What is the initial management of a patient with a pelvic fracture and associated vascular injuries after a blunt injury?

Initial Management of Pelvic Fracture with Vascular Injuries

Apply a pelvic binder immediately as the first-line intervention, followed by rapid assessment of vital signs and hemodynamic status. 1, 2

Immediate Pelvic Stabilization (Priority #1)

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

Critical Technical Details:

• The pelvic binder must be placed around the greater trochanters (not higher on the iliac crests) to be effective compared to surgical C-clamp compression. 1
• Any commercial pelvic binder is acceptable except sheet wrapping, which yields no potential benefit. 1
• Correct placement is crucial—misplacement prevents adequate compression and hemodynamic stabilization. 3
• This intervention directly reduces transfusion requirements, ICU length-of-stay, and hospital length-of-stay. 1

Simultaneous Vital Signs Assessment

While applying the pelvic binder, assess and reassess vital signs frequently, focusing on:

• Hemodynamic stability (systolic blood pressure <90 mmHg indicates instability requiring urgent intervention). 1, 4
• Signs of hemorrhagic shock (altered consciousness, ongoing bleeding). 1
• The presence of pelvic instability on examination confirms high-risk injury. 1

Algorithmic Approach Based on Hemodynamic Status

For Hemodynamically UNSTABLE Patients:

1. Pelvic binder placement (already done). 1, 2

2. Perform E-FAST within 30 minutes of arrival to identify intra-abdominal bleeding source (Grade 2+ recommendation). 1, 5

3. Obtain pelvic X-ray upon arrival to confirm fracture pattern (Grade 2+ recommendation for unstable patients). 1

4. If E-FAST positive for intra-abdominal bleeding: Proceed to immediate laparotomy with concomitant pelvic stabilization, followed by angiography if arterial pelvic bleeding persists. 5

5. If E-FAST negative: Transfer to angiography within 45 minutes of arrival for embolization of arterial bleeding. 5

For Hemodynamically STABLE Patients:

1. Pelvic binder placement (already done). 1, 2

2. Skip pelvic X-ray and proceed directly to CT scan with IV contrast of the entire pelvis (Grade 2- recommendation against X-ray in stable patients). 1

3. CT identifies: Active arterial extravasation ("blush"), hematoma volume >500 mL, and associated injuries. 2

Critical Pitfalls to Avoid

• Never delay pelvic binder application while obtaining vital signs—these should occur simultaneously. 1, 2
• Avoid non-therapeutic laparotomy in pelvic fracture patients without confirmed intra-abdominal bleeding, as this increases mortality. 2
• Do not rely on clinical pelvic examination alone in patients with altered consciousness or shock—assume pelvic trauma is present. 1
• External iliac artery injuries (though rare) require immediate surgical repair, not embolization, and carry 38-72% mortality. 6

Transport Considerations

All patients with severe pelvic trauma should be transported to a Level I trauma center with 24/7 availability of trauma surgery, interventional radiology, and orthopedic surgery (Grade 1+ recommendation). 1, 2 This approach decreases mortality by 15-30% compared to non-specialized facilities. 1