exsanguinating pelvic fractures in the United Kingdom?

Haemodynamically unstable patients with pelvic fractures present a difficult management problem in accident and emergency (A&E) departments. There have been many reports supporting various treatment methods, though no prospective controlled trials of these different approaches have been undertaken. In this paper we shall review the evidence for the available treatment options and make recommendations for management of such patients in the United Kingdom. Relevant publications were identified by a combination of techniques: a Medline search combining the terms "pelvic fracture" and "bleeding," then identifying relevant work from the abstract; scrutiny of the reference lists for all papers and examination of any likely to be relevant; personal communications leading to identification of two articles; and hand searching two journals with a high incidence of relevant papers. Only English language papers were used. Relevance to the topic was the only inclusion criterion. None of the papers reviewed was a controlled trial, though some involved experimental comparisons. Data were not combined since inclusion criteria were different in the different series. The combination of pelvic ring fractures and hypotension following blunt trauma requires skilled and urgent management. A mortality rate of42% has been reported for those patients with pelvic ring fractures who arrive haemodynamically unstable, compared with 3.4% for those arriving haemodynamically stable,' and nearly 40% of early deaths from pelvic fractures are due to uncontrollable haemorrhage.' Ninety eight per cent of patients with major pelvic fractures have multiple injuries3 and intra-abdominal injury occurs in 18-35%3; thus the patient may be exsanguinating from the pelvis, from abdominal organs, or both, yet the diagnosis or exclusion of significant intraperitoneal haemorrhage is difficult and time is short. An unnecessary laparotomy will significantly reduce the chance of survival, but equally, overlooking a serious intra-abdominal injury may have fatal consequences.