From the Guidelines
The most appropriate intervention to manage active pelvic hemorrhage in a patient with an open book pelvic fracture and hypotension is immediate pelvic stabilization followed by preperitoneal pelvic packing (PPP) and subsequent angioembolization if necessary. Initially, external pelvic stabilization should be achieved using a pelvic binder or sheet wrapped circumferentially around the pelvis at the level of the greater trochanters to reduce pelvic volume and tamponade bleeding. Simultaneously, aggressive resuscitation with blood products (typically following a 1:1:1 ratio of packed red blood cells, plasma, and platelets) should be initiated to address hemorrhagic shock. The use of preperitoneal pelvic packing (PPP) has been shown to be effective in controlling bleeding in hemodynamically unstable patients with pelvic fractures, as it addresses the venous sources of bleeding which are often the primary source of hemorrhage in these patients 1. Angioembolization can then be performed subsequently to address any ongoing arterial bleeding, with studies suggesting that the need for angioembolization following PPP is around 13-20% 1. This approach is supported by recent guidelines which recommend considering angiography and PPP as complementary procedures, and emphasize the importance of timely bleeding control, with a recommended time-to-control-of-bleeding of less than 60 minutes 1. Rapid coordination between trauma surgery, orthopedics, and interventional radiology is essential for optimal outcomes in these critically injured patients. Key points to consider include:
- Immediate pelvic stabilization using a pelvic binder or sheet
- Aggressive resuscitation with blood products
- Preperitoneal pelvic packing (PPP) to control venous bleeding
- Subsequent angioembolization to address ongoing arterial bleeding if necessary
- Timely bleeding control, with a recommended time-to-control-of-bleeding of less than 60 minutes.
From the Research
Management of Active Pelvic Hemorrhage
The patient presents with an open book pelvic fracture, hypotension, and evidence of free fluid in the suprapubic area and Morison pouch on FAST exam. Given the patient's hemodynamic instability despite fluid resuscitation and pelvic binder application, the most appropriate intervention to manage active pelvic hemorrhage needs to be determined.
Intervention Options
- Arterial Embolization: This involves embolization of bleeding vessels in the interventional radiology suite. Studies have shown that arterial embolization can be effective in controlling pelvic hemorrhage 2.
- Open Reduction and Internal Fixation: This surgical procedure aims to stabilize the pelvic fracture. However, it may not directly address the ongoing hemorrhage.
- Preperitoneal and Pelvic Packing: This is a surgical technique used to control bleeding in the pelvic area. It has been shown to be effective in some cases, but its use is not universally agreed upon as a first-line treatment for pelvic hemorrhage.
- Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA): This is a minimally invasive procedure that involves occluding the aorta to increase central blood pressure and control bleeding. Studies have demonstrated its potential in managing severe pelvic hemorrhage 3, 4, 5.
Most Appropriate Intervention
Considering the patient's presentation and the need for immediate control of hemorrhage, Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in the emergency department appears to be a viable option. This procedure can be performed quickly and has been shown to increase central blood pressure and control active pelvic bleeding 3, 4, 5. However, the decision to use REBOA should be made based on the patient's specific clinical scenario and the availability of resources. Arterial embolization is also an effective option but may require more time to initiate compared to REBOA, especially in a setting without a hybrid emergency room system 6.