What are the age-specific differences in resuscitation and emergency department management for pediatric and adult patients with pelvic fractures and suspected internal bleeding?

Age-Specific Resuscitation and Emergency Department Management for Pelvic Fractures with Suspected Internal Bleeding

Critical Age-Related Differences in Initial Management

The fundamental resuscitation principles for pelvic fractures with hemorrhagic shock remain identical across pediatric and adult populations, with immediate pelvic binder application and hemorrhage control taking absolute priority regardless of age. 1

The evidence base for pelvic fracture management does not stratify recommendations by specific age groups, as the physiologic response to hemorrhagic shock and the anatomic sources of bleeding are fundamentally similar across ages. However, several age-related considerations modify the approach:

Universal Initial Resuscitation Protocol (All Ages)

Immediate Life-Saving Interventions (First 2 Minutes)

• Apply pelvic binder immediately around the greater trochanters - this single intervention directly reduces mortality by controlling venous and cancellous bone bleeding, regardless of patient age 1
• Assess respiratory adequacy and avoid hyperventilation in severely hypovolemic patients, as this worsens shock physiology 1
• Obtain pelvic X-ray immediately upon arrival to confirm fracture pattern in hemodynamically unstable patients 1

Hemodynamic Assessment and Classification

• Classify patients using WSES Grade IV (hemodynamically unstable: systolic BP <90 mmHg) versus lower grades, as this drives all subsequent management decisions 1
• Target permissive hypotension with systolic BP 80-90 mmHg (MAP 50-60 mmHg) until definitive hemorrhage control is achieved 1
• Obtain serum lactate and base deficit immediately - lactate >3.4 mmol/L predicts arterial bleeding requiring intervention 1, 2

Age-Specific Modifications

Pediatric Patients (≤16 Years)

• Use E-FAST as alternative to CT scan when hemodynamically stable to reduce radiation exposure in children 3
• In children with mild symptoms, minimal clinical findings, and hematuria, ultrasound techniques including E-FAST may be adopted for initial evaluation rather than immediate CT 3
• Pediatric patients with severe shock and penetrating truncal mechanism require early surgical bleeding control, similar to adults 4
• The same 80% incidence of additional musculoskeletal injuries applies to pediatric pelvic fractures 5

Adult Patients

• Standard CT angiography protocols apply for hemodynamically stable adults without radiation concerns 1
• In elderly patients (>65 years), maintain higher index of suspicion for arterial bleeding, as case reports demonstrate CT angiography may miss active arterial hemorrhage even in older adults with significant comorbidities 6
• Narrow pulse pressure (<30 mmHg) is independently associated with massive transfusion (OR 3.74) and emergent surgery in adults 4

Diagnostic Algorithm (Age-Independent)

For Hemodynamically Unstable Patients

• Perform E-FAST within 30 minutes to identify intra-abdominal bleeding source (97% positive predictive value) 1, 3
• E-FAST combined with chest X-ray enables appropriate urgent intervention decisions with 98% accuracy 3
• Critical pitfall: When E-FAST shows 3 positive sites, this correlates with 61% appropriate laparotomies; 2 positive sites correlates with only 26% 3
• Minimize time between ED arrival and definitive bleeding control - mortality increases approximately 1% every 3 minutes of delay, with target <163 minutes 1

For Hemodynamically Stable Patients

• Proceed directly to thoraco-abdomino-pelvic CT scan with intravenous contrast for complete injury assessment 3
• CT angiography offers fast and detailed information on location and type of bleeding 7
• Critical caveat: CT angiography may not reveal existing active bleeding in some cases, particularly during initial resuscitation when blood pressure is critically low 6

Definitive Hemorrhage Control Algorithm (Age-Independent)

Primary Decision Point: Angiography Availability

• If angiography available within 45 minutes: Transfer directly to interventional radiology for angiographic embolization with steel coils or Gelfoam 1, 2

  • Success rates 73-97% for controlling arterial bleeding 1
  • High success rates and low complication rates make this the first method of bleeding control 7

• If angiography NOT immediately available: Perform preperitoneal pelvic packing (PPP) immediately as bridge to definitive control 1, 2

  • PPP decreases need for pelvic embolization and may be performed simultaneously with or soon after initial pelvic stabilization 4

Critical Management Pitfall

• 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
• This recommendation is absolute and applies to all age groups 4

Mechanism-Based Bleeding Source Prediction

• Falls from height (>3 meters): 85% bleed from the fracture itself, regardless of fracture stability 8
• Impact/motor vehicle collision: 65% with stable fractures bleed from associated injuries; 70% with unstable fractures bleed from fracture itself 8
• Mechanism of action is key to determining bleeding source and should guide diagnostic workup 8

Associated Injury Evaluation (All Ages)

• Perform perineal and rectal digital examination if high suspicion of rectal injuries 1
• Obtain retrograde urethrogram or urethrocystogram with contrast CT if perineal hematoma present with pelvic disruption on X-ray 1
• More than 80% of patients with unstable pelvic fractures have additional musculoskeletal injuries requiring systematic evaluation 5

Coagulopathy Management (Age-Independent)

• Determine coagulopathy presence early using point-of-care bedside testing with TEG or ROTEM for targeted resuscitation 1, 2
• Correct the "lethal triad" (hypothermia, acidosis, coagulopathy) aggressively 1, 2
• Implement haemostatic resuscitation regime with early platelets and fresh frozen plasma 4
• Maintain core temperature >36°C through active warming measures 2

Transport Considerations (All Ages)

• All patients 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 1
• This decreases mortality by 15-30% compared to non-specialized facilities 1

High-Risk Indicators Requiring Aggressive Intervention

• Type B or C fractures with core temperature <36°C 2
• Lactate >3.4 mmol/L 2
• Arterial contrast extravasation on CT angiography 2
• Shock index ≥1.0 (heart rate/systolic BP) 4
• Sacroiliac joint disruption, female gender, and duration of hypotension predict need for angiography 4