What is the next step for a patient with a pelvic fracture, hypotension, and tachycardia?

Management of Unstable Patient with Pelvic Fracture and Hemorrhagic Shock

For a patient with pelvic fracture who is hemodynamically unstable (BP 86/50, HR 120), immediate pelvic ring closure and stabilization using a pelvic binder should be performed as the next step, followed by fluid resuscitation and blood products. 1

Initial Management Algorithm

1. Immediate pelvic ring closure and stabilization

   • Apply pelvic binder immediately to limit expansion of pelvic hematoma 1
   • This reduces pelvic volume and provides tamponade effect on venous bleeding
   • Should be done before transfer to CT or angiography

2. Fluid resuscitation and blood products

   • Initiate crystalloid fluid therapy 1
   • Begin blood product resuscitation
   • Target systolic BP of 80-90 mmHg until major bleeding is controlled 1
   • Avoid hypotonic solutions like Ringer's lactate 1

3. Bleeding control measures

   • Time to bleeding control should not exceed 60 minutes 1
   • Options after initial stabilization:
     • Angiographic embolization if facilities immediately available
     • Pre-peritoneal packing if embolization cannot be performed within 60 minutes 1

Rationale for Pelvic Binder as First Step

The 2023 European guideline on management of major bleeding following trauma explicitly states that "patients with pelvic ring disruption in haemorrhagic shock should undergo early pelvic ring closure and stabilization" 1. This recommendation is supported by multiple guidelines that emphasize immediate pelvic stabilization as the critical first intervention 1.

The pelvic binder:

• Reduces pelvic volume
• Provides tamponade effect on bleeding vessels
• Stabilizes fracture fragments to prevent further vascular injury
• Can be applied rapidly at bedside without delaying other interventions

Hemodynamic Management

After applying the pelvic binder:

• Initiate fluid therapy with crystalloids 1
• Begin blood product resuscitation according to massive transfusion protocol
• Maintain permissive hypotension with target systolic BP 80-90 mmHg until bleeding is controlled 1
• Consider norepinephrine if fluid resuscitation fails to maintain target BP 1, 2

Common Pitfalls to Avoid

1. Delaying pelvic stabilization - This should be done immediately before other interventions
2. Excessive fluid resuscitation - Can disrupt clot formation and worsen bleeding
3. Targeting normal blood pressure - Permissive hypotension (SBP 80-90 mmHg) is recommended until bleeding is controlled 1
4. Focusing only on pelvic fracture - Assess for other sources of bleeding concurrently
5. Delaying definitive bleeding control - Time to bleeding control should not exceed 60 minutes 1

Evidence Quality Assessment

The most recent and highest quality evidence comes from the 2023 European guideline 1, which strongly recommends immediate pelvic ring closure and stabilization for patients with pelvic fractures and hemorrhagic shock. This is consistent with the 2019 French guideline on early management of severe pelvic injury 1, which emphasizes that time to bleeding control should not exceed 60 minutes.

The evidence consistently shows that immediate mechanical stabilization of the pelvis is the first priority in hemodynamically unstable patients with pelvic fractures, followed by appropriate resuscitation and definitive bleeding control.