What is the optimal ICU management for a patient with a pelvic fracture?

ICU Management of Pelvic Fracture Patients

Patients with pelvic fractures and hemodynamic instability require immediate pelvic ring closure and stabilization as the first priority, followed by a systematic approach to hemorrhage control using multimodal therapy including external fixation, preperitoneal packing, and/or angioembolization. 1

Initial Assessment and Hemorrhage Control

Immediate Stabilization

• Apply or maintain pelvic binder placement around the greater trochanters immediately upon ICU admission if not already in place to reduce ongoing venous hemorrhage from the pelvic fracture 1
• Assess hemodynamic status continuously, as mortality remains approximately 30% despite multimodal treatment in patients with hemodynamic instability from severe pelvic fractures 1

Risk Stratification for Ongoing Bleeding

The European guideline identifies specific risk factors that predict arterial bleeding requiring intervention 1:

• Type B or C fractures (rotationally or vertically unstable patterns) have significantly higher bleeding risk compared to Type A fractures 1
• Core temperature < 36°C indicates physiologic exhaustion and ongoing hemorrhage 1
• Lactate > 3.4 mmol/L independently predicts arterial bleeding requiring intervention 1
• Arterial contrast extravasation on CT angiography occurs in approximately 18.9% of pelvic fractures and mandates immediate hemorrhage control 1

Hemorrhage Control Algorithm

For Ongoing Bleeding After External Stabilization

If angioembolization can be achieved rapidly (within 45 minutes):

• Transfer directly to interventional radiology for angioembolization with steel coils or Gelfoam suspension 1, 2
• This is the preferred approach when intra-abdominal bleeding has been excluded and interventional radiology is immediately available 2

If angioembolization cannot be achieved in a timely manner:

• Perform temporary extra-peritoneal pelvic packing (PPP) immediately as a bridge to definitive hemorrhage control 1
• PPP can be combined with open abdominal surgery when concomitant intra-abdominal injuries require laparotomy 1
• No significant mortality difference exists between angioembolization and PPP, making either acceptable based on resource availability 1

REBOA Considerations

• Consider REBOA only as a temporary bridge in patients with noncompressible life-threatening hemorrhage approaching hemodynamic collapse 1
• REBOA can temporarily improve hemodynamics but has conflicting survival evidence and significant complication risks 1
• REBOA should only be used by trained personnel within established protocols, not as routine practice 1

Definitive Mechanical Stabilization

Timing Based on Physiologic Status

For hemodynamically stable patients without physiologic derangement:

• Proceed with early definitive pelvic fracture fixation within 24 hours to facilitate mobilization, pain control, and prevent chronic instability 3, 4

For physiologically deranged polytrauma patients:

• Apply damage control principles: postpone definitive fixation until after day 4 post-injury to allow resuscitation and reversal of the "lethal triad" (acidosis, hypothermia, coagulopathy) 1, 3
• Maintain temporary external stabilization during the resuscitation phase in the ICU 1

Fixation Technique Selection

For Type C fractures (vertically unstable):

• Use Ganz C-clamp after heavy traction (15% body weight) of the ascended lower limb, which can be placed in the ICU or emergency room by trained operators 1
• Alternatively, use anterior-inferior external fixator placement to allow concurrent laparotomy access if needed 1

For Type B fractures (rotationally unstable):

• External fixator reduces ring disruption in B1 and B3 patterns 1
• Consider adjunctive temporary external fixation with posterior pelvic ring fixation for selected lateral compression patterns 3

Critical Monitoring Parameters

Serial Assessment Requirements

• Monitor for the "lethal triad": hypothermia, acidosis, and coagulopathy, which indicate physiologic exhaustion and predict mortality 1
• Maintain core temperature > 36°C through active warming measures 1
• Target lactate clearance to < 3.4 mmol/L as indicator of adequate resuscitation 1
• Perform serial radiographs at 2,6, and 12 weeks to assess for loss of reduction or hardware failure 5

Associated Injury Surveillance

• More than 80% of patients with unstable pelvic fractures have additional musculoskeletal injuries requiring systematic evaluation 6
• Assess bladder, urethral, and lumbosacral nerve root injuries given their intimate pelvic location and high injury risk 6, 4
• Evaluate for intra-abdominal injuries using focused assessment with sonography for trauma (FAST) or CT imaging 6, 2

Special Considerations for Open Pelvic Fractures

Open pelvic fractures have mortality exceeding 50% and require immediate multidisciplinary management 1:

• Prioritize bleeding control first, followed by contamination management 1
• Perform surgical debridement, temporary stoma creation if needed, and external fixation 1
• Consider hemipelvectomy only in extremis situations 1
• Transfer to experienced referral centers given the rarity (1.7% of all pelvic fractures) and complexity of these injuries 1

Common Pitfalls to Avoid

• Do not perform clinical pelvic examination maneuvers (compression/distraction) in the ICU, as external stabilization is already in place and manipulation risks displacing fractures or dislodging clot 1
• Do not confuse pelvic binders with abdominal binders or thoracic compression devices - pelvic binders must be positioned around the greater trochanters, not the abdomen 1, 7
• Do not delay hemorrhage control interventions - the critical decision between operating room versus interventional radiology should occur within 45 minutes of ICU admission 1, 2
• Avoid sheet wrapping, which yields no potential benefit compared to commercial pelvic binders 1

Resuscitation Strategy

• Apply damage control resuscitation principles as an essential adjunct to surgical damage control 1
• Use topical hemostatic agents (collagen-based or gelatin-based) in combination with surgical measures for venous or moderate arterial bleeding from parenchymal injuries 1
• Correct coagulopathy aggressively, as it contributes to the lethal triad and predicts mortality 1