In a 32‑year‑old woman with severe pelvic pain, hypotension (blood pressure 88/50 mm Hg) after a motor vehicle accident and a computed tomography scan showing a large external pelvic hematoma with active contrast extravasation, what is the most appropriate immediate management?

Management of Hemodynamically Unstable Pelvic Trauma with Active Bleeding

In a 32-year-old woman with severe pelvic pain, hypotension (BP 88/50), and CT-confirmed large external pelvic hematoma with active bleeding after MVA, the most appropriate immediate management is angiographic embolization with concurrent blood product transfusion, NOT emergency laparotomy. 1

Why Angiographic Embolization is the Definitive Answer

Angiographic embolization achieves a 73-97% success rate for controlling arterial pelvic bleeding and is the definitive treatment for this clinical scenario. 1 The key distinction here is that CT has already identified an external pelvic hematoma with active contrast extravasation, which represents ongoing arterial hemorrhage requiring immediate angiographic intervention. 1

Critical Decision Point: Rule Out Intra-Abdominal Bleeding

• Emergency laparotomy is contraindicated for isolated pelvic bleeding, as it cannot control pelvic arterial hemorrhage and actually increases mortality. 1
• Laparotomy is only indicated when E-FAST demonstrates significant hemoperitoneum suggesting concurrent intra-abdominal solid organ injury requiring surgical control (61% probability of requiring laparotomy if abundant hemoperitoneum present). 1
• In this case, CT has already localized the bleeding source to the pelvis externally, making laparotomy both unnecessary and harmful. 2, 1

Concurrent Resuscitation Strategy

While arranging immediate angiography, begin massive transfusion protocol with packed RBCs targeting hemoglobin 7-9 g/dL. 1

• Transfuse blood products immediately using a 1:1:1 to 1:1:2 ratio of plasma:platelets:RBCs while pursuing definitive hemorrhage control. 1, 3
• Maintain permissive hypotension targeting systolic BP 80-100 mmHg until bleeding is definitively controlled, as aggressive fluid resuscitation worsens hemorrhage. 1
• Administer tranexamic acid 10-15 mg/kg followed by 1-5 mg/kg/hour infusion to prevent fibrinolysis. 1

Time-Critical Nature of Intervention

Each 3-minute delay from arrival to definitive bleeding control increases mortality by approximately 1%. 1 This underscores why observation alone (Option C) is completely inappropriate in a hypotensive patient with documented active bleeding on CT. 1

• CT scan has 93.9% positive predictive value for detecting active bleeding compared to angiography, making the diagnosis already established. 1
• Do not delay angiography for additional imaging when systolic BP is 80-100 mmHg, as this represents ongoing hemorrhagic shock requiring immediate intervention. 1

Pelvic Stabilization Measures

• Apply or maintain a pelvic binder immediately to control the predominant venous (80-90%) and cancellous bone bleeding component while arterial bleeding is addressed. 1
• Do not remove the pelvic binder prematurely, as it provides essential hemorrhage control during transport and angiography. 1
• Pelvic ring closure and stabilization should be performed for patients with pelvic ring disruption in hemorrhagic shock. 2

When Preperitoneal Packing Would Be Considered

Preperitoneal pelvic packing (PPP) is reserved for patients in extremis who cannot be safely transferred to angiography within 60 minutes. 1 In this case, if the patient has:

• CT already completed showing isolated pelvic arterial bleeding
• Angiography suite available within 60 minutes
• No evidence of intra-abdominal injury

Then angiography is the superior choice, as PPP primarily controls venous bleeding (80-90% component) but arterial bleeding requires embolization. 1

Why IV Fluids and Observation is Wrong

Observation alone is inappropriate in a hypotensive patient with documented active bleeding on CT, as this represents ongoing arterial hemorrhage requiring immediate intervention. 1 The patient's BP of 88/50 indicates hemorrhagic shock, and serum lactate and base deficit would be elevated, confirming the severity. 2, 4

Summary Algorithm

1. Confirm isolated pelvic bleeding (already done via CT showing external pelvic hematoma)
2. Initiate massive transfusion protocol with 1:1:1 ratio while maintaining permissive hypotension 1, 3
3. Proceed immediately to angiographic embolization as definitive treatment 1
4. Maintain pelvic binder throughout transport and procedure 1
5. Perform bilateral embolization even for unilateral fractures due to extensive pelvic collateral circulation 1