What is the initial step in managing a patient with a road traffic accident (RTA) injury, presenting with hypotension and an unstable hip?

Initial Management of Hypotensive RTA Patient with Unstable Pelvis

The correct initial step is C: pelvic binder application—this must be performed immediately (within 2 minutes) as the first life-saving intervention before any imaging or surgical procedures. 1

Immediate Resuscitation Algorithm

Step 1: Apply Pelvic Binder First (0-2 minutes)

• Pelvic ring closure and stabilization is the immediate priority for all hypotensive patients with unstable pelvic fractures. 1
• The pelvic binder can be applied using a commercial device, bed sheet wrapped tightly around the pelvis, or pelvic C-clamp. 2, 1
• This intervention controls venous and cancellous bone bleeding through mechanical tamponade and takes less than 2 minutes to perform. 1
• Do not delay binder application for imaging or other interventions—it is immediately life-saving. 1

Step 2: Simultaneous Resuscitation

• Initiate permissive hypotension targeting systolic blood pressure of 80-90 mmHg until definitive hemorrhage control is achieved. 1, 3
• Transfuse packed red blood cells while minimizing crystalloid administration to avoid dilutional coagulopathy. 1
• Perform E-FAST and chest X-ray at bedside to exclude other sources of hemorrhage (thorax, abdomen). 2, 3

Step 3: Determine Need for Additional Interventions

• If ongoing hypotension persists despite adequate binder placement, this indicates arterial bleeding requiring angiographic embolization or preperitoneal packing. 1
• Bleeding control procedures (embolization or packing) should not exceed 60 minutes from hospital admission. 2
• Mortality increases by approximately 1% for every 3 minutes of delay in achieving hemorrhage control. 2

Why Other Options Are Wrong

A. Exploratory Laparotomy - CONTRAINDICATED

• Non-therapeutic laparotomy should be avoided in patients with pelvic fracture hemorrhage, as it dramatically increases mortality. 1
• Laparotomy results in poor outcomes due to extensive collateral circulation in the retroperitoneum, making surgical control of pelvic bleeding extremely difficult. 1
• The overall mortality rate for severe pelvic injuries is 30-45%, but increases substantially when laparotomy is performed as the primary intervention. 1
• Laparotomy is only indicated when E-FAST shows abundant hemoperitoneum (≥3 positive sites) suggesting intra-abdominal injury. 3

B. Open Reduction - DELAYED

• Open reduction of the hip is not an initial step in a hypotensive patient with active pelvic bleeding. 2
• Definitive orthopedic fixation should be deferred until hemorrhage is controlled and the patient is hemodynamically stable. 2
• The priority is hemorrhage control, not fracture reduction. 2

D. CT Abdomen - POTENTIALLY DANGEROUS DELAY

• Traditionally, patients with penetrating or blunt trauma demonstrating hemodynamic instability should be operatively managed without CT imaging. 2
• CT should only be performed if the patient can be stabilized with initial pelvic binder application and resuscitation. 2
• The degree of hemodynamic instability and distance to the CT scanner must be considered—do not transport an unstable patient. 2
• If CT is performed, it should be done with IV contrast during portal venous phase to identify contrast extravasation ("blush") indicating arterial bleeding. 2

Definitive Hemorrhage Control (After Binder)

Angiographic Embolization

• 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 highly effective (73-97% success rates) for controlling arterial bleeding that cannot be controlled by mechanical stabilization alone. 1
• In hemodynamically unstable patients with multiple bilateral bleeding targets, non-selective bilateral embolization of internal iliac arteries should be performed. 2

Preperitoneal Packing (Alternative)

• Preperitoneal packing can be performed in <20 minutes and controls venous bleeding effectively. 1
• This technique decreases the need for pelvic embolization and provides crucial time when angiography is not immediately available. 1
• Only 13-20% of patients require subsequent angioembolization after successful packing. 1

Critical Pitfalls to Avoid

• Do not remove the pelvic binder prematurely—mechanical stabilization must be maintained until definitive hemorrhage control is achieved. 1
• Do not delay pelvic binder application for external fixation in non-responders to resuscitation, as 44% of patients with fractures amenable to external fixation have arterial bleeding requiring embolization. 1
• Pelvic binders should not be kept for more than 24-48 hours due to risk of skin necrosis and pressure ulcerations. 2
• Do not rely on pelvic X-ray alone—it has low sensitivity (50-68%) and high false negative rates (32%) for identifying life-threatening injuries. 2