How should a pelvic hemorrhage be assessed and managed after a road traffic accident?

Assessment and Management of Pelvic Hemorrhage After Road Traffic Accident

Immediate Assessment in the Emergency Department

Patients with pelvic trauma and hemodynamic instability require immediate pelvic stabilization, rapid identification of bleeding source, and early bleeding control—do not delay for extensive imaging. 1

Initial Clinical Evaluation and Resuscitation

• Apply a pelvic binder immediately in the pre-hospital setting or upon arrival if pelvic fracture is suspected based on mechanism of injury (high-energy motor vehicle crash, fall from height, or motorcycle collision). 1

• Establish large-bore IV access and initiate fluid resuscitation targeting a mean arterial pressure of ≥80 mmHg (or ≥80 mmHg in severe traumatic brain injury) using crystalloid solutions, with early addition of blood products if massive hemorrhage is evident. 1

• Obtain pelvic X-ray, chest X-ray, and E-FAST simultaneously during resuscitation to identify pelvic ring disruption and exclude other sources of hemorrhage (thoracic, intra-abdominal). 1 However, pelvic X-ray has limited sensitivity (50-68%) and should not delay definitive intervention. 1

• Monitor serum lactate and base deficit as sensitive early markers of hemorrhagic shock severity—single hemoglobin or hematocrit measurements are unreliable in acute bleeding. 1

• Assess coagulopathy early using point-of-care testing (TEG or ROTEM) to guide targeted blood product resuscitation, as coagulopathy significantly increases mortality in pelvic hemorrhage. 1

Hemodynamically Unstable Patients (SBP <90 mmHg or requiring ongoing transfusion/vasopressors)

Proceed directly to bleeding control without delay—the time between injury and intervention inversely correlates with survival. 1

• Perform immediate pelvic ring closure and stabilization using pelvic binder, C-clamp (for vertical shear/C-type injuries), or external fixation (for B-type injuries) to reduce pelvic volume and tamponade venous bleeding. 1, 2

• If hemodynamic instability persists despite pelvic stabilization, the patient requires either:

  • Angiography with embolization (preferred for arterial bleeding, success rate 96%) 1, 3
  • Preperitoneal packing combined with surgical exploration if angiography cannot be achieved rapidly 1, 2
  • Resuscitative endovascular balloon occlusion of the aorta (REBOA) for non-compressible life-threatening hemorrhage 1

• Do not perform diagnostic peritoneal lavage as it carries significant risk and provides limited information in pelvic trauma. 4

• Laparotomy should only be performed if E-FAST demonstrates significant free intraperitoneal fluid suggesting intra-abdominal injury requiring surgical control—avoid non-therapeutic laparotomies that delay definitive pelvic hemorrhage control. 1, 3

Hemodynamically Stable or Transiently Responsive Patients

Proceed to contrast-enhanced CT scan with arterial phase imaging to definitively identify bleeding source and guide intervention. 1, 5

• Multi-phase CT with IV contrast is the gold standard for stable patients, providing detailed information on active arterial extravasation, retroperitoneal hematoma size, and associated injuries. 1, 5

• CT with 3D bone reconstruction reduces operative time, tissue damage, and neurological complications during subsequent fixation. 1

• Patients with CT evidence of active arterial bleeding (contrast extravasation) should undergo angiography and selective embolization even if transiently stable, as early embolization improves outcomes. 5, 3

• Retrograde urethrogram or CT cystogram is mandatory if perineal hematoma, blood at urethral meatus, or high-riding prostate is present. 1

• Digital rectal examination and proctoscopy are required if open pelvic fracture or perineal wounds suggest possible rectal injury. 1

Specific Bleeding Control Strategies

Angiography and Embolization

• Angiography with selective embolization is the first-line treatment for arterial pelvic hemorrhage, with success rates exceeding 95% and low complication rates. 5, 3

• Early angiography (within 3 hours of admission) combined with controlled resuscitation using vasopressors is more effective than delayed intervention. 3

• Bilateral internal iliac artery embolization can be performed safely when specific bleeding vessels cannot be identified. 5

Surgical Hemorrhage Control

• Preperitoneal packing is effective for severe venous bleeding from pelvic venous plexus when mechanical stability has been restored with external fixation or C-clamp. 1, 2

• Damage control surgery should be employed in patients with hemorrhagic shock, ongoing bleeding, coagulopathy, hypothermia, acidosis, or combined injuries requiring time-consuming procedures. 1

Adjunctive Measures

• Administer tranexamic acid 1g IV over 10 minutes followed by 1g over 8 hours, initiated as soon as possible (ideally within 3 hours of injury) in all bleeding trauma patients. 1

• Target hemoglobin 70-90 g/L with packed red blood cells, and maintain fibrinogen ≥1.5-2.0 g/L using fibrinogen concentrate or cryoprecipitate. 1

• Employ early measures to prevent hypothermia and actively warm hypothermic patients to maintain normothermia, as hypothermia worsens coagulopathy. 1

Critical Pitfalls to Avoid

• Do not delay pelvic stabilization waiting for imaging in unstable patients—apply pelvic binder immediately based on mechanism and clinical suspicion. 1

• Avoid excessive crystalloid resuscitation before bleeding control, as this dilutes clotting factors and worsens coagulopathy—use balanced resuscitation with early blood products. 1

• Do not perform non-therapeutic laparotomy in unstable patients without clear intra-abdominal injury—this delays definitive pelvic hemorrhage control and increases mortality. 3

• Recognize that vertical shear fractures with inferior hemipelvis displacement indicate high risk of severe arterial injury requiring urgent angiography. 1

• Do not rely on pelvic X-ray alone to exclude significant pelvic hemorrhage in stable patients—proceed directly to CT with contrast. 1