In a 32-year-old woman after a motor vehicle accident with severe pelvic pain, hypotension (blood pressure 88/50 mm Hg) and computed tomography showing a large external pelvic hematoma with active contrast extravasation, what is the most appropriate immediate management: emergency laparotomy, transfusion of packed red blood cells, or intravenous fluids with observation?

Emergency Management of Pelvic Hematoma with Active Bleeding

In a 32-year-old woman with severe pelvic pain, hypotension (BP 88/50), and CT showing a large external pelvic hematoma with active bleeding after MVA, the most appropriate immediate management is transfusion of packed red blood cells (pRBCs) as part of a massive transfusion protocol, NOT emergency laparotomy. 1, 2

Critical Initial Actions

The key distinction here is that this is an EXTERNAL pelvic hematoma (retroperitoneal/preperitoneal space), not intraperitoneal bleeding. 1 This fundamentally changes the management approach:

• External pelvic hematomas do NOT require laparotomy - opening the peritoneum will not access the bleeding source and may worsen outcomes by disrupting tamponade 1
• Immediate laparotomy is indicated ONLY for intraperitoneal bleeding with hemodynamic instability - specifically when FAST shows significant free intraabdominal fluid 1
• This patient requires immediate hemorrhage control through resuscitation, mechanical stabilization, and potentially angioembolization or preperitoneal packing 1, 2

Immediate Resuscitation Protocol

Begin massive transfusion protocol immediately with warmed pRBCs rather than crystalloids alone: 2, 3

• Administer O-negative blood immediately if cross-matched products unavailable 2, 4, 5
• Transfuse blood products in 1:1 ratio (4 units pRBCs to 4 units FFP) 2
• Limit crystalloids to ≤1-2 L to avoid dilutional coagulopathy 2, 3
• Target systolic BP 80-100 mmHg until bleeding controlled (permissive hypotension) 6, 3
• Maintain core temperature ≥36°C with active warming 2, 3

Administer tranexamic acid 1g IV within 3 hours of injury onset 2, 3

Mechanical Pelvic Stabilization

Apply immediate pelvic binder or external fixation for hemodynamically unstable pelvic ring injuries: 1

• External fixation provides rigid temporary stability and serves as adjunct to hemorrhage control 1
• Can be completed in <20 minutes with minimal blood loss 1
• Use rolled surgical towels under binder for posterior compression in sacroiliac disruption 1

Definitive Hemorrhage Control Options

After initial resuscitation and mechanical stabilization, proceed with one of these interventions based on response: 1

Preperitoneal Pelvic Packing (PPP)

• Indicated for persistent hemodynamic instability despite resuscitation 1
• Performed via separate suprapubic midline incision (not laparotomy) 1
• Three laparotomy pads placed each side of bladder in retroperitoneal space 1
• Can be completed in <20 minutes 1
• Packing removed within 48-72 hours 1
• Only 13-20% require subsequent angioembolization 1

Angiographic Embolization

• Perform for uncontrolled pelvic hemorrhage when patient stable enough for transfer to IR suite 1, 2
• Target hypogastric (internal iliac) arteries 2
• Complementary to PPP, not mutually exclusive 1
• May be difficult in unstable patients 1

Laboratory Monitoring

Obtain immediately: 2, 6

• Complete blood count, PT/aPTT, fibrinogen (maintain >1.5 g/L) 2
• Serum lactate (>2 mmol/L indicates shock) 1, 2, 6
• Blood type and cross-match 2
• Consider viscoelastic testing (TEG/ROTEM) if available 2, 6

Why NOT Emergency Laparotomy?

Laparotomy is contraindicated for external pelvic hematomas because: 1

• The bleeding source is in the retroperitoneal/preperitoneal space, not accessible via laparotomy 1
• Opening the peritoneum disrupts tamponade effect and worsens bleeding 1
• Laparotomy is indicated ONLY when there is concurrent intraperitoneal injury with free fluid on FAST 1
• If laparotomy needed for abdominal injuries, PPP should be done through separate suprapubic incision 1

Why NOT IV Fluids and Observation Alone?

Observation is inappropriate because: 1

• Patient meets ATLS Class III-IV hemorrhagic shock criteria (BP <90 mmHg) 1
• Active contrast extravasation on CT indicates ongoing arterial bleeding 1
• Hemodynamically unstable patients with pelvic fractures have mortality rates approaching 40-50% without intervention 1
• Delayed intervention increases mortality by 1% every 3 minutes 1

Common Pitfalls to Avoid

• Do not perform laparotomy for external pelvic hematomas - this worsens outcomes 1
• Do not delay blood product administration - crystalloids alone worsen dilutional coagulopathy 2, 3
• Do not target normotensive BP before bleeding control - permissive hypotension (SBP 80-100) reduces blood loss 6, 3
• Do not rely on single hematocrit measurements - poor sensitivity for detecting ongoing bleeding 1, 6
• Do not use vasopressors as primary therapy - they mask hypovolemia and worsen tissue perfusion 3