Guideline sources The following summarized guidelines for the evaluation and management of pelvic trauma are prepared by our editorial team based on guidelines from the European Association of Urology (EAU 2023; 2022), the Pan-European Multidisciplinary Task Force for Advanced Bleeding Care in Trauma (ABC-T 2023; 2019), the Eastern Association for the Surgery of Trauma (EAST/AOTA 2023), the World Society of Emergency Surgery (WSES/AAST 2020; 2019), the Society of Interventional Radiology (SIR 2020), the Eastern Association for the Surgery of Trauma (EAST 2019; 2011), the World Society of Emergency Surgery (WSES 2017), and the American Urological Association (AUA 2014). 1 2 3 4 5 6 7 8 9 10 11 12 Calculator Calculator Gurd and Wilson criteria for fat e Schonfeld's criteria for fat embol Guidelines https://web.pathway.md/diseases/rec7Er9h38v7ZEqmA 1/8 6/29/23, 11:01 PM Pelvic trauma Pathway 1. Classification and risk stratification WSES classification: The WSES (WSES) classification divides pelvic ring injuries into three classes: minor (WSES grade I) comprising hemodynamically and mechanically stable lesions. WSES grade I includes Anterior-Posterior Compression I and Lateral Compression I hemodynamically stable pelvic ring injuries moderate (WSES grade II, III) comprising hemodynamically stable and mechanically unstable lesions. WSES grade II includes Anterior-Posterior Compression II-III and Lateral Compression II-III hemodynamically stable pelvic ring injuries. WSES grade III includes Vertical Shear and Combined Mechanism hemodynamically stable pelvic ring injuries severe (WSES grade IV) comprising hemodynamically unstable lesions independently from mechanical status. WSES grade IV includes any hemodynamically unstable pelvic ring injuries. 2. Diagnostic investigations Physical examination: As per WSES 2017 guidelines: Perform perineal and rectal digital examination in patients with a high suspicion of rectal injuries. B Perform proctoscopy in patients with a positive rectal examination. B Laboratory testing: measure serum lactate and base deficit to estimate the extent of traumatic-hemorrhagic shock, and to monitor response to resuscitation. B FAST ultrasound: As per WSES 2017 guidelines, use e-FAST ultrasound in hemodynamically and mechanically unstable patients with pelvic trauma, in order to identify injuries that require pelvic stabilization, angiography, a rapid reductive maneuver, and/or laparotomy. B As per EAST 2011 guidelines: Avoid relying on FAST results to exclude intraperitoneal bleeding in the presence of a pelvic fracture, as they are not sufficiently sensitive in this situation. D Perform laparotomy to control hemorrhage in patients with a pelvic fracture, unstable vital signs, and positive FAST results. A Pelvic radiography: As per WSES 2017 guidelines, obtain pelvic XRs in hemodynamically and mechanically unstable patients with pelvic trauma, to identify injuries that require pelvic stabilization, angiography, a rapid reductive maneuver, and/or laparotomy. B As per EAST 2011 guidelines, fracture pattern on pelvic XRs does not solely predict mortality, hemorrhage, or the need for angiography. B Computed tomography: As per WSES 2017 guidelines, obtain a CT scan of the abdomen and pelvis with intravenous contrast to exclude pelvic hemorrhage in patients with pelvic trauma who are hemodynamically stable. B https://web.pathway.md/diseases/rec7Er9h38v7ZEqmA 2/8 6/29/23, 11:01 PM Pelvic trauma Pathway As per EAST 2011 guidelines: Obtain CT of the abdomen and pelvis with IV contrast to evaluate for intra-abdominal and pelvic bleeding in hemodynamically stable patients with pelvic fracture, regardless of FAST results. B Avoid relying on the absence of contrast extravasation on CT to exclude active bleeding. D Retrograde urethrocystography: As per WSES 2017 guidelines, obtain a retrograde urethrogram or/and urethrocystogram, as well as CT with intravenous contrast, in patients with a perineal hematoma and evidence of pelvic disruption on pelvic XRs. B As per EAST 2011 guidelines, obtain a retrograde urethrocystogram, if required, after CT with intravenous contrast. B Pelvic angiography: Consider performing pelvic angiography in patients with pelvic fracture and hemodynamic instability or signs of ongoing bleeding after non-pelvic sources of blood loss have been ruled out. B Consider performing pelvic angiography in > 60 years old patients with a major pelvic fracture (open book, butterfly segment, or vertical shear), regardless of hemodynamic status. C 3. Diagnostic procedures Diagnostic peritoneal lavage: diagnostic peritoneal lavage is the best test to exclude intra- abdominal bleeding in hemodynamically unstable patients. B 4. Medical management Pain management: Consider administering NSAIDs (such as ketorolac) for pain management in adult patients with a traumatic fracture. C Insufficient evidence to recommend for the preference of selective NSAIDs (COX-2 inhibitors) or nonselective NSAIDs. I 5. Nonpharmacologic interventions Pelvic binders: As per WSES 2017 guidelines, apply pelvic binders to stabilize the pelvic ring and decrease the amount of pelvic hemorrhage in patients with pelvic fractures who are undergoing initial resuscitation. A Show 2 more As per EAST 2011 guidelines: https://web.pathway.md/diseases/rec7Er9h38v7ZEqmA 3/8 6/29/23, 11:01 PM Pelvic trauma Pathway Temporary pelvic binders effectively reduce unstable pelvic fractures and decrease pelvic volume. B Temporary pelvic binders may limit pelvic hemorrhage, but do not seem to affect mortality. B Pelvic orthotic devices: The use of a pelvic orthotic device effectively reduces fracture displacement and decreases pelvic volume. B In patients with pelvic hemorrhage, the use of a pelvic orthotic device does not seem to limit blood loss. B 6. Therapeutic procedures Retroperitoneal pelvic packing: As per ABC-T 2023 guidelines, perform temporary extraperitoneal packing when bleeding is ongoing and/or when angioembolization cannot be achieved promptly. Consider combining extraperitoneal packing with open abdominal surgery when necessary. B As per EAST 2011 guidelines, consider performing retroperitoneal pelvic packing to control hemorrhage as a salvage technique in patients in whom bleeding persists after angiographic embolization. C Pelvic angioembolization: As per SIR 2020 guidelines, perform embolization as first-line therapy and the standard of care over surgery in patients with pelvic trauma. B As per ABC-T 2019 guidelines, perform angiographic embolization in patients with ongoing hemodynamic instability despite adequate pelvic ring stabilization. B As per WSES 2017 guidelines, consider performing angioembolization in patients with pelvic fracture and hemodynamic instability or evidence of ongoing bleeding, after pelvic stabilization, initiation of aggressive hemostatic resuscitation, and exclusion of extra-pelvic sources of blood loss. B Show 3 more As per EAST 2011 guidelines, consider performing pelvic angiography/embolization in patients with pelvic fractures and hemodynamic instability or signs of ongoing bleeding, after non-pelvic sources of blood loss have been ruled out. B Resuscitative endovascular balloon occlusion of the aorta: As per ABC-T 2019 guidelines, consider performing aortic balloon occlusion only under extreme circumstances in patients with pelvic fracture in order to gain time until appropriate bleeding control measures can be implemented. C As per WSES 2017 guidelines, consider performing REBOA in zone III in patients with suspected pelvic bleeding who are hemodynamically unstable, as defined by a systolic BP < 90 mmHg ora lack of hemodynamic response to blood product transfusion. C Show 3 more 7. Surgical interventions https://web.pathway.md/diseases/rec7Er9h38v7ZEqmA 4/8 6/29/23, 11:01 PM Pelvic trauma Pathway Timing of surgery: as per WSES 2017 guidelines, resuscitate hemodynamically unstable patients and coagulopathic patients prior to proceeding with definitive pelvic fracture fixation. B Show 3 more Damage-control surgery: as per WSES 2017 guidelines, perform resuscitative thoracotomy with aortic cross-clamping to achieve temporary control of hemorrhage in patients with exsanguinating traumatic hemorrhage. A External pelvic fixation: perform external pelvic fixation to provide rigid temporary pelvic ring stability and aid in early hemorrhage control in hemodynamically unstable patients with pelvic ring disruptions. A Show 3 more Internal pelvic fixation: Perform anatomic fracture reduction and stable internal fixation in patients with posterior pelvic ring instability. Typical injury patterns requiring surgical fixation include: rotationally unstable pelvic ring disruptions, such as anteroposterior compression type-II, and lateral compression type-II fractures vertically unstable pelvic ring disruptions, such as anteroposterior compression type III, lateral compression type III, and vertical shear fractures. B Show 2 more 8. Specific circumstances Patients with kidney injury, evaluation: As per AAST/WSES 2019 guidelines, obtain extended FAST to detect intra-abdominal free fluid. A Recognize that extended FAST has low sensitivity and specificity in kidney trauma. B Show 5 more As per AUA 2014 guidelines, obtain IV contrast-enhanced abdominal/pelvic CT with immediate and delayed images in patients with suspected renal injury. B Show 2 more Patients with kidney injury, management: As per AAST/WSES 2019 guidelines, offer nonoperative management as the treatment of choice in all hemodynamical stable or stabilized minor (AAST I-II), moderate (AAST III), or severe (AAST IV-V) lesions. B Show 18 more As per AUA 2014 guidelines, offer nonoperative management in hemodynamically stable patients with renal injury. B Show 4 more Patients with ureteral injury: As per EAU 2022 guidelines, suspect ureteral injury in all cases of abdominal penetrating trauma, and in deceleration-type blunt trauma. A Show 3 more https://web.pathway.md/diseases/rec7Er9h38v7ZEqmA 5/8 6/29/23, 11:01 PM Pelvic trauma Pathway As per WSES 2019 guidelines, suspect ureteral injury in patients with high-energy blunt trauma, particularly in deceleration injuries with multi-system involvement and in all cases of penetrating abdominal trauma. B Show 9 more As per AUA 2014 guidelines, obtain IV contrast-enhanced abdominal/pelvic CT with delayed imaging (urogram) in stable patients with trauma with suspected ureteral injuries. B Show 10 more Patients with bladder injury: As per EAU 2022 guidelines, obtain cystography with active retrograde filling of the bladder with dilute contrast (300-350 mL) in the presence of visible hematuria and pelvic fracture. A Show 5 more As per EAST 2019 guidelines, obtain CT cystography for the diagnosis of bladder rupture in moderate-risk (gross hematuria) and high-risk (gross hematuria and pelvic fracture) patients. B Show 4 more As per WSES 2019 guidelines, recognize that IV contrast-enhanced CT with delayed phase is less sensitive and specific than retrograde cystography in detecting bladder injuries. B Show 14 more As per AUA 2014 guidelines, obtain retrograde cystography (plain film or CT) in stable patients with gross hematuria and pelvic fracture. B Show 5 more Patients with urethral injury: As per EAU 2023 guidelines: Obtain retrograde urethrography with voiding cystourethrography to evaluate pelvic fracture urethral injuries. A Obtain retrograde urethroscopy and antegrade cystoscopy as an adjunct to imaging to evaluate pelvic fracture urethral injuries, if further information is required. B As per EAU 2022 guidelines, obtain flexible cystourethroscopy and/or retrograde urethrography for the evaluation of male patients with urethral injuries. A Show 10 more As per WSES 2019 guidelines, evaluate patients with post-traumatic urethral hemorrhage for urethral injuries. B Show 11 more As per AUA 2014 guidelines, obtain retrograde urethrography in patients with blood at the urethral meatus after pelvic trauma. B Show 5 more Clinical findings Symptoms Past medical history Bleeding Bone fracture Constipation Injury https://web.pathway.md/diseases/rec7Er9h38v7ZEqmA 6/8 6/29/23, 11:01 PM Pelvic trauma Pathway Erectile dysfunction Abdominal exam Hematuria Numbness Destot's sign Pain Integument exam Pain with bowel movements Painful intercourse Bruises Vaginal bleeding Vital signs Signs of shock Genitourinary exam Scrotal hematoma References 1. Cullinane DC, Schiller HJ, Zielinski MD et al. Eastern Association for the Surgery of Trauma practice management guidelines for hemorrhage in pelvic fracture update and systematic review. J Trauma. 2011 Dec;71 6 1850 68. Open 2. Leslie Kobayashi, Raul Coimbra, Adenauer M O Goes Jr et al. American Association for the Surgery of Trauma-World Society of Emergency Surgery guidelines on diagnosis and management of abdominal vascular injuries. J Trauma Acute Care Surg. 2020 Dec;89 6 1197 1211. Open 3. Coccolini F, Stahel PF, Montori G et al. Pelvic trauma: WSES classification and guidelines. World J Emerg Surg. 2017 Jan 18;12 5. Open 4. N.D. Kitrey Chair), F. Campos-Juanatey, P. Hallscheidt et al. EAU Guidelines on Urological Trauma. EAU. 2022. Open 5. Federico Coccolini, Ernest E Moore, Yoram Kluger et al. Kidney and uro-trauma: WSES AAST guidelines. World J Emerg Surg. 2019 Dec 2;14 54. Open 6. Siddharth A Padia, Christopher R Ingraham, John M Moriarty et al. Society of Interventional Radiology Position Statement on Endovascular Intervention for Trauma. J Vasc Interv Radiol. 2020 Mar;31 3 363 369.e2. Open 7. Donat R Spahn, Bertil Bouillon, Vladimir Cerny et al. The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition. Crit Care. 2019 Mar 27;23 1 98. Open 8. Morey AF, Brandes S, Dugi DD rd et al. Urotrauma: AUA guideline. J Urol. 2014 Aug;192 2 327 35. Open 9. Lawrence L Yeung, Amy A McDonald, John J Como et al. Management of blunt force bladder injuries: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2019 Feb;86 2 326 336. Open 10. N. Lumen Chair), F. Campos-Juanatey, K. Dimitropoulos et al. EAU Guidelines on Urethral Strictures. EAU. 2023. Open 11. Rolf Rossaint, Arash Afshari, Bertil Bouillon et al. The European guideline on management of major bleeding and coagulopathy following trauma: sixth edition. Crit Care. 2023 Mar 1;27 1 80. Open https://web.pathway.md/diseases/rec7Er9h38v7ZEqmA 7/8 6/29/23, 11:01 PM Pelvic trauma Pathway 12. Patrick B Murphy, George Kasotakis, Elliott R Haut et al. Efficacy and safety of non-steroidal anti- inflammatory drugs NSAIDs) for the treatment of acute pain after orthopedic trauma: a practice management guideline from the Eastern Association for the Surgery of Trauma and the Orthopedic Trauma Association. Trauma Surg Acute Care Open. 2023 Feb 21;8 1):e001056. Open https://web.pathway.md/diseases/rec7Er9h38v7ZEqmA 8/8