What is the next step in management for a vehicle crash patient with hip pain, who was initially hypotensive and tachycardic, but stabilized after receiving 2 units of packed RBC and 1L of PLR, with a GCS of 15 and no signs of external bleeding or abdominal tenderness?

Next Step Management for Stabilized Vehicle Crash Patient with Hip Pain

The next step is immediate pelvic X-ray or CT scan to identify pelvic fracture as the source of ongoing hemorrhage, followed by urgent pelvic stabilization (binder/sheet wrap) and angiographic embolization if a pelvic ring disruption is confirmed. 1

Critical Assessment of Current Clinical Status

This patient presents with Class III hemorrhagic shock (initially 80/50 BP, HR 120) that has partially responded to resuscitation (now 110/70, HR 111), making them a transient responder who requires immediate definitive hemorrhage control rather than continued observation. 2 The combination of:

• Hip pain in a vehicle crash patient
• Requirement of 2 units PRBCs + 1L crystalloid for stabilization
• Persistent tachycardia (HR 111) despite improved BP
• Soft, non-tender abdomen (ruling out intra-abdominal source)

This clinical picture strongly suggests occult pelvic hemorrhage as the bleeding source. 1

Immediate Diagnostic Algorithm

Primary Imaging Decision

• Perform pelvic X-ray immediately at bedside if the patient shows any signs of hemodynamic instability or if CT would delay definitive management 1
• Proceed to CT pelvis with IV contrast if the patient maintains stable vital signs (BP >100 systolic, HR <100), as this provides superior detail for angiography planning 3, 1
• The shock index (HR/SBP = 111/110 = 1.01) indicates ongoing significant hemorrhage risk and predicts need for intervention 1

Critical Pitfall to Avoid

Do not assume stability based on current vital signs alone. Transient responders—those who initially improve with resuscitation but have persistent tachycardia or narrow pulse pressure—frequently deteriorate and require immediate operative or interventional management. 2, 3 The patient's persistent HR of 111 despite resuscitation is a red flag. 1

Definitive Management Pathway

If Pelvic Ring Disruption Confirmed

1. Apply pelvic binder or sheet wrap immediately to achieve mechanical pelvic closure and tamponade venous bleeding 1, 3

2. Proceed urgently to angiographic embolization rather than continued resuscitation, as patients with pelvic ring disruption in hemorrhagic shock require immediate stabilization followed by angioembolization or surgical bleeding control 1, 3

3. Maintain permissive hypotension (target SBP 80-100 mmHg) until definitive hemorrhage control is achieved, avoiding excessive crystalloid that worsens coagulopathy 1, 2, 3

If No Pelvic Fracture Identified

• Evaluate for occult femoral or acetabular fractures with dedicated hip imaging, as hip pain with hemorrhagic shock in trauma suggests major skeletal injury 1
• Consider retroperitoneal hemorrhage from lumbar spine or major vessel injury if pelvic bones are intact 1

Ongoing Resuscitation Strategy

Blood Product Management

• Continue restrictive transfusion strategy targeting hemoglobin 7-9 g/dL while pursuing definitive hemorrhage control 3
• Initiate massive transfusion protocol if patient requires additional transfusion or shows minimal response to current resuscitation 2
• Monitor for coagulopathy with serial PT/PTT and fibrinogen, as trauma-induced coagulopathy develops early 1

Hemodynamic Targets

• Target systolic BP 80-100 mmHg (permissive hypotension) until bleeding is controlled 1, 2, 3
• Monitor base deficit and lactate serially to assess adequacy of resuscitation and tissue perfusion 1, 2
• Assess capillary refill time as prolonged CRT >2 seconds indicates inadequate perfusion despite improved BP 2

Timeline for Definitive Intervention

Patients with Class III hemorrhagic shock require bleeding control procedures within 60 minutes of presentation. 2 This patient has already received significant resuscitation (2 units PRBCs + 1L crystalloid) and remains tachycardic, indicating they are a transient responder who needs immediate intervention rather than continued observation. 2, 3

The time elapsed between injury and definitive bleeding control should be minimized, as delays increase mortality in hemorrhagic shock. 1

Monitoring During Workup

• Serial vital signs every 5-15 minutes to detect deterioration 2
• Urine output monitoring targeting >1 mL/kg/hour as indicator of adequate perfusion 2
• Mental status assessment as confusion/anxiety indicates inadequate cerebral perfusion 2
• Avoid relying on single hematocrit measurements as they poorly reflect acute blood loss and are confounded by resuscitation 3, 1