Clinical Scorecard: Infectious Risks Associated with Extra-Peritoneal Pelvic Packing in Emergency Settings

At a Glance

Key Highlights

• EPP is an effective and safe procedure for controlling exsanguinating pelvic hemorrhage, even when performed in the ER.
• Local infection is the main complication of pelvic packing, occurring in 15–35% of cases, with increased risk if packing removal is delayed beyond 48 hours.
• Infection risk is higher in patients with open fractures or associated bladder/bowel injuries; infection diagnosis requires microbiological contamination plus clinical signs (fever, leukocytosis, elevated CRP).

Guideline-Based Recommendations

Diagnosis

• Define hemodynamic instability as persistent systolic blood pressure < 90 mmHg despite resuscitation and transfusion of ≥ 2 units PRBCs.
• Diagnose pelvic infection by microbiological contamination of packing fluid plus at least one clinical criterion: fever > 38 °C, leukocytosis > 15 × 10³/mL, or CRP > 10 mg/L within 48 hours of packing removal.

Management

• Perform EPP promptly in unstable pelvic fracture patients before laparotomy if needed.
• Remove pelvic packing within 24–48 hours after hemodynamic stabilization to reduce infection risk.
• Consider external fixation and angioembolization for persistent hypotension or evidence of arterial bleeding.

Monitoring & Follow-up

• Monitor vital signs and laboratory markers (CRP, leukocyte count) during and after EPP.
• Perform microbiological analysis of packing material upon removal.
• Assess for signs of infection within 48 hours post-packing removal.

Risks

• Local pelvic infection occurring in 15–35% of cases, increased with delayed packing removal (>48 h).
• Higher infection risk in patients with open fractures or associated bladder/bowel injuries.
• Potential difficulty and debated efficacy of alternative hemorrhage control methods like REBOA.

Patient & Prescribing Data

Hemodynamically unstable patients with pelvic fractures without severe head injury or immunosuppression

EPP performed in ER does not increase infection risk compared to OR; early removal of packing and multidisciplinary management optimize outcomes.

Clinical Best Practices

• Implement immediate EPP in unstable pelvic fracture patients as part of a standardized protocol including external fixation and angioembolization as needed.
• Remove pelvic packing within 24–48 hours to minimize infection risk.
• Use microbiological and clinical criteria to diagnose pelvic infections promptly.
• Exclude patients with confounding factors (severe head injury, immunosuppression, open fractures) when evaluating outcomes.
• Consider propensity score matching to adjust for baseline differences in clinical studies assessing EPP outcomes.

References

• Logothetopulos, 1926 - Introduction of pelvic packing
• Pohlemann, 1994 - Modification of EPP technique
• Italian Consensus Conference, Bergamo 2013 - Role of EPP in unstable pelvic fractures
• Burlew et al. - Pelvic space infections post EPP
• Trauma Injury Severity Score (TRISS) methodology