What is the next step for a patient with a pelvic fracture, hypotension, and grossly positive diagnostic peritoneal lavage (DPL)?

Management of a Patient with Pelvic Fracture, Hypotension, and Positive Diagnostic Peritoneal Lavage

The next step for a patient with pelvic fracture, hypotension, and grossly positive diagnostic peritoneal lavage is immediate celiotomy (laparotomy).

Rationale for Immediate Celiotomy

• A grossly positive diagnostic peritoneal lavage (DPL) in a hypotensive patient with pelvic fracture strongly indicates significant intraabdominal hemorrhage requiring immediate surgical intervention 1
• European guidelines specifically recommend that patients with significant free intra-abdominal fluid and hemodynamic instability undergo urgent intervention 1
• When a laparotomy is performed in patients with hemodynamic instability after trauma with large peritoneal effusion, mortality increases by approximately 1% every 3 minutes of delay 1

Clinical Decision Algorithm

Initial Assessment

• Hypotension (systolic BP <90 mmHg) in a trauma patient with pelvic fracture suggests major hemorrhage 1
• Grossly positive DPL indicates significant intraabdominal bleeding requiring immediate surgical control 1, 2
• The combination of these findings indicates the patient is in Class III or IV hemorrhagic shock with >30% blood volume loss 1

Management Priorities

1. Immediate celiotomy for surgical control of intraabdominal bleeding 1
2. Concurrent pelvic stabilization (external fixation or pelvic binder) to control pelvic hemorrhage 1
3. Consider subsequent angioembolization if bleeding persists after surgical control 1

Why Other Options Are Not Appropriate

• Angiography and embolization: While valuable for isolated pelvic bleeding, this should not be the first step when grossly positive DPL indicates significant intraabdominal hemorrhage requiring immediate surgical control 2, 3
• CT scan: Inappropriate in hemodynamically unstable patients with positive DPL as it delays definitive treatment and increases mortality 1
• C-clamp application: Important for pelvic stabilization but should be performed concurrently with or after addressing the intraabdominal hemorrhage 1
• Pneumatic antishock garment: Less effective than modern interventions and associated with higher transfusion requirements 2

Integrated Approach

• Damage control surgery principles should be applied with rapid control of hemorrhage as the primary goal 1
• External pelvic stabilization should be performed concurrently with or immediately after celiotomy 1
• Pre-peritoneal pelvic packing may be considered in conjunction with celiotomy if significant pelvic bleeding is identified 1
• Subsequent angioembolization should be considered if bleeding persists after surgical control 1

Common Pitfalls

• Delaying celiotomy to pursue other interventions when grossly positive DPL indicates intraabdominal hemorrhage significantly increases mortality 1
• Focusing solely on the pelvic fracture while ignoring the positive DPL finding 2, 3
• Failing to distinguish between a grossly positive DPL (frank blood) versus positive by cell count only - the former indicates immediate need for celiotomy 2
• Not implementing concurrent pelvic stabilization measures during or immediately after celiotomy 1