What's new in emergencies, trauma and shock? Extraperitoneal pelvic pressure packing: Placing this procedure in context.

To date, there are no randomized studies that report the value of damage control surgery, including retroperitoneal packing. Still, most nonrandomized (case-series/cohort) studies and clinical guidelines support the damage control surgery. The paper in this issue of JETS[1] dealing with “extraperitoneal pressure packing” (EPPP), better known as preperitoneal pelvic packing, presents a novel approach to the use of EPPP in patients who remain hemodynamically compromised despite standard resuscitation approaches. The novelty is the fact that the authors use this technique in isolation, either without routine external “fixation” or without routine angio-embolization of the iliac branches. They did selective later angio-embolization if needed after 48 h, and their “unpacking” was performed in the angio-suite. This paper does concur with a recent Danish study[2] that demonstrated adequate hemostasis with packing alone in a setting without angio-embolization, however, with the use of pelvic binders.

What the authors do not mention in their paper is what type of “external fixation” they were avoiding. Orthopedic metal-work fixation has become less commonly used in the unstable pelvic fracture subgroup over the past 5 years. What has become routine is pelvic wrapping (also known as pelvic binding), as part of the analgesic and fracture immobilization component of the management of these injuries. This “wrapping” can be in the form of a folded bed-sheet, SAM-pelvic splint®, Pelvigrip® device or the TPOD®. These devices are not considered as “external fixation,” yet may provide functionally more mechanical stability while allowing for rapid placement of the device. They are considered as the current standard of care.[345] What is not clear in the paper is whether any of these devices were used in conjunction with their packing technique, although it appears from the text as if these options were not used, once again making this paper somewhat novel.

The “routine” use of angiography, advocated by Tötterman's group is not universal, and the Denver group has always advocated for selective (although early) angiography. The Norwegian group also advocates for liberal laparotomy, as ultrasound (FAST-exam) is often unreliable as is diagnostic peritoneal lavage.[56]

With these introductory points mentioned, it is pertinent to highlight the indications for this procedure, whether used alone, as advocated here, or in combination with other modalities: This is not a panacea but should be applied only to patients with the compelling bleeding source in the pelvic girdle, after excluding other bleeding sources and where basic maneuvers, such as pelvic wrapping, fluid resuscitation with blood and other blood-products and fracture splinting have failed, resulting in an exsanguinating patient. In the overall scheme of pelvic trauma, this situation occurs in a small percentage of pelvic fractures (3-20%).[56] Those at risk of a “pelvic-related” mortality, number around 9% of all pelvic fractures, although in our experience the mortality for the group needing packing was high (67%).[7] Exsanguinating patients usually die in the emergency department, often before this procedure can be completed. Those who can be packed may have a better prognosis. Finally, the authors report no sepsis-related late-mortality despite a 35% sepsis-rate. They were indeed fortunate as this is a common consequence of pelvic packing, indeed being the cause of the two mortalities in our own small series of pelvic packing.[57]

The authors of the paper presented in this journal give hope to those working in regions with limited resources and especially those without advanced imaging capability or specialist orthopedic expertise, for successful hemorrhage control in pelvic fractures that may otherwise lead to death, provided the basics have been properly performed, including pelvic wrapping/binding in the resuscitation area.