Outcomes of emergency department and operating room preperitoneal pelvic packing in hemodynamically unstable severe pelvic fractures: a retrospective risk-adjusted observational study.

backgroundHemodynamically unstable patients with pelvic fractures have a high mortality rate. Most bleeding from pelvic fractures originates from venous and bony sources; therefore, direct compression of the pelvic wall can be effective, and preperitoneal pelvic packing (PPP) should be considered as a first-line intervention. PPP can be performed in both the emergency department (ED) and the operating room (OR). However, outcomes according to the location of PPP have not been clearly established. This study evaluated the outcomes of ED-PPP and OR-PPP based on the location where the surgery was performed.

methodsThis single-center, retrospective, observational study included patients who underwent PPP for pelvic fractures with an Abbreviated Injury Scale score of ≥ 4 from July 2015 to June 2025. Data were collected from a prospectively maintained trauma registry. Patients were categorized into ED-PPP and OR-PPP groups according to the site of PPP. Baseline characteristics, injury severity (Injury Severity Score, Revised Trauma Score, and Trauma and Injury Severity Score), and interventions, including ED thoracotomy, resuscitative endovascular balloon occlusion of the aorta, tranexamic acid administration, and time to PPP and transfusion, were compared. Mortality outcome measures were evaluated at 24 h, 7 days, and as overall in-hospital mortality and were risk-adjusted using W- and Z-statistic.

resultsFifty patients were included, with 17 and 33 in the ED-PPP and OR-PPP groups, respectively. Patients in the ED-PPP group were more critically ill at presentation, with lower systolic blood pressure, lower Glasgow Coma Scale scores, and a higher incidence of cardiac arrest before PPP. Time from scene to PPP (114.4 ± 68.6 vs. 284.3 ± 186.9 min) and to transfusion (84.5 ± 53.3 vs. 126.3 ± 72.5 min) was shorter in the ED-PPP group. The W-statistic demonstrated a greater number of actual survivors than expected in the ED-PPP and OR-PPP groups at 24 h (38.31 vs. 29.69) and 7 days (26.55 vs. 17.57), despite the high crude mortality rates (76.5% vs. 27.3%). Risk-adjusted in-hospital mortality showed no significant difference (W-statistic 3.02 vs. 5.45).

conclusionPPP is associated with improved early and intermediate survival. ED-PPP significantly reduces the time to hemorrhagic control and should be strongly considered as an important rescue damage control intervention for patients with life-threatening pelvic bleeding.