What is the most appropriate immediate management for a hemodynamically unstable patient with a pelvic fracture and active pelvic hemorrhage?

Immediate Management of Hemodynamically Unstable Pelvic Fracture with Active Bleeding

Apply a pelvic binder immediately, initiate damage control resuscitation with blood products, perform E-FAST to rule out intra-abdominal bleeding, and proceed directly to preperitoneal pelvic packing with external fixation—this patient is too unstable for angiography. 1

Initial Resuscitation and Stabilization

The time between arrival and definitive bleeding control must be minimized—every 3 minutes of delay increases mortality by approximately 1%. 1, 2

• Apply or maintain a pelvic binder immediately to control venous and cancellous bone bleeding (80-90% of pelvic hemorrhage is venous) while preparing for definitive hemorrhage control 1, 2
• Begin damage control resuscitation with packed red blood cells targeting hemoglobin 7-9 g/dL, using FFP:pRBC ratio of at least 1:2 3, 2
• Administer tranexamic acid 1g IV over 10 minutes immediately (must be given within 3 hours of injury), followed by 1g infusion over 8 hours 3
• Target permissive hypotension (systolic BP 80-100 mmHg) until bleeding is definitively controlled—aggressive fluid resuscitation worsens hemorrhage 2
• Obtain serum lactate and base deficit as sensitive markers of hemorrhagic shock severity 1

Rapid Diagnostic Assessment (Do Not Delay Intervention)

With BP 80/50 and active bleeding, this patient is in extremis—diagnostic workup must be completed within minutes, not hours. 1

• Perform E-FAST and pelvic X-ray immediately to identify extra-pelvic bleeding sources requiring laparotomy 1, 2
• If E-FAST shows abundant hemoperitoneum (≥3 positive sites), proceed to emergency laparotomy first to control intra-abdominal hemorrhage, then address pelvic bleeding 2, 4
• If E-FAST is negative or shows minimal free fluid, the bleeding source is pelvic and requires either angioembolization or preperitoneal packing 2, 4
• Do NOT obtain CT scan in this unstable patient—it delays definitive treatment and increases mortality 1, 2

Definitive Hemorrhage Control: Preperitoneal Pelvic Packing

For a patient this unstable (BP 80/50), preperitoneal pelvic packing with external fixation is the most appropriate intervention—angiography takes too long and this patient cannot wait. 1

Why Pelvic Packing Over Angiography in This Case:

• Preperitoneal pelvic packing can be completed in less than 20 minutes with minimal operative blood loss, making it ideal for patients in extremis 1
• Angiography is time-consuming and may not be immediately available 24/7, whereas packing is quick and technically straightforward 5
• Packing controls the 80-90% venous bleeding component immediately, while angiography only addresses the 10-20% arterial component 1
• When arterial bleeding is present, venous bleeding is present 100% of the time—packing addresses both simultaneously 1

Technique for Preperitoneal Pelvic Packing:

• Perform direct preperitoneal packing through a separate suprapubic midline incision accessing the space of Retzius 1
• Place three laparotomy pads on each side of the bladder in the retroperitoneal space, packed below the pelvic brim toward the iliac vessels 1
• Combine packing with external fixation or pelvic binder to provide stable counterpressure for effective hemorrhage control 1
• Plan pack removal within 48-72 hours 1

External Fixation Options:

• Apply anterior external fixation through iliac crest or supra-acetabular route for APC-II/III and LC-II/III injury patterns 1
• Consider posterior C-clamp for vertical shear injuries with sacroiliac joint disruptions, but this is contraindicated in comminuted sacral fractures, transforaminal sacral fractures, or iliac wing fractures 1
• If trained operators are available, a Ganz clamp can be placed in the emergency room for Tile C fractures after heavy traction of the ascended lower limb 1

Secondary Angioembolization (If Needed)

Only 13-20% of patients require subsequent angioembolization after successful pelvic packing. 1

• Perform secondary angioembolization only if there is ongoing hemorrhage or transfusion requirements after packing 1
• Do NOT perform systematic secondary angiographic verification—it is unnecessary if the patient stabilizes 1
• If angiography is performed, use bilateral embolization even for unilateral fractures due to extensive pelvic collateral circulation 1

Critical Pitfalls to Avoid

• Do NOT proceed to angiography if the patient cannot be transferred safely—if angioembolization cannot be performed within 60 minutes of diagnosis, proceed directly to preperitoneal packing 1
• Do NOT perform emergency laparotomy for isolated pelvic bleeding—it cannot control pelvic arterial bleeding and increases mortality 2
• Do NOT remove the pelvic binder prematurely—it must remain in place until definitive hemorrhage control is achieved 2
• Do NOT delay intervention for additional imaging—this patient's BP of 80/50 indicates they are in hemorrhagic shock requiring immediate intervention 1, 3, 2

Alternative Approach: When Angiography is Appropriate

Angiography with embolization (success rate 73-97%) is the preferred definitive treatment when the patient can be stabilized enough for transfer and the procedure can be performed within 60 minutes. 1, 2, 5

• This requires initial stabilization with pelvic binder, blood products, and possibly REBOA as a bridge 5
• However, with BP 80/50 and active bleeding, this patient likely cannot wait for angiography 1, 5