What is the best management for a patient with a pelvic fracture, hypotension, and tachycardia?

From the Guidelines

The best management for a patient with a pelvic fracture, hypotension, and tachycardia is immediate hemorrhage control and resuscitation, starting with the application of a pelvic binder to stabilize the fracture and reduce bleeding, as recommended by the most recent guidelines 1.

Initial Management

The patient should be managed with a multidisciplinary approach, involving trauma surgery, orthopedics, and interventional radiology.

• Apply a pelvic binder or sheet to stabilize the fracture and reduce the pelvic volume, which helps tamponade bleeding.
• Establish two large-bore IV access lines and initiate fluid resuscitation with 1-2 liters of warmed crystalloid solution (such as 0.9% normal saline or Lactated Ringer's), followed by blood products if needed.
• Begin with 2 units of packed red blood cells and follow a 1:1:1 ratio of PRBCs, plasma, and platelets if massive transfusion is required.
• Administer tranexamic acid 1g IV over 10 minutes within 3 hours of injury, followed by 1g over 8 hours.

Ongoing Management

• Maintain systolic blood pressure around 80-90 mmHg (permissive hypotension) until definitive hemorrhage control is achieved.
• Continuously monitor vital signs, urine output, and laboratory values.
• Early activation of the massive transfusion protocol is essential.
• Angioembolization or preperitoneal packing may be necessary for ongoing bleeding, with preperitoneal packing being a quick and effective technique to control bleeding in hemodynamically unstable pelvic fractures 1.
• The need for angioembolization following preperitoneal packing has been reported to be between 13 and 20% 1.

Definitive Management

• Definitive management of the pelvic fracture should be done once the patient is hemodynamically stable.
• This approach prioritizes addressing the lethal triad of hypothermia, acidosis, and coagulopathy while preparing for definitive management of the pelvic fracture.
• The use of pelvic binders, preperitoneal packing, and angioembolization as complementary procedures is recommended, with the choice of procedure depending on the patient's condition and the availability of resources 1.

From the Research

Management of Pelvic Fracture

The patient presents with an open book pelvic fracture, hypotension, and tachycardia, indicating potential hemorrhage and shock. The management of such patients requires a multidisciplinary approach, focusing on swift and adequate resuscitation, reversal of shock and acidosis, and rapid control of hemorrhage.

Key Elements in Management

• Swift and adequate resuscitation to address hypotension and potential hemorrhage 2
• Reversal of shock and acidosis to prevent further complications 2
• Rapid control of hemorrhage through various strategies, including external pelvic stabilization, angioembolization, and preperitoneal pelvic packing 2, 3
• Multimodality therapies, requiring appropriately trained and immediately available personnel 2

Resuscitation Strategies

• The use of massive transfusion protocol may not improve outcomes in pelvic fracture patients, but it can lead to a higher use of fresh frozen plasma and improved ratio of fresh frozen plasma to red blood cells 4
• Restrained volume therapy in the preclinical setting may improve trauma outcomes by reducing haemodilution and concomitant trauma-associated coagulopathy 5
• Blood transfusion in the initial 6 hours after pelvic fracture can be crucial, with the volume required varying depending on the type of pelvic fracture 6

Procedural Interventions

• External fixation and angiographic embolisation are procedural interventions that can be used to manage high-energy pelvic fractures 3
• Preperitoneal pelvic packing can be an effective strategy for controlling hemorrhage in patients with pelvic fractures 2, 3
• The choice of intervention depends on the severity of the fracture, the patient's condition, and the availability of resources and expertise 2, 3