What is the initial approach to resuscitation and stabilization in a 9-year-old child with a pelvic fracture due to a road traffic accident?

Initial Approach and Resuscitation of a 9-Year-Old Child with Pelvic Fracture from Road Traffic Accident

Immediate Life-Saving Interventions (First 5 Minutes)

Apply a pelvic binder immediately around the greater trochanters to control venous and cancellous bone bleeding, which is the single most critical intervention that can be performed within 2 minutes and directly reduces mortality. 1, 2

Simultaneous ABC Assessment

• Airway: Establish airway patency with cervical spine immobilization using bimanual stabilization and cervical collar placement 3
• Breathing: Assess respiratory adequacy; avoid hyperventilation in severely hypovolemic patients 1
• Circulation: Recognize that cardiorespiratory arrest in the first minutes after trauma typically results from airway obstruction, inadequate ventilation, or massive blood loss, and has dismal outcomes 3

Hemodynamic Classification and Risk Stratification

The WSES classification divides pelvic injuries based on hemodynamic status, which drives all subsequent management decisions 4:

• WSES Grade IV (Severe): Any hemodynamically unstable pelvic fracture (systolic BP <90 mmHg) regardless of mechanical stability 4
• WSES Grade II-III (Moderate): Hemodynamically stable but mechanically unstable fractures 4
• WSES Grade I (Minor): Both hemodynamically and mechanically stable 4

Resuscitation Strategy Based on Hemodynamic Status

For Hemodynamically Unstable Patients (WSES Grade IV)

Target permissive hypotension with systolic BP 80-90 mmHg (mean arterial pressure 50-60 mmHg) until definitive hemorrhage control is achieved. 1

• Initiate fluid resuscitation with packed red blood cells immediately, minimizing crystalloid administration to avoid dilutional coagulopathy 1
• Obtain serum lactate and base deficit by arterial blood gas analysis as sensitive markers of traumatic-hemorrhagic shock (lactate >3.4 mmol/L predicts arterial bleeding) 4, 5
• Do not rely on hemoglobin or hematocrit as early markers of hemorrhagic shock extent 4, 1
• Consider tranexamic acid 10-15 mg/kg followed by 1-5 mg/kg/h infusion if administered within 3 hours of injury 1

Diagnostic Workup Algorithm

For hemodynamically unstable patients:

• Obtain pelvic X-ray immediately upon arrival to confirm fracture pattern 4, 2
• Perform E-FAST within 30 minutes to identify intra-abdominal bleeding source (97% positive predictive value) 2
• Minimize time between ED arrival and definitive bleeding control, as mortality increases approximately 1% every 3 minutes of delay, with target <163 minutes 1

For hemodynamically stable patients:

• Skip pelvic X-ray and proceed directly to multiphasic CT scan with IV contrast to exclude pelvic hemorrhage 4
• CT with 3D bone reconstructions reduces tissue damage, neurological complications, operative time, and required expertise 4

Definitive Hemorrhage Control Algorithm

Step 1: Mechanical Stabilization (Already Applied)

• Maintain pelvic binder around greater trochanters; do not remove prematurely 1, 2
• This controls venous bleeding and reduces pelvic volume 4

Step 2: Determine Bleeding Source

Markers of arterial hemorrhage requiring intervention:

• Ongoing hemodynamic instability despite adequate pelvic ring stabilization 4, 2
• CT "blush" (active arterial extravasation) and large hematoma 1, 2
• Pelvic hematoma volume >500 mL on CT 2
• Core temperature <36°C, lactate >3.4 mmol/L 5
• Type B or C fractures on Young-Burgess classification 5

Step 3: Definitive Intervention Based on Availability

If angiography available within 45 minutes:

• Transfer directly to interventional radiology for angiographic embolization with steel coils or Gelfoam 1, 5
• Success rates 73-97% for controlling arterial bleeding 1, 2
• Probability of arterial bleeding on angiography is 73% in non-responders to initial resuscitation 1

If angiography not immediately available:

• Perform preperitoneal pelvic packing (PPP) immediately as bridge to definitive control 1, 2, 5
• PPP can be performed in <20 minutes, controls venous bleeding effectively, and only 13-20% require subsequent angioembolization 1
• Remove pelvic packs only after 48 hours to lower re-bleeding risk 2

Critical Pitfalls to Avoid

Never perform exploratory laparotomy for isolated pelvic hemorrhage - non-therapeutic laparotomy dramatically increases mortality in patients with pelvic fracture hemorrhage due to extensive retroperitoneal collateral circulation making surgical control extremely difficult 1, 2

• Do not delay pelvic binder application for imaging or other interventions 1
• Do not remove binder prematurely before definitive hemorrhage control 1
• Do not delay angiography for external fixation in non-responders, as 44% of patients with fractures amenable to external fixation have arterial bleeding requiring embolization 1
• Avoid excessive positive end-expiratory pressure in severely hypovolemic patients 1

Associated Injury Evaluation

• Perform perineal and rectal digital examination if high suspicion of rectal injuries 4
• Obtain retrograde urethrogram or urethrocystogram with contrast CT if perineal hematoma present with pelvic disruption on X-ray 4
• If positive rectal examination, perform proctoscopy 4

Coagulopathy Management

• Determine coagulopathy presence early using point-of-care bedside testing with TEG or ROTEM for targeted resuscitation 4
• Coagulopathic patients with traumatic hemorrhagic shock from unstable pelvic ring injuries have significantly increased mortality 4
• Correct the "lethal triad" (hypothermia, acidosis, coagulopathy) aggressively 2, 5

Transport Considerations

All children with severe pelvic trauma should be transported to a Level I trauma center with 24/7 availability of trauma surgery, interventional radiology, and orthopedic surgery, as this decreases mortality by 15-30% compared to non-specialized facilities 2, 6