What is the most appropriate action for a patient with pelvic trauma, active bleeding, large hematoma, and hypotension (Blood Pressure (BP) = 80/50)?

Management of Hemodynamically Unstable Pelvic Trauma with Active Bleeding

The most appropriate action is immediate pelvic stabilization with a pelvic binder followed by angiographic embolization—NOT emergency laparotomy, which is contraindicated and associated with significantly higher mortality in isolated pelvic hemorrhage. 1

Why Emergency Laparotomy is Wrong

• Non-therapeutic laparotomy dramatically worsens outcomes and should be avoided in patients with pelvic fracture hemorrhage. 1
• Laparotomy results in poor outcomes due to the extensive collateral circulation in the retroperitoneum, making surgical control of pelvic bleeding extremely difficult. 1
• Mortality rates for severe pelvic ring disruptions with hemodynamic instability are already 30-45%, but this increases substantially when laparotomy is performed as the primary intervention. 1
• The only indication for laparotomy in this setting is if E-FAST demonstrates abundant hemoperitoneum (3 positive sites) suggesting concomitant intra-abdominal solid organ injury requiring surgical control. 2

Immediate Management Algorithm

Step 1: Simultaneous Resuscitation and Pelvic Stabilization (First 2 Minutes)

• Apply a pelvic binder immediately around the greater trochanters—this takes less than 2 minutes and is life-saving. 1
• Initiate permissive hypotension strategy targeting systolic BP 80-90 mmHg until hemorrhage is controlled. 2
• Begin massive transfusion protocol with packed red blood cells while minimizing crystalloid administration to avoid dilutional coagulopathy. 1
• Do NOT remove the binder prematurely—mechanical stabilization must be maintained until definitive hemorrhage control is achieved. 1

Step 2: Rapid Source Identification (Next 5-10 Minutes)

• Perform chest X-ray and E-FAST to rule out extra-pelvic sources of hemorrhage (thoracic bleeding, intra-abdominal solid organ injury). 2
• If E-FAST shows no or minimal hemoperitoneum (<3 positive sites) and chest X-ray is negative, the pelvis is the primary bleeding source. 2
• The CT scan already shows active bleeding ("blush") and large hematoma—these are markers of arterial hemorrhage requiring angiographic intervention. 1

Step 3: Definitive Hemorrhage Control

Since the patient remains hypotensive (BP 80/50) despite pelvic stabilization, this indicates arterial bleeding that cannot be controlled by mechanical stabilization alone. 1

• Proceed directly to angiographic embolization as the primary definitive intervention. 2, 1
• Angiography and embolization have success rates of 73-97% for controlling arterial bleeding in pelvic fractures. 1
• If angiography is not immediately available, preperitoneal packing can be performed in <20 minutes to buy time, with only 13-20% requiring subsequent angioembolization. 1

Critical Decision Point: When CT is Already Done

• Since this patient already has a CT scan showing active bleeding and large hematoma, proceed directly to angiography without delay. 2
• The CT demonstrates the "contrast blush" indicating active arterial extravasation—this has 93.9% positive predictive value for requiring embolization. 2
• Time is critical: mortality increases approximately 1% every 3 minutes of delay to hemorrhage control. 1

Monitoring for Ongoing Hemorrhage

• After embolization, hourly red blood cell transfusion requirements should decrease dramatically (from 3.7 to 0.1 units/hour). 1
• If hypotension persists with base deficit >10 for >6 hours after initial intervention, repeat angiography is indicated. 3
• The combination of continued hypotension (SBP <90), absence of intra-abdominal injury, and persistent base deficit >10 has 97% probability of ongoing pelvic bleeding requiring repeat embolization. 3

Common Pitfalls to Avoid

• Do NOT delay angiography to perform external fixation in non-responders—44% of patients with fractures amenable to external fixation have arterial bleeding requiring embolization. 1
• Do NOT perform exploratory laparotomy for isolated pelvic hemorrhage without clear evidence of intra-abdominal injury on E-FAST. 1
• Do NOT remove the pelvic binder to "assess" the pelvis—this can precipitate catastrophic re-bleeding. 1
• Do NOT target normal blood pressure during initial resuscitation—permissive hypotension (SBP 80-90 mmHg) reduces ongoing hemorrhage until definitive control. 2

Why "Reassess" is Also Wrong

• This patient is in hemorrhagic shock (BP 80/50) with CT-documented active bleeding—reassessment without intervention will result in death. 2
• Patients presenting with hemorrhagic shock and an identified source of bleeding should undergo immediate bleeding control procedures. 2
• The time elapsed between injury and definitive intervention should be minimized—every minute counts. 2, 1