What is the immediate management for a patient with a road traffic accident (RTA) presenting with fractures, instability, hypotension, and a computed tomography (CT) scan showing a pelvic hematoma?

Management of Hemodynamically Unstable RTA Patient with Pelvic Hematoma

In a hemodynamically unstable patient with pelvic fractures and CT-confirmed pelvic hematoma, the immediate priority is RBC transfusion combined with mechanical pelvic stabilization (which you've stated is unavailable), followed by angiographic embolization—NOT emergency laparotomy, which dramatically increases mortality in isolated pelvic hemorrhage. 1, 2

Immediate Resuscitation and Stabilization

Since a pelvic binder is not available (as stated in your question), you must proceed directly to the next steps while initiating aggressive resuscitation:

• Transfuse packed red blood cells immediately using a massive transfusion protocol with a 1:1:1 ratio of RBCs:FFP:platelets to reconstitute whole blood and address trauma-induced coagulopathy 2, 3
• Target permissive hypotension with systolic BP 80-90 mmHg until definitive hemorrhage control is achieved—avoid aggressive fluid resuscitation that worsens coagulopathy 2
• Minimize crystalloid administration to prevent dilutional coagulopathy 2

Why Emergency Laparotomy is WRONG

Emergency laparotomy for isolated pelvic hemorrhage is associated with significantly higher mortality rates and should be avoided. 4, 2

• The retroperitoneum has extensive collateral circulation making surgical control of pelvic bleeding extremely difficult and often futile 2
• Non-therapeutic laparotomy increases mortality substantially in patients with major pelvic injuries 4, 2
• Laparotomy is only indicated if there is significant free intra-abdominal fluid on FAST/CT indicating intra-abdominal organ injury, not for pelvic hematoma alone 1

Definitive Hemorrhage Control Algorithm

Step 1: Determine Source of Bleeding

Perform E-FAST immediately to differentiate between intra-abdominal bleeding (requiring laparotomy) versus isolated pelvic/retroperitoneal bleeding 1

• If abundant hemoperitoneum (3 positive FAST sites) is present, this indicates intra-abdominal organ injury requiring laparotomy 1
• If FAST is negative or shows only retroperitoneal blood, the source is pelvic fracture hemorrhage 1

Step 2: Assess Response to Resuscitation

Non-responders to initial resuscitation (those requiring >2 units PRBCs or with repeated hypotension despite transfusion) have a 73% probability of arterial bleeding requiring angiographic intervention 5, 2

• Sustained improvement in BP >90 mmHg for >2 hours after ≤2 units PRBCs = responder (unlikely arterial bleeding) 5
• Ongoing hypotension despite adequate resuscitation = non-responder (arterial bleeding highly likely) 5

Step 3: Definitive Intervention Based on Hemodynamic Status

For non-responders (your patient):

• Proceed immediately to angiography and embolization as the primary definitive intervention with success rates of 73-97% 2, 1
• Angiography is highly effective for controlling arterial bleeding that cannot be controlled by mechanical stabilization alone 4, 2
• Do not delay angiography even if the fracture pattern appears amenable to external fixation—44% of such patients still have arterial bleeding requiring embolization 5, 2

If angiography is unavailable or delayed >60 minutes:

• Consider preperitoneal pelvic packing (PPP) as a temporizing measure that can be performed in <20 minutes 1
• PPP achieves temporary hemostasis and buys time for transfer to angiography 1
• PPP should be combined with external fixation if possible (though you've stated binder unavailable) 1

Critical Markers of Arterial Hemorrhage

Your patient likely has arterial bleeding based on:

• CT showing pelvic hematoma in a hemodynamically unstable patient 1
• Ongoing hypotension despite resuscitation (non-responder status) 5
• If CT shows contrast "blush" (active extravasation), this has 75% positive predictive value for arterial bleeding on angiography 5

Common Pitfalls to Avoid

• Do not perform exploratory laparotomy for isolated pelvic hemorrhage without clear evidence of intra-abdominal organ injury on FAST/CT 4, 2
• Do not delay angiography for external fixation in non-responders—time to hemorrhage control should be <163 minutes as mortality increases ~1% every 3 minutes 2
• Do not rely on single hematocrit measurements as isolated markers of ongoing bleeding 2
• Do not remove pelvic packs prematurely if PPP is performed—wait at least 48 hours to lower re-bleeding risk 4

Answer to Your Question

Between your two options: Choose A (RBC transfusion) as the immediate next step, NOT B (emergency laparotomy). However, understand that RBC transfusion alone is insufficient—you must simultaneously arrange for angiographic embolization as the definitive hemorrhage control procedure. 1, 2, 5