What are the precautions for a patient with a pelvic fracture, particularly those with a history of bleeding disorders or taking anticoagulant medication?

Pelvic Fracture Precautions

Patients with pelvic fractures and bleeding disorders or on anticoagulation require immediate aggressive hemostatic resuscitation, early coagulation testing with correction of coagulopathy, and a multidisciplinary approach prioritizing mechanical stabilization followed by hemorrhage control through packing and/or angioembolization based on hemodynamic status.

Initial Hemorrhage Control and Stabilization

Immediate Mechanical Stabilization

• Apply or maintain a pelvic binder around the greater trochanters immediately to control venous and cancellous bone bleeding—this is the first-line intervention for all suspected unstable pelvic fractures regardless of coagulation status 1.
• Pelvic closure can alternatively be achieved using a bed sheet, external fixator, or pelvic C-clamp if a binder is unavailable 1.
• Patients with pelvic ring disruption in hemorrhagic shock require immediate pelvic ring closure and stabilization as the priority intervention 1.

Critical Assessment for Coagulopathy

• Immediately obtain point-of-care coagulation testing (INR, PT/PTT, fibrinogen, platelet count) upon arrival for all pelvic fracture patients with hemodynamic instability 2.
• Draw arterial blood gas with lactate and base deficit—lactate >3.4 mmol/L independently predicts arterial bleeding and coagulopathy 2, 3.
• Measure core temperature immediately, as hypothermia <36°C is both a predictor of arterial bleeding and a component of the lethal triad (hypothermia, acidosis, coagulopathy) that drives mortality 2, 3.
• Recheck coagulation parameters every 30-60 minutes during active resuscitation to guide blood product replacement 2.

Hemorrhage Control Algorithm Based on Hemodynamic Status

For Hemodynamically Unstable Patients

• Transfer immediately to the operating room for preperitoneal packing (PPP) when bleeding is ongoing and angioembolization cannot be achieved within 45 minutes 1, 3, 4.
• PPP decreases the need for pelvic embolization and provides crucial time for selective hemorrhage management 1.
• Perform subsequent angiography/angioembolization after packing if signs of continued bleeding persist—the combined protocol of initial packing followed by secondary angioembolization significantly reduces mortality compared to angioembolization alone 1.
• Consider REBOA only as a temporary bridge in patients with noncompressible life-threatening hemorrhage approaching hemodynamic collapse 1, 3.

For Hemodynamically Stable Patients

• If arterial contrast extravasation ("blush") is seen on CT angiography and angioembolization can be achieved rapidly, transfer directly to interventional radiology 1, 3.
• Arterial contrast extravasation on CT is a strong predictor of arterial bleeding requiring intervention 1.
• Patients who remain hemodynamically stable with negative CT can proceed directly to definitive mechanical stabilization 1.

Special Considerations for Anticoagulated/Coagulopathic Patients

Aggressive Coagulopathy Correction

• Transfuse FFP, platelets, and RBCs in 1:1:1 ratio during massive transfusion to prevent dilutional coagulopathy 2.
• Monitor fibrinogen levels closely and correct aggressively, as hypofibrinogenemia is an early marker of trauma-induced coagulopathy 2.
• Track lactate clearance to <3.4 mmol/L as an indicator of adequate resuscitation 2, 3.
• Apply damage control resuscitation principles in severely injured patients with deep hemorrhagic shock, ongoing bleeding, and coagulopathy 1, 3.

Risk Stratification

• Type B and C pelvic fractures (rotationally/vertically unstable) have significantly higher rates of coagulopathy and arterial bleeding 2.
• Pelvic hematoma volumes >500 mL on CT indicate significant bleeding and increased coagulopathy risk 1, 2.
• Elderly patients require angiography/angioembolization more frequently than younger adults, regardless of apparently normal hemodynamics, even in mechanically stable low-risk fractures 1.

Definitive Management Timing

For Hemodynamically Stable Patients

• Proceed with early definitive pelvic fracture fixation within 24 hours for hemodynamically stable patients with mechanically unstable fractures and no physiologic derangement 3, 4.
• Rotationally unstable (APC-II, LC-II) and vertically unstable fractures (APC-III, LC-III) require anatomic reduction and stable internal fixation 1, 4.

For Physiologically Deranged Patients

• Postpone definitive fixation until after day 4 post-injury in physiologically deranged polytrauma patients to allow reversal of the lethal triad 3, 4.
• Apply damage control principles when hypothermia, acidosis, coagulopathy, or need for time-consuming procedures are present 1.

Critical Monitoring Parameters

• Monitor continuously for the "lethal triad": hypothermia, acidosis, and coagulopathy—these indicate physiologic exhaustion and predict mortality 1, 3.
• Maintain core temperature >36°C through active warming measures 3.
• If bleeding persists after initial angioembolization, consider repeat angiography/angioembolization—this has been found to be an effective strategy 1.

Key Pitfalls to Avoid

• Never perform non-therapeutic laparotomy as the primary intervention—this approach has been associated with high mortality in patients with major pelvic injuries 1.
• Do not remove pelvic packs before 48 hours to lower the risk of re-bleeding 1.
• Recognize that 85% of pelvic bleeding originates from bone, soft tissues, or major venous structures—angioembolization alone benefits only a small minority and should be employed only after extrapelvic and non-arterial sources are controlled 1.
• Always rule out extra-pelvic sources of blood loss before attributing hemodynamic instability solely to the pelvic fracture 1.