What is the management for a patient with hypotension and pelvic pain after a motor vehicle accident with a computed tomography (CT) scan showing hyperdensity and ongoing bleeding?

Management of Hypotensive Pelvic Trauma with Active Bleeding

In a hypotensive patient with pelvic trauma and CT evidence of active bleeding (hyperdensity/contrast blush), the priority is immediate hemorrhage control through angiographic embolization after rapid pelvic stabilization, NOT exploratory laparotomy, unless there is concurrent intra-abdominal injury requiring surgical intervention. 1

Immediate Resuscitation Strategy

• Initiate permissive hypotension targeting systolic blood pressure of 80-100 mmHg until bleeding is controlled, as aggressive fluid resuscitation can worsen hemorrhage through clot dislodgement and dilutional coagulopathy 1
• Transfuse packed red blood cells to maintain hemoglobin between 7-9 g/dL while pursuing definitive hemorrhage control 1
• Administer crystalloids initially, with colloids as adjuncts within prescribed limits 1

Critical Diagnostic Algorithm

The decision between angiography and laparotomy hinges on identifying the bleeding source:

If E-FAST is Negative or Shows Minimal Free Fluid:

• Proceed directly to angiographic embolization after pelvic stabilization, as the bleeding source is likely pelvic arterial hemorrhage 1, 2
• CT contrast blush has 75% positive predictive value for arterial bleeding requiring embolization 2
• In hypotensive patients with pelvic fractures, 73% of non-responders to initial resuscitation have arterial bleeding on angiography 2

If E-FAST Shows Abundant Hemoperitoneum:

• Exploratory laparotomy is indicated when there is abundant hemoperitoneum (≥3 positive E-FAST sites) with 61% rate of appropriate therapeutic laparotomy 1
• The hypotensive patient with free intra-abdominal fluid on ultrasound or CT who cannot be stabilized with initial fluid resuscitation requires early surgery 1

Pelvic-Specific Hemorrhage Control

Immediate mechanical stabilization is essential:

• Apply pelvic binder, sheet wrap, or C-clamp to achieve pelvic closure and tamponade venous bleeding 1
• Consider pre-peritoneal packing to decrease need for embolization and provide time for selective hemorrhage management 1
• Avoid non-therapeutic laparotomy in isolated pelvic bleeding, as it increases mortality 1

Definitive Management: Angiographic Embolization

Angiography with embolization is the treatment of choice for arterial pelvic hemorrhage:

• Perform thoraco-abdomino-pelvic CT with contrast before angiography when hemodynamic status permits 1
• In uncontrollable hemorrhagic shock, proceed directly to angiography after chest X-ray and E-FAST rule out extra-pelvic massive hemorrhage 1
• Angiographic embolization achieves hemorrhage control in 87% of cases 3

Indicators for Repeat Angiography

Monitor for ongoing hemorrhage requiring repeat intervention:

• Persistent or recurrent hypotension (SBP <90 mmHg) 4
• Persistent base deficit ≥10 for >6 hours 4
• Absence of intra-abdominal injury as alternative bleeding source 4
• The presence of all three factors carries 97% probability of ongoing pelvic bleeding 4

Critical Pitfalls to Avoid

• Do not delay angiography for external fixation in non-responders to resuscitation, as 44% of patients with fractures amenable to external fixation have arterial bleeding requiring embolization 2
• Do not rely on single hematocrit measurements as they poorly reflect acute blood loss and are confounded by resuscitation 1
• Do not perform laparotomy for isolated pelvic bleeding without evidence of intra-abdominal injury, as this increases mortality 1
• Base deficit and lactate are superior markers of ongoing hemorrhage compared to vital signs alone 5

Damage Control Approach

If profound shock with coagulopathy develops:

• Employ damage control surgery principles with abbreviated procedures, packing, and deferred definitive repair 1
• This applies when there is deep hemorrhagic shock, signs of ongoing bleeding, coagulopathy, hypothermia, or acidosis (the "lethal triad") 1