Global, regional, and national burden of injury associated internal hemorrhage in the abdomen and pelvis from 1990-2021.

Uncontrollable hemorrhage is a major cause of injury related deaths, accounting for more than 80% of military fatalities. Beyond military conflicts, severe hemorrhage is responsible for over 35% of pre-hospital deaths and nearly 40% of deaths within the first 24 h following injury. Injury associated internal hemorrhage in abdomen and pelvis (IAIHAP) refers to internal bleeding resulting from vascular rupture of abdominal tissues, organs, or pelvis due to severe trauma. Notably, injury-associated hemorrhage is a major contributor to “preventable deaths” (potentially survivable patients who ultimately died), with over two-thirds of lethal bleeding occurring in the trunk, and 64% of such truncal injuries specifically located in the abdomen and pelvis. Blunt trauma to abdominal organs represents the predominant mechanism leading to internal bleeding in the region. The spleen and liver are particularly susceptible to hemorrhage in blunt injuries, contributing significantly to organ injury-related mortality. The pelvis, located at the inferior aspect of the trunk, comprises the pelvic girdle and perineum, housing urinary and reproductive organs. This anatomically complex region is highly vulnerable to internal hemorrhage following trauma. Severe pelvic fractures, often termed “killing fractures” due to their refractory hemorrhage, epitomize the lethal risk of major IAIHAP. Pelvic and abdominal injuries are closely linked, as pelvic fractures frequently coexist with abdominal organ damage and their occurrence increases with trauma severity Age-related differences exist, with adults showing greater susceptibility to pelvic injuries, whereas children more often sustain concurrent splenic or hepatic injuries. In recent years, the global burden of injuries and health crises induced by armed conflicts and terrorism has been exacerbated significantly. Taking the ongoing Russia-Ukraine war as an example, it has resulted in over 70,000 Ukrainian military fatalities and more than 40,000 civilian deaths or injuries, collapsing healthcare infrastructure and amplifying risks of infectious disease outbreaks and mental health disorders. Preventable deaths in these settings are often driven by delayed evacuation, suboptimal hemorrhage control, and limited access to blood products. Advances in prehospital management, including permissive hypotension, hemostatic agents, and prehospital plasma, have shown significant reductions in mortality from abdominopelvic hemorrhage. Integrating these evidence-based interventions into trauma systems should be a global priority to mitigate preventable deaths, particularly in regions with high injury burdens.