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

Management of Severe Pelvic Trauma with Active Bleeding and Hypotension

In a 32-year-old female 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 (Option B) combined with immediate pelvic stabilization and preparation for angiographic embolization. 1

Critical First Steps: Simultaneous Resuscitation and Hemorrhage Control

The correct answer is B (Transfusion of pRBCs), but this must be combined with immediate pelvic binder application and preparation for definitive hemorrhage control. 1

Immediate Actions (Within First 2-5 Minutes)

• Apply a pelvic binder immediately to control the 80-90% venous component of pelvic bleeding, which can be completed in less than 2 minutes. 1, 2
• Begin transfusion of uncrossmatched type-O packed red blood cells immediately, as this can be available 30-45 minutes sooner than type-specific or crossmatched blood. 3, 4
• Target permissive hypotension with systolic BP 80-90 mmHg until definitive hemorrhage control is achieved, as aggressive fluid resuscitation can worsen hemorrhage. 1, 2
• Establish large-bore IV access (ideally 8-Fr central access) for rapid transfusion capability. 3

Why Emergency Laparotomy (Option A) is WRONG

Emergency laparotomy is contraindicated for isolated pelvic bleeding and dramatically increases mortality. 1

• Non-therapeutic laparotomy increases baseline mortality from 30-45% to substantially higher rates in patients with major pelvic injuries. 1
• Laparotomy cannot control pelvic arterial bleeding due to extensive collateral circulation in the retroperitoneum, making surgical control extremely difficult. 1
• Laparotomy is only indicated if E-FAST demonstrates significant hemoperitoneum (61% probability of intra-abdominal injury requiring surgical control), suggesting concurrent solid organ injury requiring surgical intervention. 5

Why IV Fluids and Observation (Option C) is WRONG

Observation is inappropriate in a hypotensive patient with documented active bleeding on CT, as this represents ongoing arterial hemorrhage requiring immediate intervention. 5

• Active bleeding on CT ("blush") has 82-89% sensitivity and 75-100% specificity for detecting arterial pelvic bleeding requiring intervention. 1
• Each 3-minute delay in achieving hemorrhage control increases mortality by approximately 1%. 1, 2
• Mortality escalates from 16% to 64% if definitive hemorrhage control is delayed beyond 60 minutes. 1

Definitive Hemorrhage Control Algorithm

Step 1: Rule Out Extra-Pelvic Bleeding (Completed - CT Already Done)

• The CT shows external pelvic hematoma with active bleeding, indicating the source is pelvic arterial hemorrhage. 5
• If E-FAST had shown abundant hemoperitoneum, emergency laparotomy would be indicated, but this scenario describes isolated pelvic bleeding. 5

Step 2: Prepare for Angiographic Embolization

Angiographic embolization is the definitive treatment for arterial pelvic bleeding, with success rates of 73-97%. 1, 5

• Active contrast extravasation on CT has 93.9% positive predictive value for detecting active bleeding requiring angiographic intervention. 1, 5
• Bilateral internal iliac artery embolization should be performed even for unilateral fractures due to extensive pelvic collateral circulation. 2
• Embolization must be performed within 60 minutes of admission to minimize mortality risk. 1

Step 3: Alternative if Angiography Cannot Be Performed Within 60 Minutes

If angiographic embolization cannot be performed within 60 minutes, preperitoneal pelvic packing (PPP) should be undertaken. 1, 2

• PPP can be completed in less than 20 minutes and effectively controls venous bleeding while awaiting definitive angiography. 1, 2
• Only 13-20% of patients require secondary angiographic embolization after successful PPP. 2

Resuscitation Protocol During Hemorrhage Control

Blood Product Administration

• Transfuse packed RBCs using a 1:1:1 ratio with fresh frozen plasma and platelets if massive transfusion is required (>5 units in 3 hours). 6, 7
• Target hemoglobin level of 7-9 g/dL during active hemorrhage control. 5
• Uncrossmatched type-O blood has no discernible risk for transfusion-related complications in hemorrhaging trauma patients. 4

Adjunctive Measures

• Administer tranexamic acid 10-15 mg/kg followed by 1-5 mg/kg/h infusion to prevent fibrinolysis. 1, 5
• Actively warm the patient and all transfused fluids to prevent hypothermia-induced coagulopathy. 3, 6
• Monitor serum lactate and base deficit as sensitive markers for assessing severity of hemorrhagic shock. 1, 2

Critical Pitfalls to Avoid

• Do not remove the pelvic binder prematurely, as mechanical stabilization must be maintained until definitive hemorrhage control is achieved. 5
• Do not delay angiography for additional imaging when active bleeding is already documented on CT. 5
• Do not rely on single hematocrit measurements as an isolated laboratory marker for bleeding, as sensitivity may be very low. 1, 8
• Do not perform exploratory laparotomy for isolated pelvic bleeding without clear evidence of intra-abdominal injury on E-FAST. 1, 5

Expected Outcomes After Successful Intervention

• Hourly red blood cell transfusion requirements should decrease dramatically (from 3.7 to 0.1 units/hour) after successful angiographic embolization. 1
• Overall mortality for severe pelvic ring disruptions with hemodynamic instability remains 30-45%, but this increases substantially when inappropriate interventions (such as laparotomy) are performed. 1