What is the immediate management for a 35-year-old patient involved in a road traffic accident (RTA), who is unconscious, hypotensive, and has multiple injuries including signs of a significantly unstable pelvic fracture?

Immediate Management of Unstable Pelvic Fracture with Hypotension

Apply a pelvic binder immediately as the first priority for this hypotensive patient with an unstable pelvic fracture—surgical exploration is contraindicated and dramatically increases mortality. 1, 2

Why Pelvic Binder is the Correct Answer

External pelvic compression must be applied as soon as possible in all patients with suspected severe pelvic trauma (Grade 1+ recommendation). 1 The pelvic binder:

• Achieves mechanical stabilization within 2 minutes and is immediately life-saving by controlling venous and cancellous bone bleeding through pelvic ring closure 2
• Must be placed around the great trochanters (not the iliac crests) to be effective compared to surgical C-clamp compression 1
• Reduces transfusion requirements, ICU length-of-stay, and hospital length-of-stay 1
• Should never be delayed for imaging or other interventions 2

Why Surgical Exploration is Wrong and Dangerous

Non-therapeutic laparotomy should be avoided in patients with pelvic fracture hemorrhage, as it is associated with significantly higher mortality rates. 2 Specifically:

• Laparotomy results in poor outcomes due to extensive collateral circulation in the retroperitoneum, making surgical control of pelvic bleeding extremely difficult 2
• Overall mortality for severe pelvic ring disruptions with hemodynamic instability is 30-45%, but increases substantially when laparotomy is performed as the primary intervention 2
• Exploratory laparotomy for isolated pelvic bleeding without clear evidence of intra-abdominal injury dramatically increases mortality 2, 3

Complete Management Algorithm After Pelvic Binder

Step 1: Simultaneous Resuscitation

• Initiate permissive hypotension targeting systolic BP 80-90 mmHg until bleeding is controlled 2, 3
• Transfuse packed red blood cells while minimizing crystalloid administration to avoid dilutional coagulopathy 2, 3
• Monitor serum lactate and base deficit to estimate extent of bleeding and shock 2

Step 2: Rapid Diagnostic Assessment

• Perform E-FAST (Extended Focused Assessment with Sonography for Trauma) to identify intra-abdominal bleeding 1, 3
• Abundant hemoperitoneum (≥3 positive E-FAST sites) indicates need for laparotomy with 61% rate of appropriate therapeutic intervention 1, 3
• Negative E-FAST or minimal free fluid indicates pelvic arterial hemorrhage requiring angiographic intervention 3
• Obtain pelvic X-ray for hemodynamically unstable patients requiring urgent interventions 1

Step 3: Definitive Hemorrhage Control

If ongoing hypotension persists despite adequate binder placement:

• Proceed to angiographic embolization as the primary definitive intervention for arterial bleeding, with success rates of 73-97% 2
• The probability of arterial bleeding on angiography is 73% in non-responders to initial resuscitation 2
• Preperitoneal pelvic packing (PPP) may be performed if angiography is not immediately available, can be completed in <20 minutes, and only 13-20% require subsequent angioembolization 2
• Time to hemorrhage control should be <163 minutes, as mortality increases approximately 1% every 3 minutes of delay 2

Critical Pitfalls to Avoid

• Do not remove the pelvic binder prematurely—mechanical stabilization must be maintained until definitive hemorrhage control is achieved 2
• Do not delay pelvic binder application for imaging or other interventions, as it takes <2 minutes and is life-saving 2
• Do not perform laparotomy for isolated pelvic bleeding without evidence of intra-abdominal injury on E-FAST 2, 3
• Do not delay angiography for external fixation in non-responders, as 44% of patients with fractures amenable to external fixation have arterial bleeding requiring embolization 2

Associated Injuries Consideration

This patient has multiple injuries and is unconscious, which means:

• More than 75% of high-energy pelvic injuries have associated head, thorax, abdominal, or genitourinary injuries 1
• The unconscious state and multiple injuries mandate systematic evaluation for extra-pelvic bleeding sources 1
• E-FAST has 97% negative predictive value in patients with shock for ruling out intra-abdominal bleeding 1