BACKGROUND The current management of pelvic fracture patients who are hemodynamically unstable in the United States consists of aggressive resuscitation, mechanical stabilization, and angioembolization. Despite this multidisciplinary approach, our recent analysis confirms an alarming 40% mortality in these high-risk patients. Therefore, we pursued alternate therapies to improve patient outcomes. European trauma groups have suggested the technique of pelvic packing via laparotomy to directly address the venous bleeding that comprises 85% of pelvic fracture hemorrhage. We hypothesized that a modified technique of direct preperitoneal pelvic packing (PPP) would reduce the need for angiography, decrease blood transfusion requirements, and lower mortality. METHODS Since September 2004, all patients at our ACS-verified level I trauma center with hemodynamic instability and pelvic fractures underwent PPP/external fixation, according to our protocol. Statistics are reported as mean +/- SEM and analyzed using Student's t test. RESULTS During the study period, 28 consecutive patients underwent PPP. There was one protocol deviation of prePPP angiography to evaluate an extremity vascular injury. The majority were men (68%) with a mean age of 40 +/- 3.9 years and a mean injury severity score of 55 +/- 3.0. The mean emergency department (ED) systolic blood pressure was 77 +/- 3.0 mm Hg, heart rate was 120 +/- 4.3 bpm, and base deficit 13 +/- 0.8 mmol/L. Pelvic fracture classifications included lateral compression (LC) II (9), anteroposterior compression (APC) III (8), LC I (3), vertical shear (3), LC III (3), and APC II (2). Patients required 4 +/- 1.2 units of packed red blood cells (PRBCs) during 82 +/- 13 minutes in the ED. Blood transfusion requirements before postoperative surgical intensive care unit (SICU) admission compared with the subsequent 24 postoperative hours were significantly different (12 +/- 2.0 versus 6 +/- 1.1; p = 0.006). The first 4 patients underwent routine angiography postPPP, with 1 undergoing therapeutic embolization; 4 of the subsequent 24 patients underwent angioembolization with clinical concern of ongoing pelvic hemorrhage. Seven (25%) patients died from multiple organ failure (2), postinjury myocardial infarction/pulseless electrical activity (PEA) arrest (2), invasive mucormycosis (1), withdrawal of care (1), and closed head injury (1); there were no deaths as a result of acute blood loss. CONCLUSIONS PPP is a rapid method for controlling pelvic fracture-related hemorrhage that can supplant the need for emergent angiography. There is a significant reduction in blood product transfusion after PPP, and this approach appears to reduce mortality in this select high-risk group of patients.