In a 32-year-old female after a motor vehicle accident with severe pelvic pain, hypotension (BP 88/50) and CT showing a large external pelvic hematoma with active contrast extravasation, what is the most appropriate immediate management?

Management of Severe Pelvic Trauma with Active Bleeding and Hypotension

This patient requires immediate angiographic embolization as the definitive hemorrhage control intervention, preceded by simultaneous pelvic stabilization with a binder and packed red blood cell transfusion—emergency laparotomy is contraindicated and dramatically increases mortality in isolated pelvic hemorrhage. 1, 2, 3

Why Emergency Laparotomy is Wrong

• Non-therapeutic laparotomy in pelvic fracture hemorrhage is associated with significantly higher mortality rates, with baseline mortality of 30-45% rising substantially when laparotomy is used as the primary intervention 1, 2
• Laparotomy results in poor outcomes due to the extensive collateral circulation in the retroperitoneum, making surgical control of pelvic bleeding extremely difficult 2
• The only indication for laparotomy in this scenario would be abundant hemoperitoneum on FAST examination indicating concomitant intra-abdominal injury—which is not described in this case 3

Immediate Management Algorithm

Step 1: Simultaneous Resuscitation and Mechanical Stabilization (First 2 Minutes)

• Apply a pelvic binder immediately to control venous and cancellous bone bleeding from the fracture itself, which can be completed in less than 2 minutes 1, 3
• Begin transfusion of packed red blood cells immediately using uncrossmatched type-O blood, which can be delivered 30-45 minutes faster than type-specific units 2
• Target systolic blood pressure of 80-90 mmHg using permissive hypotension strategy until definitive hemorrhage control is achieved 1, 2, 3
• Establish large-bore intravenous access (preferably 8-Fr central line) to enable rapid delivery of blood products 2
• Actively warm all administered fluids and the patient to prevent hypothermia-induced coagulopathy 2

Step 2: Definitive Hemorrhage Control (Within 60 Minutes)

The CT showing active contrast extravasation ("blush") is an accurate indicator of ongoing arterial hemorrhage requiring immediate angiographic intervention. 4, 5, 6

• Proceed directly to angiographic embolization as the primary definitive intervention for this patient with CT-documented active bleeding and hemodynamic instability despite adequate pelvic ring stabilization 1
• Active contrast extravasation on CT has 82-89% sensitivity and 75-100% specificity for detecting arterial pelvic bleeding requiring intervention 2
• The probability of arterial bleeding requiring angiography is 73% in non-responders to initial resuscitation 2
• In hemodynamically unstable patients with active bleeding on CT, perform non-selective bilateral embolization of the internal iliac arteries 1
• Angiographic embolization has success rates of 73-97% for controlling arterial hemorrhage 2, 3

Step 3: Critical Timing Considerations

• Time to hemorrhage control must be less than 60 minutes from admission—mortality increases approximately 1% every 3 minutes of delay 2
• Mortality escalates from 16% to 64% if embolization is performed after 60 minutes 2
• If angiographic embolization cannot be performed within 60 minutes, pre-peritoneal pelvic packing should be undertaken as a temporizing measure, which can be completed in under 20 minutes 1, 2

Why IV Fluids and Observation is Wrong

• This patient has active arterial bleeding documented on CT with hemodynamic instability (BP 88/50)—observation is contraindicated 1, 2
• Ongoing hemodynamic instability despite adequate pelvic ring stabilization indicates arterial bleeding that cannot be controlled by mechanical stabilization alone 2
• The hourly need for red blood cell transfusions should decrease dramatically (from 3.7 to 0.1 units/hour) only after successful angiographic embolization 2

Monitoring During Resuscitation

• Use serum lactate and base deficit to estimate and monitor the extent of bleeding and shock—lactate >3.4 mmol/L predicts arterial bleeding requiring intervention 2, 3, 7
• Do not rely on single hematocrit measurements as an isolated laboratory marker for bleeding 2, 3
• Recheck coagulation parameters (INR, PT/PTT, fibrinogen, platelet count) every 30-60 minutes during active resuscitation 7
• Transfuse FFP, platelets, and RBCs in 1:1:1 ratio during massive transfusion to prevent dilutional coagulopathy 7

Common Pitfalls to Avoid

• Do not delay angiography for external fixation in non-responders to resuscitation, as 44% of patients with fractures amenable to external fixation have arterial bleeding requiring embolization 2
• Do not remove the pelvic binder prematurely—mechanical stabilization should be maintained until definitive hemorrhage control is achieved 3
• Avoid hyperventilation and excessive positive end-expiratory pressure in severely hypovolemic trauma patients 2