CLINICAL MANAGEMENT UPDATE Eastern Association for the Surgery of Trauma Practice Management Guidelines for Hemorrhage in Pelvic Fracture—Update and Systematic Review Daniel C. Cullinane, MD, Henry J. Schiller, MD, Martin D. Zielinski, MD, Jaroslaw W. Bilaniuk, MD, Bryan R. Collier, DO, John Como, MD, Michelle Holevar, MD, Enrique A. Sabater, MD, S. Andrew Sems, MD, W. Matthew Vassy, MD, and Julie L. Wynne, MD Background: Hemorrhage from pelvic fracture is common in victims of blunt traumatic injury. In 2001, the Eastern Association for the Surgery of Trauma (EAST) published practice management guidelines for the manage- ment of hemorrhage in pelvic trauma. Since that time there have been new practice patterns and larger experiences with older techniques. The Practice Guidelines Committee of EAST decided to replace the 2001 guidelines with an updated guideline and systematic review reflecting current practice. Methods: Building on the previous systematic literature review in the 2001 EAST guidelines, a systematic literature review was performed to include references from 1999 to 2010. Prospective and retrospective studies were included. Reviews and case reports were excluded. Of the 1,432 articles identified, 50 were selected as meeting criteria. Nine Trauma Surgeons, an Interventional Radiologist, and an Orthopedic Surgeon reviewed the articles. The EAST primer was used to grade the evidence. Results: Six questions regarding hemorrhage from pelvic fracture were addressed: (1) Which patients with hemodynamically unstable pelvic frac- tures warrant early external mechanical stabilization? (2) Which patients require emergent angiography? (3) What is the best test to exclude extrapel- vic bleeding? (4) Are there radiologic findings which predict hemorrhage? (5) What is the role of noninvasive temporary external fixation devices? and (6) Which patients warrant preperitoneal packing? Conclusions: Hemorrhage due to pelvic fracture remains a major cause of morbidity and mortality in the trauma patient. Strong recommendations were made regarding questions 1 to 4. Further study is needed to answer questions 5 and 6. Level of Evidence: Four Level I, 10 Level II, and 12 Level III recommen- dations were made based on the literature. There was no class I evidence available. Fifteen class II articles and 35 class II articles were included in the review. Key Words: Pelvic fracture, Hemorrhage, Angiography, Embolization, External fixator, C-clamp, Temporary pelvic binder, Pelvic packing, Trauma, Intravenous contrast extravasation, Blush, PASG, Pelvic hematoma, FAST, CT scan, Fracture pattern. (J Trauma. 2011;71: 000 – 000) STATEMENT OF THE PROBLEM Hemorrhage from pelvic fracture is common in victims of blunt traumatic injury. In 2001, the Eastern Association for the Surgery of Trauma (EAST) published practice management guidelines for the management of hemorrhage in pelvic trauma. 1 Since that time there have been a number of new practice patterns and larger experiences with older tech- niques. The Practice Guidelines Committee of EAST decided to update the 2001 EAST guidelines and systematic review for hemorrhage due to pelvic fracture. The design of the project was to update the previous guideline as well as to evaluate new treatment methods and techniques. Six specific questions are addressed regarding the management of pelvic fracture hemorrhage: 1. Which patients with hemodynamically unstable pelvic fractures warrant early external mechanical stabilization? 2. Which patients require emergent angiography? 3. What is the best test to exclude extrapelvic bleeding? 4. Are there radiologic findings which predict hemorrhage? 5. What is the role of noninvasive temporary external fixa- tion devices? 6. Which patients warrant preperitoneal packing (PPP)? PROCESS The Practice Management Guidelines Committee of the EAST (www.east.org) developed the process used by this committee for review and development of practice manage- ment guidelines. A computerized search of the National Library of Medicine MEDLINE database was undertaken using the OVID interface. English language citations were included for the period of 1999 through 2010 using the primary search strategy: pelvis, fracture hemorrhage, trauma, and retroperitoneal hematoma. The dates were selected to allow comprehensive review of articles published since the prior systematic review with minimal overlap. Submitted for publication April 21, 2011. Accepted for publication October 18, 2011. Copyright © 2011 by Lippincott Williams & Wilkins From the Mayo Clinic (D.C.C., H.J.S., S.A.S., M.D.Z.), Rochester, Minnesota; Morristown Memorial Hospital (J.W.B.), Morristown, New Jersey; Vanderbilt University Medical Center (B.R.C.), Nashville, Tennessee; MetroHealth Med- ical Center (J.C.), Cleveland, Ohio; Mount Sinai Hospital (M.H.), Chicago, Illinois; HIMA-San Pablo Hospital (E.A.S.), Bayamon, Puerto Rico; Evans- ville Surgical Associates (W.M.V.), Newburgh, Indiana; and University of Arizona (J.L.W.), Tucson, Arizona. Presented at the 22nd Annual Scientific Assembly of the Eastern Association for the Surgery of Trauma, January 16, 2009, Lake Buena Vista, Florida. The authors declare no conflicts of interest. Address for reprints: Daniel C. Cullinane, MD, Department of Surgery, Mayo Clinic, 200 First St, SW, Rochester, MN 55905; email: cullinane.daniel@ mayo.edu. DOI: 10.1097/TA.0b013e31823dca9a balt5/zta-ta/zta-ta/zta99909/zta3152-09z xppws S1 11/16/11 7:21 Art: TA204988 Input-sv The Journal of TRAUMA ® Injury, Infection, and Critical Care • Volume 71, Number 6, December 2011 1 AQ: 1 AQ: 10 AQ: 11 AQ: 2 <article-id pub-id-typedoi>10.1097/TA.0b013e31823dca9a</article-id> ● <fpage></fpage> ● <lpage></lpage>