What is the most appropriate 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

Transfuse packed red blood cells immediately while simultaneously performing pelvic ring stabilization with a pelvic binder, followed by angiographic embolization—emergency laparotomy is contraindicated and dramatically increases mortality in isolated pelvic hemorrhage. 1

Why Emergency Laparotomy is Wrong

• Non-therapeutic laparotomy is associated with significantly higher mortality rates in patients with major pelvic injuries and should be avoided. 1
• Laparotomy results in poor outcomes because the extensive collateral circulation in the retroperitoneum makes surgical control of pelvic bleeding extremely difficult. 1
• Overall mortality for severe pelvic ring disruptions with hemodynamic instability is 30-45%, but this increases substantially when laparotomy is performed as the primary intervention. 1
• Emergency laparotomy should only be considered if there is clear evidence of concurrent intra-abdominal injury requiring surgical control, not for isolated pelvic hemorrhage. 1

Immediate Management Algorithm

Step 1: Simultaneous Resuscitation and Mechanical Stabilization

Initiate fluid resuscitation with packed red blood cells immediately while applying a pelvic binder within 2 minutes of presentation. 1

• Target systolic blood pressure of 80-90 mmHg (MAP 50-60 mmHg) using permissive hypotension strategy until hemorrhage is controlled. 2, 3
• Pelvic ring closure and stabilization using a pelvic binder, bed sheet, or pelvic C-clamp controls venous and cancellous bone bleeding immediately. 2, 1
• The pelvic binder can be applied in less than 2 minutes and is life-saving—do not delay for imaging or other interventions. 1
• Minimize crystalloid administration to avoid dilutional coagulopathy; prioritize packed red blood cell transfusion. 1

Step 2: Identify Arterial Bleeding

This patient's ongoing hypotension (BP 80/50) despite a large hematoma indicates likely arterial hemorrhage requiring angiographic intervention. 1, 4

• Patients presenting with hemorrhagic shock and an identified source of bleeding should undergo immediate bleeding control procedures unless initial resuscitation measures are successful. 2
• Non-responders to initial resuscitation (failure to achieve sustained SBP >90 mmHg after ≤2 units pRBC) have a 73% probability of arterial bleeding on angiography. 4
• In patients with fractures amenable to external fixation, 44% still have arterial bleeding requiring embolization—do not delay angiography for external fixation in non-responders. 1, 4

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. 2, 1

• Angiography and embolization are highly effective for controlling arterial bleeding that cannot be controlled by fracture stabilization alone, with success rates of 73-97%. 1
• Preperitoneal packing may be performed simultaneously or soon after initial pelvic stabilization if angiography is not immediately available, as it provides crucial time and decreases the need for subsequent embolization. 1
• Time is critical: mean time to hemorrhage control should be <163 minutes, as mortality increases with delay. 2

Monitoring and Resuscitation Targets

• Use serum lactate and base deficit to estimate and monitor the extent of bleeding and shock. 2
• Base excess values <-5 are associated with significantly higher mortality and indicate inadequate resuscitation. 5
• Persistent base deficit ≥10 for more than 6 hours, combined with continued hypotension and absence of intra-abdominal injury, predicts ongoing pelvic hemorrhage with 97% probability. 6
• If restricted volume replacement fails to achieve target blood pressure, administer norepinephrine as the first-line vasopressor. 3

Critical Pitfalls to Avoid

• Do not perform exploratory laparotomy for isolated pelvic bleeding without clear evidence of intra-abdominal injury—this dramatically increases mortality. 1
• Do not remove the pelvic binder prematurely; mechanical stabilization should be maintained until definitive hemorrhage control is achieved. 1
• Do not delay angiography for external fixation in patients who remain hypotensive after initial resuscitation and pelvic binder application. 1, 4
• Do not rely on single hematocrit measurements as an isolated laboratory marker for bleeding. 2
• Consider repeat angiography if hypotension and acidosis persist despite initial therapeutic or non-diagnostic angiography—80% of these patients will have arterial hemorrhage requiring embolization. 6

Special Considerations

• Apply damage control principles: rapid pelvic stabilization, permissive hypotension, and correction of the lethal triad (hypothermia, acidosis, coagulopathy) take priority. 1
• Antifibrinolytic agents (tranexamic acid 10-15 mg/kg followed by 1-5 mg/kg/h infusion) may be considered in the bleeding trauma patient. 2
• Avoid hyperventilation and excessive positive end-expiratory pressure in severely hypovolemic trauma patients. 2