score matching was used to adjust for differences in baseline characteristics in the two groups: a one-to-one matched analysis using nearest-neighbor matching was performed based on the estimated propensity score of each patient. RESULTS Two hundred forty-four patients presented hemodynamically unstable, with a pelvic fracture (180 no-EPP, 64 EPP). With propensity score matching, 37 patients in each group were analyzed. Survival within the first 24 hours was significantly improved in the EPP group (81.1% vs. 59.5%, p = 0.042) and we registered similar results in overall survival rate (78.4% EPP group vs. 56.8% no-EPP group, p = 0.047). Those patients who underwent early EPP (n = 64) were associated with a significant improvement in hemodynamic stability, with a pre-EPP mean arterial pressure of 49.9 mm Hg and post-EPP mean arterial pressure of 70.1 mm Hg (p < 0.01). CONCLUSION Extraperitoneal pelvic packing is an effective procedure that can be performed immediately, even within the trauma bay, to improve hemodynamic stability and overall survival in patients who sustain severe blunt pelvic trauma. The early use of EPP can be lifesaving. LEVEL OF EVIDENCE Therapeutic, Level III.

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Pelvic trauma continues to have a high mortality rate despite damage control techniques for bleeding control. The aim of our study was to evaluate how Extra-peritoneal Pelvic Packing (EPP) and Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) impact the efficacy on mortality and hemodynamic impact. We retrospectively evaluated patients who sustained blunt trauma, pelvic fracture and hemodynamic instability from 2002 to 2018. We excluded a concomitant severe brain injury, resuscitative thoracotomy, penetrating trauma and age below 14 years old. The study population was divided in EPP and REBOA Zone III group. Propensity score matching was used to adjust baseline differences and then a one-to-one matched analysis was performed. We selected 83 patients, 10 for group: survival rate was higher in EPP group, but not significantly in each outcome we analyzed (24 h, 7 day, overall). EPP had a significant increase in main arterial pressure after procedure (+20.13 mmHg, p < 0.001), but this was not as great as the improvement seen in the REBOA group (+45.10 mmHg, p < 0.001). EPP and REBOA are effective and improve hemodynamic status: both are reasonable first steps in a multidisciplinary management. Zone I REBOA may be useful in patients ‘in extremis condition’ with multiple sites of torso hemorrhage, particularly those in extremis.