Appendix B: Pelvic Packing Technique

1. Clinical Indications

a. Persistent hypotension (SBP <90) despite resuscitation and stabilization of unstable pelvic fracture.

2. Key Anatomy

a. Pre-peritoneal space: Space of Retzius

b. Peritoneal space: abdominal cavity

c. Retroperitoneal space: space posterior to peritoneum

d. Venus plexus along anterior sacrum

e. Large potential space for hemorrhage in the pre and retroperitoneal space

Figure 1. Pelvic ring injury can result in a large potential space for hemorrhage in the pre-peritoneal space. Source: Combat Orthopeadic Trauma Surgery Course (COTS+)

3. Steps

a. Make a longitudinal low, vertical midline incision between the umbilicus and pubis.

b. Divide the rectus sheath along the linea, to enter the pre-peritoneal space (Space of Retzius), taking care to avoid entering the peritoneal space.

c. Evacuate pelvic hematoma if present.

d. Place 3-4 packs on each side of the retroperitoneal space to tamponade bleeding. Place the packs posteriorly and deep.

e. Close fascia or skin over the packs.

4. Pearls/Pitfalls

a. Do not place packs intra-peritoneal, this will not tamponade the targeted bleeding.

b. Ensure packs are rolled so you can more effectively roll them posteriorly into the retroperitoneal space.

c. Be sure to also stabilize the pelvis with a sheet/binder or external fixator.

Figure 2. Illustrated steps of pelvic packing as described in text. Source: COTS+