Overview
Definition:
Pelvic packing is a surgical technique involving the placement of sterile gauze or other absorbent materials into the pelvic cavity to apply direct pressure and tamponade bleeding vessels, primarily used to control life-threatening hemorrhage from pelvic fractures or retroperitoneal sources.
Epidemiology:
Pelvic fractures are associated with significant morbidity and mortality, with approximately 10-15% of patients experiencing exsanguinating hemorrhage
Pelvic packing is indicated in hemodynamically unstable patients with suspected pelvic bleeding, often seen in high-energy trauma.
Clinical Significance:
Effective pelvic packing is a critical resuscitation maneuver in patients with severe pelvic trauma
It buys time for definitive surgical control of hemorrhage, allowing for resuscitation and stabilization, thereby improving survival rates in otherwise fatal injuries.
Indications
Hemorrhage Control:
Persistent hemodynamic instability (e.g., systolic blood pressure < 90 mmHg, heart rate > 120 bpm) despite initial fluid resuscitation and blood product transfusion, with clinical suspicion of ongoing pelvic bleeding
Presence of an open-book or vertical shear pelvic fracture is a strong indicator.
Failure Of Other Methods:
Failure of initial conservative measures such as pelvic binders, external fixation, or angioembolization to control hemorrhage
It serves as a temporizing measure when definitive surgical intervention is delayed or not immediately feasible.
Specific Enarios:
Massive retroperitoneal hemorrhage from pelvic arterial or venous injury
Uncontrolled venous bleeding from fractured pelvic bones that cannot be effectively controlled by other means
As a bridge to definitive treatment like laparotomy for pelvic artery ligation or packing of intra-abdominal hematomas contributing to pelvic pressure.
Preoperative Preparation
Resuscitation:
Aggressive resuscitation with balanced blood products (red blood cells, plasma, platelets) in a 1:1:1 ratio is paramount
Maintain adequate mean arterial pressure (MAP) to perfuse vital organs
Consider administration of tranexamic acid (TXA) within 3 hours of injury.
Imaging:
Rapid assessment with FAST (Focused Assessment with Sonography for Trauma) exam to rule out intra-abdominal hemorrhage
CT angiography (CTA) of the pelvis and abdomen is crucial to identify arterial injury amenable to embolization, but should not delay packing in unstable patients.
Anesthesia And Monitoring:
General anesthesia with rapid sequence induction and intubation is typically required
Continuous hemodynamic monitoring, including arterial line and central venous pressure monitoring, is essential
Monitoring urine output via Foley catheter.
Procedure Steps
Surgical Approach:
A midline laparotomy is the standard approach
This allows for assessment of intra-abdominal injuries and provides access to the retroperitoneum and origin of pelvic vessels.
Pelvic Exploration:
Careful mobilization of the colon and small bowel cephalad to expose the pelvic brim and retroperitoneum
Identify the iliac vessels and ureters
Gentle blunt dissection of the retroperitoneum is performed to access the hematoma.
Packing Technique:
Using multiple large, sterile laparotomy sponges (e.g., 4x4s or 6x6s), pack the gauze firmly into the retroperitoneum around the pelvic hematoma
Start packing the most posterior and superior portions of the hematoma first, then sequentially fill the cavity
Ensure uniform pressure without creating avascular planes or damaging adjacent structures
At least 6-8 sponges are typically used, but the amount depends on cavity size.
Abdominal Closure:
The abdominal cavity is then closed loosely with a temporizing suture (e.g., running nylon or polypropylene sutures) or a vacuum-assisted closure device to prevent compartment syndrome
The pelvic hematoma is left exposed with the packing in situ, covered by a sterile dressing.
Postoperative Care
Monitoring:
Close monitoring of hemodynamic status, urine output, and core body temperature
Serial abdominal examinations are performed to assess for evolving hematomas or visceral compromise.
Reoperation And Removal:
The patient will require a return to the operating room within 24-48 hours for re-exploration, removal of packing, and definitive hemorrhage control
This may involve arterial ligation, venous repair, internal iliac artery ligation, or definitive pelvic fracture fixation
Careful removal of packing is performed to avoid dislodging clots and reinitiating bleeding.
Icu Management:
Management in the Intensive Care Unit (ICU) includes ongoing resuscitation, mechanical ventilation, pain management, and prevention of complications such as deep vein thrombosis and pressure ulcers
Nutritional support should be initiated early.
Complications
Early Complications:
Rebleeding upon packing removal
Damage to adjacent organs (bowel, ureters, bladder)
Compartment syndrome of the abdominal wall
Acute kidney injury
Sepsis from retained packing or infected hematoma.
Late Complications:
Intestinal obstruction due to adhesions
Fistula formation (e.g., entero-cutaneous, colo-vesical)
Chronic pain
Pelvic infection
Hernia formation.
Prevention Strategies:
Meticulous surgical technique during packing and removal
Aggressive resuscitation and early definitive management
Appropriate antibiotic prophylaxis
Judicious use of packing material
Early removal of packing at reoperation.
Key Points
Exam Focus:
Pelvic packing is a temporizing measure for exsanguinating pelvic hemorrhage in unstable patients
It is performed via a midline laparotomy
Re-exploration is mandatory within 24-48 hours for definitive control.
Clinical Pearls:
In a hemodynamically unstable patient with a pelvic fracture, consider pelvic packing even before definitive imaging if hemorrhage is suspected
The goal is to achieve hemostasis by direct tamponade
Remember to pack from posterior to anterior and superior to inferior.
Common Mistakes:
Delaying pelvic packing in an unstable patient
Inadequate packing leading to persistent bleeding
Excessive or too forceful packing leading to iatrogenic injury
Failure to re-explore and remove packing in a timely manner
Omitting assessment of intra-abdominal injuries during laparotomy.