What is the best initial management for a patient with a pelvic fracture, active bleeding, large hematoma, and hypotension (blood pressure 80/50)?

Management of Pelvic Fracture with Active Bleeding and Hypotension

The correct answer is C - pelvic binder, which should be applied immediately as the first life-saving intervention, followed by packed red blood cell transfusion and preparation for angiographic embolization. 1, 2

Immediate Management Algorithm

Step 1: Apply Pelvic Binder (Answer C)

• Pelvic binder application is the single most critical intervention that can be performed within 2 minutes and directly reduces mortality by controlling venous and cancellous bone bleeding. 1, 3
• The binder should be placed around the greater trochanters to achieve pelvic ring closure and stabilization. 3
• This mechanical stabilization limits expansion of the pelvic hematoma and provides immediate hemorrhage control for the 85% of pelvic bleeding that is venous in origin. 4

Step 2: Transfuse Packed Red Blood Cells (Answer B - Also Correct)

• Initiate immediate fluid resuscitation with packed red blood cells while minimizing crystalloid administration to avoid dilutional coagulopathy. 2, 5
• Target permissive hypotension with systolic BP 80-90 mmHg (mean arterial pressure 50-60 mmHg) until definitive hemorrhage control is achieved. 2, 3, 5
• Use serum lactate and base deficit to monitor the extent of bleeding and shock. 2, 5

Step 3: Definitive Hemorrhage Control

• With CT scan showing active bleeding ("blush") and large hematoma, this patient has arterial hemorrhage requiring angiographic embolization as the definitive intervention. 2, 5
• Angiography and embolization have success rates of 73-97% for controlling arterial bleeding that cannot be controlled by fracture stabilization alone. 1, 2, 6
• The probability of arterial bleeding on angiography is 73% in non-responders to initial resuscitation. 2
• Time is critical: mean time to hemorrhage control should be <163 minutes, as mortality increases with delay. 2, 3

Why the Other Answers Are Wrong

Answer A: Emergency Laparotomy - INCORRECT

• Non-therapeutic laparotomy should be avoided in patients with pelvic fracture hemorrhage, as it has been associated with significantly higher mortality rates. 1, 2
• Laparotomy results in poor outcomes due to the extensive collateral circulation in the retroperitoneum, making surgical control of pelvic bleeding extremely difficult. 2
• The overall mortality rate for patients with severe pelvic ring disruptions increases substantially when laparotomy is performed as the primary intervention. 2
• Laparotomy is only indicated if FAST examination shows abundant hemoperitoneum indicating concomitant intra-abdominal bleeding. 5

Answer D: Reassess - INCORRECT

• With BP 80/50, active bleeding on CT, and large hematoma, this patient is in hemorrhagic shock requiring immediate intervention, not observation. 2, 3
• Delaying definitive management increases mortality approximately 1% every 3 minutes. 3

Alternative Intervention if Angiography Unavailable

• If angiographic embolization cannot be performed within 60 minutes, preperitoneal pelvic packing (PPP) in association with external fixation should be performed as a bridge to definitive control. 1
• PPP achieves significant hemostasis and permits haemodynamic stability allowing transfer to angiography. 1
• This technique can be performed in <20 minutes and controls venous bleeding effectively, with only 13-20% of patients requiring subsequent angioembolization. 3

Critical Pitfalls to Avoid

• Do not delay pelvic binder application for imaging or other interventions - it takes <2 minutes and is life-saving. 3
• Do not remove the binder prematurely - mechanical stabilization should be maintained until definitive hemorrhage control is achieved. 3
• Do not perform exploratory laparotomy for isolated pelvic bleeding without clear evidence of intra-abdominal injury on FAST examination. 2, 5
• Do not rely on single hematocrit measurements as an isolated laboratory marker for bleeding. 2, 5