What is the most appropriate management for a patient with a pelvic fracture, large hematoma, active bleeding, and hypotension after a motor vehicle accident (MVA)?

Management of Pelvic Fracture with Active Bleeding and Hypotension

Transfuse packed red blood cells immediately while simultaneously applying pelvic stabilization and preparing for angiographic embolization—emergency laparotomy is contraindicated and dramatically increases mortality in isolated pelvic hemorrhage. 1, 2

Why Emergency Laparotomy is Wrong

• Non-therapeutic laparotomy should be avoided in patients with pelvic fracture hemorrhage, as it has been associated with significantly higher mortality rates, with baseline mortality of 30-45% increasing substantially when laparotomy is performed as the primary intervention. 1
• Laparotomy results in poor outcomes due to the extensive collateral circulation in the retroperitoneum, making surgical control of pelvic bleeding extremely difficult. 1
• The only indication for laparotomy in this setting would be abundant hemoperitoneum on FAST examination (≥3 positive sites), indicating concomitant intra-abdominal injury requiring surgical control—but the question specifies CT shows pelvic hematoma with active bleeding, not intra-abdominal pathology. 3, 2

Immediate Management Algorithm

Step 1: Simultaneous Resuscitation and Hemorrhage Control

• Transfuse packed red blood cells immediately to maintain hemoglobin between 7-9 g/dL while pursuing definitive hemorrhage control. 1, 3, 2
• Target systolic blood pressure of 80-90 mmHg using permissive hypotension strategy until bleeding is controlled—this patient's BP of 80/50 mmHg is at the lower acceptable limit. 1, 3, 2
• Apply or ensure proper placement of a pelvic binder immediately to control venous and cancellous bone bleeding, which can be achieved within minutes and is life-saving. 1, 2
• Minimize crystalloid administration beyond initial resuscitation to avoid dilutional coagulopathy. 3

Step 2: Recognize the Bleeding Source

• CT scan showing active bleeding ("blush") and large hematoma are markers of arterial hemorrhage requiring angiographic intervention, not surgical exploration. 1, 2
• This patient is a non-responder to initial resuscitation (Class III-IV hemorrhagic shock based on BP 80/50), which indicates a 73% probability of arterial bleeding requiring angiographic embolization. 1, 4
• Ongoing hemodynamic instability despite adequate pelvic ring stabilization confirms arterial bleeding that cannot be controlled by mechanical stabilization alone. 1, 3

Step 3: Definitive Hemorrhage Control

• Proceed directly to angiographic embolization as the primary definitive intervention for isolated pelvic arterial bleeding, with success rates of 73-97%. 1, 3, 2
• Patients presenting with hemorrhagic shock and an identified source of bleeding should undergo immediate bleeding control procedures unless initial resuscitation measures are successful. 5
• Time is critical: mean time to hemorrhage control should be <163 minutes, with mortality increasing with delay. 1, 2

Classification of This Patient's Hemorrhagic Shock

• Based on BP 80/50 mmHg, this patient falls into Class III or Class IV hemorrhagic shock (blood loss 1,500-2,000+ ml, >30-40% blood volume), requiring both crystalloid and blood transfusion. 5
• The decreased blood pressure and presumed tachycardia indicate significant ongoing hemorrhage requiring immediate intervention. 5

Adjunctive Measures During Resuscitation

• Administer tranexamic acid 10-15 mg/kg followed by 1-5 mg/kg/h infusion to prevent fibrinolysis. 1, 3
• Monitor serum lactate and base deficit to estimate and monitor the extent of bleeding and shock—do not rely on single hematocrit measurements as they poorly reflect acute blood loss. 1, 3, 2
• Avoid hyperventilation and excessive positive end-expiratory pressure in this severely hypovolemic patient. 1

Critical Pitfalls to Avoid

• Do not delay angiography for additional imaging or external fixation in non-responders to resuscitation, as 44% of patients with fractures amenable to external fixation have arterial bleeding requiring embolization. 1
• Do not remove the pelvic binder prematurely—mechanical stabilization must be maintained until definitive hemorrhage control is achieved. 3, 2
• Do not perform exploratory laparotomy for isolated pelvic hemorrhage without clear evidence of intra-abdominal injury, as this dramatically worsens outcomes. 1, 2