What is the management for a patient with a pelvic fracture, active bleeding, large pelvic hematoma, and hypotension (Blood Pressure = 80/50 mmHg)?

Management of Pelvic Fracture with Active Bleeding and Hypotension

The correct answer is B - Transfuse packed red blood cells, along with immediate pelvic stabilization and preparation for angiographic embolization; emergency laparotomy is contraindicated in isolated pelvic hemorrhage and significantly increases mortality. 1

Why Emergency Laparotomy is Wrong

• Non-therapeutic laparotomy should be avoided in patients with pelvic fracture hemorrhage, as it has been associated with significantly higher mortality rates in patients with major pelvic injuries. 1
• Laparotomy results in poor outcomes due to the extensive collateral circulation in the retroperitoneum, making surgical control of pelvic bleeding extremely difficult. 1
• The overall mortality rate for patients with severe pelvic ring disruptions and hemodynamic instability remains 30-45%, but this increases substantially when laparotomy is performed as the primary intervention. 1

Immediate Management Algorithm

Step 1: Resuscitation and Pelvic Stabilization (First 15 minutes)

• Initiate fluid resuscitation with crystalloids and packed red blood cells immediately to maintain target systolic blood pressure of 80-90 mmHg until bleeding is controlled (permissive hypotension). 1
• Perform immediate pelvic ring closure and stabilization using a pelvic binder, bed sheet, or pelvic C-clamp to control venous and cancellous bone bleeding. 1
• This patient's BP of 80/50 mmHg indicates Class III-IV hemorrhagic shock with >30% blood volume loss requiring aggressive intervention. 2

Step 2: Determine Source of Bleeding

• CT scan showing active bleeding ("blush") and large hematoma are markers of arterial hemorrhage requiring angiographic intervention. 1
• The presence of ongoing hemodynamic instability despite adequate pelvic ring stabilization indicates arterial bleeding that cannot be controlled by mechanical stabilization alone. 1

Step 3: Definitive Hemorrhage Control

• Patients with ongoing hemodynamic instability despite adequate pelvic ring stabilization should receive early angiographic embolization as the primary definitive intervention. 1
• Angiography and embolization are currently accepted as highly effective means to control arterial bleeding that cannot be controlled by fracture stabilization, with success rates of 73-97%. 1, 3, 4
• Preperitoneal packing may be performed simultaneously or soon after initial pelvic stabilization if angiography is not immediately available, as it decreases the need for pelvic embolization and provides crucial time. 1

Critical Predictors for Angiography

• Non-responders to initial resuscitation (persistent hypotension despite ≤2 units PRBCs) have 73-100% likelihood of arterial bleeding requiring embolization. 4
• CT contrast blush has 75% positive predictive value for arterial bleeding on angiography. 4
• Persistent base deficit ≥-10 for >6 hours, continued hypotension (SBP <90), and absence of intra-abdominal injury together predict 97% probability of ongoing pelvic bleeding requiring repeat angiography. 3

Resuscitation Targets

• Maintain systolic BP 80-90 mmHg using permissive hypotension strategy until hemorrhage is controlled (this patient's BP of 80/50 is at target). 1
• Monitor base excess as a resuscitation endpoint, as BE <-5 significantly predicts mortality in hypotensive pelvic fracture patients. 5
• The hourly need for red blood cell transfusions should decrease dramatically (from 3.7 to 0.1 units/hour) after successful angiographic embolization. 6

Common 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. 4
• Do not perform exploratory laparotomy for isolated pelvic hemorrhage, as this dramatically worsens outcomes. 1
• Time is critical: mean time to hemorrhage control should be <163 minutes, with mortality increasing approximately 1% every 3 minutes of delay. 2, 6
• Consider repeat angiography if bleeding persists after initial embolization, as 18-33% of patients require repeat intervention. 3

Institutional Capacity Considerations

• If angiography is not immediately available, apply G-suit/MAST trousers for temporary hemorrhage control while arranging transfer or awaiting angiography availability. 7
• Damage control principles apply: rapid pelvic stabilization, permissive hypotension, and correction of the lethal triad (hypothermia, acidosis, coagulopathy) take priority. 1