# TABLE OF CONTENTS

# PURPOSE
The prompt diagnosis of a major pelvic ring injury and rapid and effective control of massive pelvic hemorrhage, as part of a general hemostatic resuscitation effort, is a key clinical priority in the successful management of the blunt trauma patient with a mechanically unstable pelvic ring injuries.
The purpose of this clinical practice guideline (CPG) is to review best evidence and generate expert consensus on recommendations for the management of hemodynamically unstable adult patients (age >16) with pelvic ring injuries in B.C.

# KEY MANAGEMENT QUESTIONS I. RESUSCITATION AND STABILIZATION
- What are key considerations in the initial assessment and management of patients with mechanically unstable pelvic ring injuries?
- When and how should REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta) be used in the acute management of major pelvic ring injuries?

# II. TEMPORARY PELVIC RING INJURY IMMOBILZATION
- How should the mechanically unstable fractured pelvis be immobilized initially?
- What considerations guide the duration of use of pelvic binders?
- What is the role of emergency department C-clamp application in the initial management of pelvic ring injuries?

# III. HEMORRHAGE CONTROL -ANGIOEMBOLIZATION
- When should angioembolization be used in the acute management of major pelvic ring injuries?
- When should selective versus non-selective angioembolization be used in acute management of blunt pelvic ring injury?

# IV. HEMORRHAGE CONTROL -PELVIC PACKING
- When should peritoneal pelvic packing be employed for major pelvic ring injuries? 9. How and by whom should pre-peritoneal pelvic packing be performed?
- Should pre-peritoneal pelvic packing be performed in a rural/remote or community setting?

# V. OPEN PELVIC RING INJURIES
- How should patients be assessed for the presence of open pelvic ring injury?
- What are the indications for fecal diversion in the management of open pelvic ring injuries?

# VI. DIAGNOSTIC IMAGING
- How should patients presenting with proven or suspected major pelvic ring injuries be diagnostically imaged?
- When and how should patients with pelvic ring fracture undergo evaluation of the urethra and the bladder?

# VII. TRANSFER TO HIGHER LEVEL OF CARE
- What are the indications and timing for higher level of care (HLOC) transfer of a trauma patient with major pelvic trauma to a centre with orthopedic expertise in the surgical management of complex pelvic ring injuries?
- What is the preferred process for inter-facility transfer of major pelvic ring injuries?
- Which patients with pelvic ring fractures can be managed in a centre with general orthopedic surgery?
- Which mechanically unstable pelvic ring injuries can be managed in a centre without orthopedic surgery?
- How should the orthopedic surgeon on-call in a community hospital be involved in the early management of the patients with pelvic ring injury?

# VIII. HOSPITAL CARE
- What are the care requirements for acceptable management of the stabilized admitted patient with a major pelvic ring injury?

# IX. DEFINITIVE SURGICAL CARE
- What is the preferred timeframe for definitive surgical fixation of major pelvic ring injury?
- How should bladder rupture (intraperitoneal and extraperitoneal) associated with major pelvic injuries be managed?

# X. TRANSFER TO LOWER LEVEL OF CARE (REPATRIATION)
- What are the indications and timing for repatriation back to a sending facility (or equivalent) of patients with major pelvic ring injury transferred to a regional centre with expertise for advanced orthopedic care?

# XI. REHABILITATION
- What is the preferred rehabilitation strategy for patients treated for major pelvic ring injury?
- When and how should patients who have undergone definitive surgical fixation of major pelvic ring injury be mobilized?
- What are the indications for in-patient rehabilitation of a patient treated for major pelvic ring injury?

# XII. FOLLOW-UP
- What is the recommended follow-up for a discharged patient with unstable pelvic ring injury? 

# GUIDELINES REFERENCED

# ALGORITHM SUMMARY OF RECOMMENDATIONS
Recommendations are newly drafted by the Complex Orthopedic SAG, unless indicated otherwise.

# I. RESUSCITATION AND STABILIZATION
A. When there is suspected active bleeding from a pelvic ring injury, apply a pelvic binder in the correct position. This should be applied pre-hospital.  B. Patients with suspected pelvic ring injuries with signs of hemodynamic instability should be transported directly to a regional centre with orthopedic expertise in the surgical management of complex pelvic ring injuries. If the patient is received into a hospital with general orthopedic capabilities, then resuscitation should be commenced followed by immediate transfer to a centre with orthopedic expertise in the surgical management of complex pelvic ring injuries for definitive treatment of active bleeding when advisable and feasible. 
C. All patients require IV Tranexamic Acid as soon as possible and ideally within an hour of injury. In the presence of hemodynamic instability, patients should be urgently resuscitated using blood products according to Massive Transfusion Protocols.  D. Patients with suspected pelvic ring injuries from high-energy trauma should have a CT scan with IV contrast of the pelvis on admission. Given the energy required to cause pelvic ring injury, other injuries should be expected and investigations should also include CT of the head and Cspine without contrast and CT of the chest and abdomen with contrast.  E. All patients with blunt polytrauma undergoing damage control laparotomy should have imaging of the pelvis before surgery (X-ray or CT). All patients should have a pelvic binder in-situ during surgery and this should not be removed for a post binder pelvic X-ray until the patient is hemodynamically stable.  F. Active bleeding from the pelvis in patients who do not respond to resuscitation can be managed by surgical packing of the pelvis or interventional radiology with selective embolization of active arterial bleeding vessels. Any hospital receiving trauma patients must have, based on its resources and facilities, clear protocols in place for managing patients with pelvic ring injury and hemodynamic instability.  G. In a patient in extremis, where resuscitation is failing, REBOA can be a first measure to temporarily control hemorrhage in conjunction with pelvic packing as a bridge to definitive care. REBOA should only be attempted in institutions with protocols and expertise in place, and in the context of local discussions and surgeon discretion. This novel technology requires further assessment regarding efficacy and safety in the setting of pelvic ring injury with hemodynamic instability.

# II. TEMPORARY PELVIC RING INJURY IMMOBILZATION
A. To immobilize the mechanically unstable fractured pelvis, apply a pelvic binder in the correct position as initial means of immobilization. This should be applied pre-hospital. G. If angiography is performed, selective angioembolization is preferred in acute management of blunt pelvic ring injury to minimize the risk of soft tissue/organ necrosis following mass embolization.
H. Non-selective angioembolization is not desired in acute management of blunt pelvic ring injury. If selective angioembolization is not possible, preferred options include pre-peritoneal pelvic packing or REBOA in conjunction with packing (if protocols are in place and surgeon has experience in REBOA or packing).

# IV. HEMORRHAGE CONTROL -PELVIC PACKING
A. Active bleeding from the pelvis in patients who do not respond to resuscitation can be managed by surgical packing of the pelvis or interventional radiology with selective embolization of active arterial bleeding vessels. Trauma centres with orthopedic surgery (general or expertise in the surgical management of complex pelvic ring injuries) must have a clear protocol in place for managing hemodynamically unstable patients with pelvic ring injuries. 

# VI. DIAGNOSTIC IMAGING
A. Patients with proven or suspected major pelvic fractures should be diagnostically imaged via an initial plain X-ray in the trauma bay. They should then undergo an intravenous contrast enhanced CT scan of the abdomen and pelvis when stable. X-ray views which reflect intraoperative imaging (inlet/outlet and judet views) may be done at the discretion of the surgeon when the patient is stable and surgery is planned.
B. Volume rendered 3D images of the bony pelvis based on CT acquisition data should be conducted at the original site where imaging is conducted prior to surgery, as these images provide additional information for surgical planning.
C. All polytraumatised patients require a post-binder removal X-ray after resuscitation, even in the presence of a negative CT scan because a well-applied pelvic binder can mask a catastrophic pelvic ring injury.  D. In the setting of gastrointestinal/genitourinary (GI/GU), general surgery and/or urology consultation is recommended. Refer to Diagnostic Imaging Guidelines for Trauma for recommendations regarding imaging of bladder/urethral injury.

# VII. TRANSFER TO HIGHER LEVEL OF CARE
A. A hemodynamically unstable patient with major pelvic trauma should be transported to a centre with orthopedic expertise in the surgical management of complex pelvic ring injuries as early as possible. Trauma/general surgery at the referral centre should be the primary point of contact. E. Patients with fractures which are minimally displaced and not requiring fixation, and nonoperative cases can be managed in a centre with general orthopedic surgery but without orthopedic expertise in the surgical management of complex pelvic ring injuries. Such cases should be assessed by the local orthopedic surgeon in discussion with referral centre.
F. All hemodynamically stable patients with mechanically unstable pelvic ring injuries must be transferred to a centre with orthopedic expertise in the surgical management of complex pelvic ring injuries, with the exception of patients who cannot tolerate transfer.
G. A local orthopedic surgeon on-call at the site of initial presentation, who is certified in Orthopedic Surgery by the Royal College of Physicians and Surgeons of Canada, should assess the hemodynamically stable patient in person, inform PTN, and consult an orthopedic surgeon with expertise in the surgical management of complex pelvic ring injuries.

# VIII. HOSPITAL CARE
A. Specialised units must have written local policies for thromboprophylaxis for patients with pelvic ring injuries, which should be followed and documented in the medical records.  B. Orthopedic surgeon must clarify weight-bearing orders, including timeline, and the need for follow-up imaging and timeline, as well as indicating any rehabilitation or transfer restrictions.

# IX. DEFINITIVE SURGICAL CARE
A. Definitive fixation should be done within 72 hours of stabilization of the patient's physiological state.  B. Any bladder rupture with associated contaminated pelvic ring injury and/or trauma to the urethra should involve urology.
C. In the setting of gastrointestinal/genitourinary (GI/GU) injury, general surgery and/or urology consultation is recommended.

# X. TRANSFER TO LOWER LEVEL OF CARE (REPATRIATION)
A. Agreement for repatriation should clearly state weight-bearing orders (including timeline), the need and timing for follow-up imaging, as well as indicating any rehabilitation or transfer restrictions. The follow-up plan, including documentations must be provided by the higher level of care site. See Recommendation B for KMQ-21.
B. Medically stable patients not requiring complex orthopedic care for their pelvic ring injury should be transferred back to sending facility or a facility close to patients' residence.

# XI. REHABILITATION
A B. Patients with suspected pelvic ring injuries with signs of hemodynamic instability should be transported directly to a regional centre with orthopedic expertise in the surgical management of complex pelvic ring injuries. If the patient is received into a hospital with general orthopedic capabilities, then resuscitation should be commenced followed by immediate transfer to a centre with orthopedic expertise in the surgical management of complex pelvic ring injuries for definitive treatment of active bleeding when advisable and feasible. 

# Additional Literature Support
Several studies show decrease in mortality with the introduction of a multidisciplinary institutional protocol for the management of pelvic trauma:
- A large retroactive analysis at a single trauma centre in Hong Kong (n=1,682) found significant decrease in adjusted pelvic ring injury mortality after implementation of protocol that includes early use of pelvic binder and rapid/appropriate use of pelvic angiography.
Odds ratio for 3 years prior to protocol vs. first 4 years of protocol implementation: 2.05 (95% CI=1.26, 3.3). In the healthiest patients with unstable pelvic ring injuries, the mortality rate is now similar to that of patients with stable fracture patterns. 7  A registry analysis at the Denver Health Medical Center (n=216) found a significant decrease in mortality (from 31% to 15%, p<0.05) after revising its pelvic trauma pathway to include immediate ED presence of orthopedic surgeon, wrapping the pelvis with a sheet, and using C-clamps or early surgical fixation. 8  A retrospective study at a Level 1 trauma centre in Texas (n=199) found an over 30% decrease in 30-day mortality rate after the implementation of protocols for pelvic angiography and pelvic packing by over 30 %. Implementation of protocol for pelvic embolization alone significantly reduced the 30-day mortality rate by more than 20% (p=0.009). 9  A small analysis of prospectively collected data in Australia (n=31) found decrease in 24-hour packed red blood cells transfusion (from 16  2U to 11  1U, p<0.05) and in mortality (from 35% to 7%, p<0.05) after implementing a multidisciplinary practice protocol that includes prehospital notification of pelvic trauma, pelvic binding, and pelvic angioembolization. 10 

# Additional Literature Support

# What is the effectiveness of REBOA in controlling hemorrhage in traumatic pelvic injuries?
The use of REBOA is increasing worldwide over the past 10 years and as long as 15 years in Japan. Currently, the quality of evidence supporting the use of this novel technology is low.
- Effectiveness: A recent prospective study (n=114) by the American Association for the Surgery of Trauma showed hemodynamic improvements of 67.4% of patients with REBOA and 47.8% of patients with REBOA achieved stability (systolic blood pressure consistently >90 mm Hg for >5 minutes) compared to 27.9% who received open aortic occlusion. 11 These differences are not statistically significant and the advantages of REBOA compared to resuscitative thoracotomy remain unconfirmed.
- Complications: Studies to date show rates of complications below 1%, which include distal ischemia or thromboembolic events, intracranial massive hemorrhage, pseudoaneurysm at the access site. 12 While the introducer sheath size has been suggested as a risk factor for complications, it is unclear whether a low-profile device offers significant advantages.
- Mortality: A high mortality rate of 65% has been demonstrated but has been suggested to be attributed to the severity of the injuries rather than failure of REBOA. 12  Advantages: Insertion of an arterial catheter allows for angiography in the OR without having to transfer the patient to an interventional radiology suite. 12  Caveats: The attending surgeon requires skillset and confidence. Trained surgeons have been shown to perform REBOA in 3-15 minutes in simulated settings. 12 WSES notes that REBOA is only a temporary solution, which must be followed by definitive care, noting that most trauma centres reserve REBOA only in patients in critical condition with multiple sites of bleeding. 3 The SAG notes that REBOA is a promising clinical option, pending more high-quality evidence and stronger recommendation by other professional bodies.   Pelvic hematoma >500 cm 3 in size has an increased incidence of arterial injury and need for angiography.   Although fracture pattern or type does not predict arterial injury or need for angiography, anterior fractures are more highly associated with anterior vascular injuries, whereas posterior fractures are more highly associated with posterior vascular injuries.  These statements are points of information rather than recommendations for clinical management, and as such were excluded.

# II. TEMPORARY PELVIC RING INJURY IMMOBILIZATION

# III. HEMORRHAGE CONTROL -ANGIOEMBOLIZATION
However, these statements provide supportive evidence to the SAG's recommendations. H. Non-selective angioembolization is not desired in acute management of blunt pelvic ring injury. If selective angioembolization is not possible, preferred options include pre-peritoneal pelvic packing or REBOA in conjunction with packing (if protocols are in place and surgeon has experience in REBOA or packing).

# KNOWLEDGE SYNTHESIS External Recommendations SAG's Decision
- Pelvic angiography with bilateral embolization seems to be safe with few major complications. Gluteal muscle ischemia/necrosis has been reported in patients with hemodynamic instability and prolonged immobilization or primary trauma to the gluteal region as the possible cause, rather than a direct complication of angioembolization.   Sexual function in males does not seem to be impaired after bilateral internal iliac arterial embolization.  These statements are points of information that support selective angioembolization as preferred method. New recommendation statements were created to guide clinical management.

# Additional Literature Support

# What is the risk of complications associated with non-selective angioembolization of the pelvis?
Potential complications of non-selective angioembolization are gluteal necrosis, wound complications, claudication, neuropathy, poor fracture healing and impotence. Risk of complications ranges from 3.3 to 66 %. 14 A multicentre retrospective cohort study (n=145) comparing selective and non-selective angioembolization in pelvic trauma patients found an increased rate of overall in-patient complications in the non-selective group, longer hospital and ICU stays, and higher rate of thromboembolic complications (12.1% vs. 0, p=0.010). 

# IV. HEMORRHAGE CONTROL -PELVIC PACKING

# Additional Literature Support

# What evidence supports the use of pelvic packing to control pelvic hemorrhage after trauma?
80-90% of bleeding in patients with hemodynamically unstable pelvic ring injuries is attributed to venous bleeding, providing rationale for pelvic packing as acute surgical method of hemorrhage control. 3 Inconclusive findings regarding superiority of pelvic packing to pelvic angioembolization.
Small studies have shown shorter times for pelvic packing than pelvic angioembolization. 15,16 However, these findings are dependent on local institutional protocols.

# KMQ-9.
How and by whom should pre-peritoneal pelvic packing be performed?

# RECOMMENDATIONS
F. Hospitals with expertise should develop local protocols for pelvic packing in unstable pelvic ring injuries. 

# KNOWLEDGE SYNTHESIS

# V. OPEN PELVIC RING INJURIES AND ASSOCIATED GASTROINTESTINAL/GENITOURINARY INJURIES

# VI. DIAGNOSTIC IMAGING
KMQ-13. How should patients presenting with proven or suspected major pelvic ring injuries be diagnostically imaged?

# RECOMMENDATIONS
A. Patients with proven or suspected major pelvic fractures should be diagnostically imaged via an initial plain X-ray in the trauma bay. They should then undergo an intravenous contrast enhanced CT scan of the abdomen and pelvis when stable. X-ray views which reflect intraoperative imaging (inlet/outlet and judet views) may be done at the discretion of the surgeon when the patient is stable and surgery is planned.
B. Volume rendered 3D images of the bony pelvis based on CT acquisition data should be conducted at the original site where imaging is conducted prior to surgery, as these images provide additional information for surgical planning.
C. All polytraumatised patients require a post-binder removal X-ray after resuscitation, even in the presence of a negative CT scan because a well-applied pelvic binder can mask a catastrophic pelvic ring injury. 

# KNOWLEDGE SYNTHESIS External Recommendations SAG's Decision

# X-ray and E-FAST
- The use of Pelvic X-ray and E-FAST in the Emergency Department is recommended in hemodynamic and mechanic unstable patients with pelvic trauma and allows to identify the injuries that require an early pelvic stabilization, an early angiography, and a rapid reductive maneuver, as well as laparotomy.  B. Orthopedic surgeon must clarify weight-bearing orders (with timeline) and the need for followup imaging (with timeline), as well as indicating any rehabilitation or transfer restrictions.

# VII. TRANSFER TO HIGHER LEVEL OF CARE

# KNOWLEDGE SYNTHESIS External Recommendations SAG's Decision
- Specialised units should have written local policies for thromboprophylaxis for patients with pelvic fractures, which should be followed and documented in the medical records.
Adopted BOA statement.
Created a new recommendation to reflect the BC trauma system. 

# IX. DEFINITIVE SURGICAL CARE

# X. TRANSFER TO LOWER LEVEL OF CARE (REPATRIATION)
KMQ-23. What are the indications and timing for repatriation back to a sending facility (or equivalent) of patients with major pelvic ring injury transferred to a regional centre expertise for advanced orthopedic care?

# RECOMMENDATIONS
A. Agreement for repatriation should clearly state weight-bearing orders (including timeline), the need and timing for follow-up imaging, as well as indicating any rehabilitation or transfer restrictions. The follow-up plan, including documentations must be provided by the higher level of care site. See Recommendation B for KMQ-21.
B. Medically stable patients not requiring complex orthopedic care for their pelvic ring injury should be transferred back to sending facility or a facility close to patients' residence.

# KNOWLEDGE SYNTHESIS External Recommendations SAG's Decision
None New recommendations created based on provincial realities and the expert opinion of the SAG.

# KMQ-26.
What are the indications for in-patient rehabilitation of a patient treated for major pelvic ring injury?

# RECOMMENDATIONS
C. All patients with major pelvic trauma should receive in-patient rehabilitation.

# KNOWLEDGE SYNTHESIS External Recommendations SAG's Decision
None New recommendation created based on the expert opinion of the SAG.

# External Recommendations SAG's Decision
Ignored BOA statement regarding performance monitoring as out of scope.