What is the most appropriate management for a patient presenting with severe pelvic pain and hypotension after a Motor Vehicle Accident (MVA), with Computed Tomography (CT) findings of a pelvic hematoma and active bleeding?

Management of Severe Pelvic Trauma with Active Bleeding and Hypotension

The most appropriate management is B - transfusion of packed RBCs combined with immediate angiographic embolization, NOT emergency laparotomy for isolated pelvic bleeding. 1

Critical Decision Point: Rule Out Extra-Pelvic Bleeding Sources

The immediate priority is determining whether the hypotension is from isolated pelvic arterial bleeding versus combined intra-abdominal injury, as this fundamentally changes management 2:

• Perform E-FAST immediately if not already completed during initial assessment, as this determines whether laparotomy versus angioembolization is indicated 1
• If E-FAST shows abundant hemoperitoneum (≥3 positive sites), proceed to emergency laparotomy as this indicates 61% probability of intra-abdominal injury requiring surgical control 2, 1
• If E-FAST is negative or shows minimal free fluid, the bleeding source is pelvic arterial hemorrhage requiring angiographic embolization, NOT laparotomy 2, 1

Resuscitation Strategy During Hemorrhage Control

Transfuse packed RBCs immediately while pursuing definitive hemorrhage control 1:

• Target hemoglobin 7-9 g/dL with packed red blood cells, as ongoing hypotension despite fluid resuscitation indicates active arterial bleeding requiring both blood products and procedural intervention 1
• Continue permissive hypotension targeting systolic blood pressure 80-100 mmHg until bleeding is definitively controlled, as aggressive fluid resuscitation worsens hemorrhage through clot dislodgement and dilutional coagulopathy 1
• Minimize crystalloid administration beyond initial resuscitation to avoid dilutional coagulopathy 1
• Administer tranexamic acid 10-15 mg/kg followed by 1-5 mg/kg/h infusion to prevent fibrinolysis 1

Definitive Hemorrhage Control: Angiographic Embolization

Since CT already shows pelvic hematoma with active bleeding and the patient is hypotensive, proceed directly to angiographic embolization 2, 1:

• Angiography achieves hemorrhage control with 73-97% success rates and is the definitive treatment for arterial pelvic bleeding 1
• The CT scan already performed has 93.9% positive predictive value and 87.5% negative predictive value for detecting active bleeding compared to angiography 2
• Do NOT delay angiography for additional imaging, as mortality increases approximately 1% every 3 minutes of delay 1
• Ensure pelvic binder remains properly applied during transport to angiography suite, as mechanical stabilization must be maintained until definitive hemorrhage control is achieved 1

Why NOT Emergency Laparotomy for Isolated Pelvic Bleeding

Emergency laparotomy is contraindicated for isolated pelvic bleeding 1:

• Non-therapeutic laparotomy dramatically increases mortality (baseline 30-45% mortality increases substantially with unnecessary laparotomy) 1
• Pelvic arterial bleeding cannot be controlled through laparotomy, as the bleeding vessels are retroperitoneal and require angiographic access 2
• Laparotomy is only indicated when E-FAST demonstrates significant hemoperitoneum suggesting concurrent intra-abdominal solid organ injury 2, 1, 3

Critical Pitfalls to Avoid

• Do not remove the pelvic binder prematurely, as this controls venous and cancellous bone bleeding while arterial bleeding is addressed 1
• Do not perform CT scan if the patient becomes more unstable, as this delays definitive treatment; proceed directly to angiography based on clinical findings 1
• Do not rely on single hematocrit measurements to guide transfusion, as they poorly reflect acute blood loss and are confounded by resuscitation 1
• Observation alone (option C) is inappropriate in a hypotensive patient with documented active bleeding on CT, as this represents ongoing arterial hemorrhage requiring immediate intervention 2, 1