What is the next appropriate management step for a middle-aged patient with a pelvic injury after a motor vehicle accident (MVA), presenting with hypotension and a severe hematoma on CT scan?

Management of Hypotensive Pelvic Trauma with Severe Hematoma

The next appropriate management step is D - Transfer blood products, combined with immediate preparation for angiographic embolization, as this patient has hemodynamic instability (BP 88/55 mmHg, which is <90 mmHg systolic) from pelvic arterial hemorrhage requiring both aggressive hemostatic resuscitation and definitive hemorrhage control. 1, 2

Why Blood Products Are the Correct Answer

This patient is hemodynamically unstable with systolic BP <90 mmHg, which by definition requires immediate packed red blood cell transfusion while simultaneously pursuing definitive hemorrhage control. 3, 1 The CT scan has already been performed and shows severe hematoma, confirming the diagnosis and eliminating the need for additional imaging before intervention. 2

Critical Management Algorithm

Step 1: Immediate Resuscitation

• Transfuse packed red blood cells immediately to maintain hemoglobin 7-9 g/dL while pursuing definitive hemorrhage control 1, 2
• Use permissive hypotension strategy targeting systolic BP 80-100 mmHg until bleeding is controlled, as aggressive fluid resuscitation worsens hemorrhage through clot dislodgement and dilutional coagulopathy 3, 1
• Minimize crystalloid administration beyond initial resuscitation to avoid dilutional coagulopathy 1

Step 2: Ensure Pelvic Mechanical Stabilization

• Confirm pelvic binder or circumferential compression device is properly applied, as this controls venous and cancellous bone bleeding 1, 2
• Ongoing hypotension despite adequate pelvic stabilization confirms arterial bleeding requiring angiography 1

Step 3: Definitive Hemorrhage Control

• Proceed directly to angiographic embolization, as 73% of non-responders to initial resuscitation have arterial bleeding requiring embolization 1, 2
• Angiography achieves hemorrhage control with 73-97% success rates and is the definitive treatment for arterial pelvic bleeding 1, 2
• Mean time to hemorrhage control should be <163 minutes, with mortality increasing approximately 1% every 3 minutes of delay 4

Why the Other Options Are Wrong

Option A (Bed rest and painkillers) is completely inappropriate - This patient has hemorrhagic shock requiring immediate intervention, not conservative management. 3, 1

Option B (Emergency laparotomy) is contraindicated and dramatically increases mortality - Non-therapeutic laparotomy in isolated pelvic hemorrhage increases the baseline 30-45% mortality substantially due to the extensive collateral circulation in the retroperitoneum making surgical control of pelvic bleeding extremely difficult. 2 Laparotomy is only indicated if FAST examination shows abundant hemoperitoneum (≥3 positive sites) indicating intra-abdominal injury requiring surgical control. 1

Option C (IV fluid and observe) is inadequate - While IV fluids are part of initial resuscitation, this patient requires blood products, not just crystalloids, and "observe" is inappropriate for ongoing hemorrhagic shock. 1 The hourly need for red blood cell transfusions in these patients averages 3.7 units/hour before hemorrhage control. 4

Additional Critical Management Points

Adjunctive Measures During Resuscitation:

• Administer tranexamic acid 10-15 mg/kg followed by 1-5 mg/kg/h infusion to prevent fibrinolysis 1
• Monitor serum lactate and base deficit to assess adequacy of resuscitation - base excess <-5 significantly predicts mortality 5
• Maintain target mean arterial pressure >65 mmHg during resuscitation 1

Common Pitfalls to Avoid:

• Do not delay angiography for additional imaging in the persistently hypotensive patient 1
• Do not rely on single hematocrit measurements to guide transfusion, as they poorly reflect acute blood loss and are confounded by resuscitation 3, 1
• Do not remove the pelvic binder prematurely - mechanical stabilization must be maintained until definitive hemorrhage control is achieved 1
• Do not perform CT scan if the patient is unstable and CT has already been done - proceed directly to angiography 1

Alternative if Angiography Unavailable:

• Preperitoneal pelvic packing can be performed in <20 minutes if angiography cannot be performed within 60 minutes of diagnosis, though it carries higher risk of venous thromboembolism than angioembolization 3, 6

Expected Outcome After Successful Intervention:

• The hourly need for red blood cell transfusions should decrease dramatically from 3.7 to 0.1 units/hour after successful angiographic embolization 4