In a 32-year-old woman with severe pelvic pain and hypotension after a motor vehicle accident, with a CT showing a large external pelvic hematoma and active arterial bleeding, what is the most appropriate immediate management?

Management of Pelvic Trauma with Active Bleeding and Hypotension

The most appropriate immediate management is transfusion of packed red blood cells (pRBCs) combined with immediate pelvic stabilization and preparation for angiographic embolization—emergency laparotomy should be avoided as it dramatically increases mortality in isolated pelvic hemorrhage. 1

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. 2, 1 The extensive collateral circulation in the retroperitoneum makes surgical control of pelvic bleeding extremely difficult, and laparotomy as the primary intervention increases mortality from the baseline 30-45% to substantially higher rates. 1

Immediate Management Algorithm

Step 1: Simultaneous Resuscitation and Mechanical Stabilization

Begin transfusion of pRBCs immediately while applying a pelvic binder for mechanical closure of the pelvic ring. 1 This addresses both the hypovolemia and the venous/cancellous bone bleeding component. 2

• Target systolic blood pressure of 80-90 mmHg using permissive hypotension strategy until hemorrhage is controlled 2, 1
• Minimize crystalloid administration to avoid dilutional coagulopathy 1
• Pelvic closure can be achieved using a pelvic binder, bed sheet, or C-clamp and should take less than 2 minutes 2, 1

Step 2: Definitive Hemorrhage Control - Angiographic Embolization

This patient requires immediate angiographic embolization as the definitive intervention because CT demonstrates active arterial bleeding (contrast extravasation). 2, 1

• Bleeding control procedures should be performed as soon as possible, with time from admission to intervention not exceeding 60 minutes 2
• Mortality increases by approximately 1% for every 3 minutes of delay in achieving hemorrhage control 2, 1
• The probability of arterial bleeding requiring embolization is 73% in non-responders to initial resuscitation 3
• Angiographic embolization has success rates of 73-97% for controlling arterial pelvic hemorrhage 1, 4

For hemodynamically unstable patients with multiple bleeding targets on CT (as in this case with "large external pelvic hematoma"), non-selective bilateral embolization of the internal iliac arteries should be performed. 2

Step 3: If Angiography is Delayed

If angiographic embolization cannot be achieved within 60 minutes, preperitoneal packing should be performed to provide temporary hemostasis. 2, 1 This can be done in less than 20 minutes and controls venous bleeding effectively while buying time for angiography. 1

Why IV Fluids and Observation is Inadequate

Observation alone is inappropriate in a patient with hypotension (BP 88/50) and CT evidence of active arterial bleeding. 2, 1 This patient is in hemorrhagic shock (Class III-IV by ATLS classification based on hypotension and presumed blood loss) and requires immediate hemorrhage control procedures. 2

• Active contrast extravasation on CT has 82-89% sensitivity and 75-100% specificity for arterial bleeding requiring intervention 2
• Ongoing hemodynamic instability despite adequate pelvic ring stabilization indicates arterial bleeding that cannot be controlled by mechanical measures alone 2, 1

Critical Timing Considerations

Time to hemorrhage control is the most important prognostic factor. 2

• Mortality increases from 16% to 64% if embolization requires more than 60 minutes 2
• Blood transfusion requirements typically decrease dramatically (from 3.7 to 0.1 units/hour) after successful angiographic embolization 1

Common Pitfalls to Avoid

• Do not delay angiography for external fixation in non-responders to resuscitation—44% of patients with fractures amenable to external fixation have arterial bleeding requiring embolization 1, 3
• Do not remove the pelvic binder prematurely—mechanical stabilization should be maintained until definitive hemorrhage control is achieved 1
• Do not rely on single hematocrit measurements as an isolated marker for ongoing bleeding 1