Algorithm for the hemodynamically unstable patient with pelvic fracture - The Parkland experience.

OBJECTIVE

To evaluate the outcomes of an institutional management algorithm for hemodynamically unstable pelvic ring injuries at a Level I trauma center with rapid access to interventional radiology.

METHODS

This retrospective cohort study included adult patients (≥18 years) who underwent surgical treatment for an unstable pelvic ring injury between 2024 and 2026. Patients who were hemodynamically unstable on admission were compared with hemodynamically stable patients managed according to the same institutional protocol. The primary outcome was time to definitive pelvic ring fixation. Hemorrhage-control interventions, fixation strategy, complications, and length of hospital stay were also assessed.

RESULTS

Eighteen patients (52.9%) presented with hemodynamic shock. These patients had greater physiological derangement and higher injury severity scores than hemodynamically stable patients. Angioembolization was used more frequently in the shock group (60.0% vs 10.5%), and no patient underwent preperitoneal pelvic packing. Despite their greater initial injury severity, patients presenting with shock underwent definitive pelvic ring fixation at a similar time and using similar fixation methods to stable patients. The choice and timing of fixation were determined mainly by fracture morphology rather than initial hemodynamic status. Patients in the shock group had longer hospital stays, but major complication rates remained low in both groups.

CONCLUSIONS

At a Level I trauma center with immediate access to interventional radiology, an institutional algorithm incorporating selective early angioembolization facilitated the management of hemodynamically unstable pelvic ring injuries without routine preperitoneal pelvic packing. The timing and method of definitive pelvic stabilization were guided primarily by fracture morphology rather than initial hemodynamic status. These findings support resource-adapted institutional algorithms that integrate hemorrhage-control capabilities with pelvic ring injury characteristics.