What is the best management approach for a patient with a pelvic fracture, tender crepitus pelvis, active bleeding, large pelvic hematoma, and hypotension?

Management of Pelvic Fracture with Active Bleeding and Hypotension

Apply a pelvic binder immediately, transfuse packed red blood cells using permissive hypotension strategy (target systolic BP 80-90 mmHg), and prepare for urgent angiographic embolization—do not perform emergency laparotomy. 1, 2

Immediate Resuscitation and Mechanical Stabilization (First 5 Minutes)

The first priority is simultaneous pelvic ring closure and blood product resuscitation:

• Apply a pelvic binder or circumferential sheet wrap immediately to achieve mechanical pelvic ring closure and stabilization, which controls venous and cancellous bone bleeding 1, 2
• This intervention takes less than 2 minutes and is life-saving 2
• Begin transfusing packed red blood cells immediately while minimizing crystalloid administration to avoid dilutional coagulopathy 2, 3
• Target systolic blood pressure of 80-90 mmHg using permissive hypotension strategy until definitive hemorrhage control is achieved 2, 3

Why Emergency Laparotomy is Contraindicated

Non-therapeutic laparotomy dramatically increases mortality in patients with pelvic fracture hemorrhage and should be avoided: 1, 2

• Laparotomy as the primary intervention is associated with significantly higher mortality rates (30-45% baseline mortality increases substantially with laparotomy) 2
• The extensive collateral circulation in the retroperitoneum makes surgical control of pelvic bleeding extremely difficult 2
• Your patient has CT evidence of isolated pelvic bleeding without intra-abdominal injury requiring surgical intervention 1

Definitive Hemorrhage Control: Angiographic Embolization

This patient requires urgent angiographic embolization based on three key findings:

• CT scan showing active bleeding ("blush") indicates arterial hemorrhage that cannot be controlled by mechanical stabilization alone 1, 2, 4
• Large pelvic hematoma (>500 mL) is a marker of significant arterial bleeding 1
• Ongoing hemodynamic instability (BP 80/50) despite initial resuscitation indicates arterial bleeding requiring angiographic intervention 1, 4

Angiography and embolization are highly effective with success rates of 73-97% for controlling arterial bleeding that cannot be controlled by fracture stabilization alone 2, 4

Clinical Decision Algorithm

Follow this sequence:

1. Immediate (0-5 minutes): Apply pelvic binder + begin pRBC transfusion + permissive hypotension (target SBP 80-90) 1, 2

2. Assess response to resuscitation (5-30 minutes): 4

   • If patient achieves sustained BP >90 mmHg for >2 hours with ≤2 units pRBC = adequate responder
   • If repeated hypotension despite resuscitation = non-responder requiring immediate angiography
   • Your patient with BP 80/50 and active CT blush is a non-responder 4

3. Definitive intervention: Urgent angiography and embolization 1, 2, 4

   • Non-responders have 73% probability of arterial bleeding on angiography 4
   • Patients with CT contrast blush have 75% positive angiography rate 4

Alternative if Angiography Unavailable

If angiography cannot be achieved in a timely manner (not available 24/7 or significant delay):

• Perform preperitoneal pelvic packing (PPP) as a bridge procedure 1, 2, 5
• PPP can be performed in <20 minutes and controls venous bleeding effectively 2
• Only 13-20% of patients require subsequent angioembolization after PPP 2
• However, given your patient has CT evidence of active arterial bleeding, angiography remains the definitive treatment 1, 4

Critical Pitfalls to Avoid

Do not delay angiography for external fixation in non-responders: 44% of patients with fractures amenable to external fixation have arterial bleeding requiring embolization 2, 4

Do not remove the pelvic binder prematurely: Mechanical stabilization must be maintained until definitive hemorrhage control is achieved 2

Do not perform exploratory laparotomy for isolated pelvic hemorrhage: This dramatically worsens outcomes 1, 2

Time is critical: Mortality increases approximately 1% every 3 minutes of delay in achieving hemorrhage control 6

Monitoring Response to Treatment

After successful angiographic embolization, expect:

• Hourly pRBC transfusion requirements should decrease dramatically (from 3.7 to 0.1 units/hour) 2
• Persistent base deficit >10 for >6 hours after intervention indicates ongoing hemorrhage and need for repeat angiography 7
• Continued hypotension with persistent acidosis despite adequate pelvic stabilization warrants repeat angiography 7