How to diagnose and manage coagulopathy in a patient with a pelvic fracture, particularly those with significant bleeding, hemodynamic instability, or requiring massive transfusion?

Checking for Coagulopathy in Pelvic Fracture Patients

Immediately obtain point-of-care coagulation testing (INR, PT/PTT, fibrinogen, platelet count) and arterial blood gas with lactate and base deficit upon arrival for all pelvic fracture patients with hemodynamic instability or significant bleeding. 1

Initial Laboratory Assessment

Essential Coagulation Parameters

• Draw INR, PT/PTT, fibrinogen level, and platelet count as part of the initial trauma panel—these are your primary markers of coagulopathy 1
• Obtain arterial blood gas with lactate and base deficit to estimate the extent of bleeding and shock; lactate >3.4 mmol/L predicts arterial bleeding requiring intervention 1, 2
• Measure core temperature immediately—hypothermia <36°C is both a predictor of arterial bleeding and a component of the lethal triad (hypothermia, acidosis, coagulopathy) that drives mortality 1, 2

Clinical Indicators of Coagulopathy

• Monitor transfusion requirements closely—patients requiring massive transfusion (>10 units packed RBCs) are at extremely high risk for developing trauma-induced coagulopathy 3, 4
• Assess for the "lethal triad": hypothermia (<36°C), acidosis (base deficit), and coagulopathy (INR ≥1.5)—this combination predicts mortality and requires aggressive correction 2
• Do not rely on single hematocrit measurements as an isolated marker for bleeding, as they can be misleading in acute hemorrhage 5

Risk Stratification for Coagulopathy

High-Risk Fracture Patterns

• Type B and C pelvic fractures (rotationally and/or vertically unstable) have significantly higher rates of coagulopathy and arterial bleeding 1, 2
• Vertical shear fractures with inferior displacement of the hemipelvis should alert you to severe arterial injuries and higher bleeding risk 1
• High-energy mechanisms (motor vehicle crashes, falls from height) produce greater tissue damage and are associated with coagulopathy in >75% of cases with associated injuries 1

Physiologic Markers Predicting Coagulopathy

• Lactate >3.4 mmol/L is an independent risk factor for arterial bleeding and coagulopathy 1, 2
• Core temperature <36°C independently predicts both coagulopathy and need for angioembolization 1, 2
• Hemodynamic instability despite initial resuscitation (Class III-IV shock per ATLS classification) indicates ongoing bleeding and likely coagulopathy 1

Imaging to Identify Bleeding Source

CT Angiography Findings

• Arterial contrast extravasation ("blush") on CT angiography is a strong predictor of arterial bleeding requiring intervention and associated coagulopathy 1, 5
• Pelvic hematoma volume >500 mL indicates significant bleeding and increased risk of coagulopathy 6
• Obtain contrast-enhanced whole-body CT early in hemodynamically stable patients to identify bleeding sources and guide intervention 1

Point-of-Care Ultrasound

• Use FAST examination to detect free fluid in the abdomen, which may indicate associated intra-abdominal bleeding contributing to coagulopathy 1
• FAST has high specificity but variable sensitivity—a negative FAST does not rule out significant bleeding 1

Monitoring During Resuscitation

Serial Laboratory Assessment

• Recheck coagulation parameters every 30-60 minutes during active resuscitation and massive transfusion to guide blood product replacement 3
• Monitor fibrinogen levels closely—hypofibrinogenemia is an early marker of trauma-induced coagulopathy and should be corrected aggressively 1
• Track lactate clearance—failure to clear lactate to <3.4 mmol/L indicates inadequate resuscitation and ongoing coagulopathy risk 2

Transfusion Thresholds

• INR ≥1.5 defines coagulopathy requiring correction in trauma patients 7
• Consider prothrombin complex concentrate (PCC) for rapid INR correction in coagulopathic patients (INR ≥1.5) requiring urgent surgical intervention—PCC corrects INR faster than FFP and reduces time to intervention 7
• Transfuse FFP, platelets, and RBCs in 1:1:1 ratio during massive transfusion to prevent dilutional coagulopathy 5, 3

Critical Pitfalls to Avoid

• Do not delay coagulation testing until after imaging—obtain labs immediately upon arrival for all hemodynamically unstable pelvic fracture patients 1
• Do not ignore hypothermia—actively warm patients to maintain core temperature >36°C, as hypothermia perpetuates coagulopathy 1, 2
• Do not over-resuscitate with crystalloids—excessive crystalloid administration causes dilutional coagulopathy; prioritize blood products early 5, 3
• Do not wait for laboratory confirmation to initiate massive transfusion protocol in patients with Class III-IV shock—clinical indicators (hemodynamic instability, high-energy mechanism, unstable fracture pattern) should trigger empiric treatment 1, 5