What is the management for a patient with pelvic trauma, active bleeding, large pelvic hematoma, and hypotension?

Management of Pelvic Trauma with Active Bleeding and Hemodynamic Instability

This patient requires immediate pelvic stabilization with a pelvic binder followed by angiographic embolization—NOT emergency laparotomy—unless FAST examination demonstrates significant free intra-abdominal fluid indicating concurrent intra-abdominal injury. 1

Critical Decision Point: Determining the Source of Shock

The CT scan has already identified active pelvic bleeding with a large hematoma, so the diagnostic question is whether there is concurrent intra-abdominal injury requiring laparotomy. 1

Perform FAST Examination Immediately

• If FAST shows significant free intra-abdominal fluid with hemodynamic instability (BP 80/50), proceed to emergency laparotomy while simultaneously applying pelvic stabilization. 1
• The presence of free fluid on FAST in unstable pelvic fracture patients correlates with significant intra-abdominal lesions requiring surgical repair in 97% of cases. 2
• If FAST is negative or shows minimal fluid, the bleeding source is the pelvis itself—proceed directly to pelvic stabilization and angiographic embolization, NOT laparotomy. 1, 3

Immediate Pelvic Hemorrhage Control Algorithm

Step 1: Pelvic Binder Application (Already Done or Do Now)

• Apply external pelvic compression immediately using a pelvic binder placed around the greater trochanters to reduce pelvic volume and tamponade venous bleeding. 1, 4
• This should be done within minutes of identifying pelvic fracture with hemodynamic instability. 1

Step 2: Resuscitation Strategy During Transport

• Target systolic blood pressure of 80-100 mmHg using permissive hypotension until hemorrhage control is achieved—avoid aggressive fluid resuscitation that worsens coagulopathy. 1, 5
• Initiate massive transfusion protocol with balanced blood product resuscitation (1:1:1 ratio of packed RBCs:FFP:platelets). 1
• Transfusion alone without source control will NOT prevent death—the patient needs mechanical bleeding control. 3, 5

Step 3: Definitive Hemorrhage Control

For isolated pelvic bleeding (negative FAST):

• Proceed directly to angiographic embolization as the primary intervention. 1
• Time to hemorrhage control averages 163 minutes from admission when following this algorithm, with 97.8% success rate in controlling pelvic bleeding. 6
• Angiographic embolization achieves complete hemorrhage control in 87% of patients with massive pelvic bleeding. 7

For combined pelvic and intra-abdominal bleeding (positive FAST with significant fluid):

• Perform damage control laparotomy with simultaneous or sequential pelvic stabilization using external fixation. 2
• Consider preperitoneal pelvic packing if angiography cannot be achieved in a timely manner or if bleeding continues despite embolization. 1
• Internal tamponade with packing plus external fixation controls shock in massive pelvic hemorrhage cases. 2

Why Laparotomy Alone is WRONG for Isolated Pelvic Bleeding

• Laparotomy does not control retroperitoneal pelvic hemorrhage—the bleeding vessels are outside the peritoneal cavity and inaccessible via standard laparotomy. 1, 3
• Opening the peritoneum in isolated pelvic bleeding wastes critical time (mortality increases 1% every 3 minutes of delay) and may worsen hemodynamics. 3
• Pelvic fractures are associated with intra-abdominal injuries in only a subset of cases—the CT scan and FAST determine if laparotomy is needed. 1

Monitoring for Ongoing Hemorrhage

• Three independent predictors indicate need for repeat angiography: persistent hypotension (SBP <90), absence of intra-abdominal injury, and base deficit ≥10 for >6 hours. 8
• When all three predictors are present, there is 97% probability of ongoing pelvic arterial bleeding requiring repeat embolization. 8
• Hourly transfusion requirements should decrease dramatically after successful embolization (from 3.7 units/hour to 0.1 units/hour). 6

Common Pitfalls to Avoid

• Never perform laparotomy for isolated pelvic bleeding—this is the wrong operation and delays definitive hemorrhage control. 1, 3
• Do not rely on continued resuscitation and transfusion without source control—this creates a vicious cycle of coagulopathy and exsanguination. 3, 5
• Do not delay angiography for additional imaging in hemodynamically unstable patients once the bleeding source is identified as pelvic. 1, 6
• Recognize that 18-33% of patients may require repeat angiography if hemorrhage persists despite initial embolization. 8