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 Large External Pelvic Hematoma with Active Bleeding and Hypotension

The most appropriate immediate management is B: Transfusion of packed red blood cells, combined with immediate pelvic binder application and preparation for angiographic embolization. 1

Why Emergency Laparotomy is Contraindicated

• Non-therapeutic laparotomy dramatically increases mortality in pelvic fracture hemorrhage and must be avoided. 1
• Laparotomy cannot control pelvic arterial bleeding due to extensive retroperitoneal collateral circulation, making surgical control extremely difficult. 1
• Baseline mortality of 30-45% for severe pelvic injuries increases substantially when laparotomy is performed as the primary intervention. 1
• Emergency laparotomy is only indicated if E-FAST demonstrates significant hemoperitoneum (61% probability of intra-abdominal injury requiring surgical control), which is not described in this case. 2

Immediate Management Algorithm

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

• Transfuse uncrossmatched type-O packed red blood cells immediately while pursuing definitive hemorrhage control—this can be delivered 30-45 minutes faster than cross-matched units. 1
• Apply a pelvic binder immediately (takes <2 minutes) to control the 80-90% venous and cancellous bone bleeding component. 1, 2
• Establish large-bore IV access (preferably 8-Fr central line) to enable rapid transfusion. 1
• Target systolic blood pressure of 80-90 mmHg using permissive hypotension strategy until hemorrhage is controlled. 1

Step 2: Definitive Hemorrhage Control

For this patient with CT-documented active arterial bleeding ("blush") and large hematoma:

• Angiographic embolization is the definitive treatment, with success rates of 73-97%. 1, 2
• Active contrast extravasation on CT has 82-89% sensitivity and 75-100% specificity for arterial bleeding requiring intervention. 1
• Time is critical: mortality increases approximately 1% every 3 minutes of delay, and bleeding control must be achieved within 60 minutes. 1, 2
• If angiography cannot be performed within 60 minutes, preperitoneal pelvic packing (PPP) should be performed—it takes <20 minutes and controls venous bleeding while buying time for angiography. 1, 2

Step 3: Resuscitation Targets During Transport

• Maintain hemoglobin 7-9 g/dL in hemorrhagic shock states. 3
• Administer tranexamic acid 10-15 mg/kg followed by 1-5 mg/kg/h infusion to prevent fibrinolysis. 1
• Actively warm all fluids and the patient to prevent hypothermia-induced coagulopathy. 1
• Monitor serum lactate and base deficit to assess severity of hemorrhagic shock. 1, 2

Why IV Fluids and Observation is Wrong

• Observation alone is inappropriate in a hypotensive patient with documented active arterial bleeding on CT—this represents ongoing hemorrhage requiring immediate intervention. 2
• Crystalloids alone worsen dilutional coagulopathy and fail to restore oxygen-carrying capacity in massive hemorrhage with severe anemia. 3
• The probability of arterial bleeding requiring intervention is 73% in non-responders to initial resuscitation. 1

Critical Pitfalls to Avoid

• Do not delay pelvic binder application for imaging—it takes <2 minutes and is life-saving. 1
• Do not remove the binder prematurely; mechanical stabilization must be maintained until definitive hemorrhage control is achieved. 1, 2
• Do not delay angiography for additional imaging when systolic BP is 80-100 mmHg—each 3-minute delay adds 1% to mortality risk. 1, 2
• Do not perform CT if the patient becomes more unstable—proceed directly to angiography based on clinical findings. 2

Expected Outcomes

• After successful angiographic embolization, hourly red blood cell transfusion requirements should decrease dramatically (from 3.7 to 0.1 units/hour). 1
• Only 13-20% of patients require secondary angiographic embolization after successful PPP if that route is chosen. 2