What is the 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 (Option B) is the correct immediate answer, but this is only the first step in a comprehensive hemorrhage control algorithm that includes immediate pelvic stabilization and preparation for angiographic embolization—emergency laparotomy should be avoided as it dramatically increases mortality. 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
• The 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

Immediate Management Algorithm

Step 1: Simultaneous Resuscitation and Pelvic Stabilization

Resuscitation:

• Initiate immediate transfusion of packed red blood cells while minimizing crystalloid administration to avoid dilutional coagulopathy. 1
• Target systolic blood pressure of 80-90 mmHg using permissive hypotension strategy until hemorrhage is controlled (this patient's BP of 80/50 fits this target). 1
• Use base excess as a resuscitation monitor—values ≤ -5 are associated with significantly higher mortality. 2
• Consider tranexamic acid (10-15 mg/kg bolus followed by 1-5 mg/kg/h infusion) in the bleeding trauma patient. 1

Pelvic Stabilization:

• Apply a pelvic binder immediately—this takes less than 2 minutes and is life-saving. 1
• Pelvic ring closure controls venous and cancellous bone bleeding, which is the source in the majority of pelvic fracture hemorrhage. 1
• Do not remove the binder prematurely; mechanical stabilization must be maintained until definitive hemorrhage control is achieved. 1

Step 2: Determine if Arterial Bleeding is Present

This patient has markers indicating arterial hemorrhage:

• Large pelvic hematoma and ongoing hemodynamic instability despite adequate pelvic ring stabilization indicate arterial bleeding that cannot be controlled by mechanical stabilization alone. 1
• The probability of arterial bleeding on angiography is 73% in non-responders to initial resuscitation. 1, 3
• If CT scan shows active bleeding ("blush"), this is a marker of arterial hemorrhage requiring angiographic intervention. 1

Step 3: Definitive Hemorrhage Control

For patients with ongoing hemodynamic instability despite pelvic binder placement:

• Early angiographic embolization is the primary definitive intervention, with success rates of 73-97%. 1
• Angiography should not be delayed for external fixation in non-responders to resuscitation, as 44% of patients with fractures amenable to external fixation have arterial bleeding requiring embolization. 3
• Mean time to hemorrhage control should be less than 163 minutes, as mortality increases approximately 1% every 3 minutes of delay. 4

Alternative if angiography is not immediately available:

• Preperitoneal packing can be performed in less than 20 minutes in the ED or OR, controls venous bleeding effectively, and buys crucial time for angiography. 1
• Only 13-20% of patients require subsequent angioembolization after preperitoneal packing. 1

Monitoring Response to Treatment

• The hourly need for red blood cell transfusions should decrease dramatically (from 3.7 to 0.1 units/hour) after successful angiographic embolization. 4
• Persistent base deficit ≥10 for greater than 6 hours, continued hypotension (SBP <90), and absence of intra-abdominal injury predict ongoing pelvic hemorrhage requiring repeat angiography with 97% probability. 5
• Do not rely on single hematocrit measurements as an isolated laboratory marker for bleeding. 1

Critical Pitfalls to Avoid

• Never perform exploratory laparotomy for isolated pelvic hemorrhage without clear evidence of intra-abdominal injury. 1
• Do not delay pelvic binder application for imaging or other interventions—it takes less than 2 minutes and is life-saving. 1
• Avoid hyperventilation and excessive positive end-expiratory pressure in severely hypovolemic trauma patients. 1
• Apply damage control principles: rapid pelvic stabilization, permissive hypotension, and correction of the lethal triad (hypothermia, acidosis, coagulopathy) take priority. 1

Expected Outcome

• With appropriate management following this algorithm, pelvic hemorrhage can be controlled in 97.8% of patients. 4
• However, mortality remains 26-32% in patients presenting in shock with pelvic fractures, emphasizing the critical importance of rapid, protocol-driven care. 4, 6