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The purpose of this study was to examine the acute outcomes and mortality rates of an Advanced Trauma Life Support guideline approach for managing hemodynamically unstable pelvic ring injuries. We retrospectively reviewed the acute outcomes of 48 consecutive patients with hemodynamically unstable pelvic fractures. Patients underwent treatment via the advanced trauma life support protocol, with primary angiography based on trauma surgeon preference. Mean patient age was 51.2 years, with a mean injury severity score of 43.2±14.3. Mean systolic blood pressure was 74.8±16.1 mm Hg at presentation. Patients received an average of 7.0±6.6 units of red blood cells and 4.2±2.3 units of fresh frozen plasma in the first 6 hours. Fourteen patients underwent emergent angiography, and 12 patients were treated with embolization. Mean time to angiography was 3 hours and 55 minutes (range, 2–19 hours). Twenty patients died during hospitalization, with an overall mortality rate of 41.7%; 13 (27.1%) of them died within 24 hours. Advanced Trauma Life Support guidelines with angiography are not adequate for the management of hemodynamically unstable pelvic ring injuries and result in unacceptably high mortality rates compared with more specific approaches using transfusion protocols and interventions, such as pelvic packing.