What is the most appropriate management for a patient presenting to the emergency room (ER) with a pelvic fracture, active bleeding, a large hematoma, and hypotension, with a blood pressure (BP) of 80/50?

Management of Pelvic Fracture with Active Bleeding and Hypotension

The most appropriate management is B - Transfuse packed red blood cells, along with immediate pelvic stabilization (binder application) and preparation for angiographic embolization. 1, 2

Why Emergency Laparotomy is Contraindicated

Emergency laparotomy (Option A) is absolutely wrong and dramatically increases mortality in isolated pelvic hemorrhage. 1, 3

• Non-therapeutic laparotomy has been associated with significantly higher mortality rates in patients with major pelvic injuries, with baseline mortality of 30-45% increasing substantially when laparotomy is performed as the primary intervention 1
• Laparotomy results in poor outcomes due to the extensive collateral circulation in the retroperitoneum, making surgical control of pelvic bleeding extremely difficult 1
• Laparotomy is only indicated if FAST examination shows significant free intra-abdominal fluid (≥3 positive sites), suggesting concomitant intra-abdominal injury requiring surgical control 4, 2

Immediate Management Algorithm

Step 1: Simultaneous Resuscitation and Pelvic Stabilization (First 5 Minutes)

Apply a pelvic binder immediately around the greater trochanters - this takes <2 minutes and is life-saving by controlling venous and cancellous bone bleeding 1, 3

Initiate blood product transfusion immediately:

• Transfuse packed red blood cells to maintain hemoglobin 7-9 g/dL 2
• Target systolic BP 80-90 mmHg using permissive hypotension strategy until bleeding is controlled 1, 2
• Minimize crystalloid administration beyond initial resuscitation to avoid dilutional coagulopathy 2
• Consider tranexamic acid 10-15 mg/kg followed by 1-5 mg/kg/h infusion 1

Step 2: Rapid Source Identification (Within 30 Minutes)

Perform FAST examination immediately to determine if concomitant intra-abdominal bleeding exists 2, 5

• If FAST shows abundant hemoperitoneum (≥3 positive sites): proceed to emergency laparotomy for intra-abdominal injury 2
• If FAST is negative or shows minimal free fluid: the bleeding source is pelvic arterial hemorrhage requiring angiographic embolization, not laparotomy 2

Step 3: Definitive Hemorrhage Control

For isolated pelvic bleeding (negative FAST), proceed directly to angiographic embolization 1, 2

• The probability of arterial bleeding requiring angiography is 73% in non-responders to initial resuscitation 1
• Angiography achieves hemorrhage control with 73-97% success rates 1
• Time is critical: mean time to hemorrhage control should be <163 minutes, with mortality increasing approximately 1% every 3 minutes of delay 1

If angiography is not immediately available, preperitoneal packing may be performed as a bridge procedure 1, 3

• Preperitoneal packing can be performed in <20 minutes and controls venous bleeding effectively 1
• Only 13-20% of patients require subsequent angioembolization after packing 1
• Packs should remain in place for at least 48 hours to lower re-bleeding risk 3

Monitoring Resuscitation Adequacy

Use serum lactate and base deficit to estimate and monitor the extent of bleeding and shock 1

• Base excess values <-5 are associated with significantly higher mortality 6
• Do not rely on single hematocrit measurements as they poorly reflect acute blood loss and are confounded by resuscitation 1, 2

Critical Pitfalls to Avoid

Do not delay angiography for additional imaging or external fixation in persistently hypotensive patients - mortality increases with every minute of delay 1, 2

Do not remove the pelvic binder prematurely - mechanical stabilization must be maintained until definitive hemorrhage control is achieved 2

Do not perform exploratory laparotomy for isolated pelvic bleeding without clear FAST evidence of intra-abdominal injury - this dramatically worsens outcomes 1, 2

Do not aggressively fluid resuscitate beyond permissive hypotension targets - this worsens hemorrhage through clot dislodgement and dilutional coagulopathy 2