Unstable Pelvic Fracture With a Positive FAST
Mr S is 34, a motorcyclist, who arrives 25 minutes after a high-speed collision. Heart rate is 138/min, blood pressure 78/46 mmHg, respiratory rate 32/min, GCS 13, temperature 35.4 °C. The pelvis is unstable on compression and the abdomen is distended. FAST shows free fluid in Morison's pouch. Pelvic radiograph shows an open-book fracture. He has received 4 units of red cells and 4 units of fresh frozen plasma in the first 20 minutes, and the systolic pressure remains around 80 mmHg. Base deficit is −13, lactate 6.8 mmol/L, INR 1.8, haemoglobin 72 g/L, platelets 88 × 10⁹/L, temperature 34.8 °C.
1. Set out your priorities and sequence in the first 30 minutes, including what you do about the pelvis and the abdomen, and your blood pressure target.
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Framework This is ABCDE with catastrophic haemorrhage as the dominant problem. The two candidate sources are the pelvis and the intraperitoneal cavity, and FAST suggests the latter as well.
Sequence
- Pelvic binder applied at the level of the greater trochanters, plus a sheet; do not spring the pelvis repeatedly to "check" it.
- Two large-bore lines; activate the massive transfusion protocol with a balanced ratio (1:1:1), tranexamic acid 1 g within three hours of injury, calcium replacement, and active warming.
- Intubate for airway protection and to allow control; the GCS of 13 with shock means he cannot protect his airway.
- FAST positive in the upper abdomen in a hypotensive patient after blunt trauma = laparotomy, because intraperitoneal blood is a source you can control in theatre. If FAST were negative, the priority would be angioembolisation of the pelvis.
- Do not delay for a CT scan while he is at 80 mmHg.
Blood pressure target Permissive hypotension, systolic 80–90 mmHg, until haemorrhage is controlled - but this is contraindicated with a significant head injury. His GCS is 13 and there may be a traumatic brain injury, so target a systolic pressure of at least 90–100 mmHg rather than deliberately keeping him at 80. That tension between the two targets is the judgement call.
Also Check the urethra and rectum, log-roll when safe, and give antibiotics for the open pelvic ring if there is any perineal wound.
2. At laparotomy there is 700 mL of free blood and a large expanding retroperitoneal pelvic haematoma, with no bleeding from bowel or mesentery. What now?
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The critical decision: do not open the retroperitoneum An expanding pelvic haematoma from a fracture is fed by a low-pressure venous plexus and, sometimes, by branches of the internal iliac artery. Opening the peritoneum over it decompresses the tamponade and produces uncontrollable bleeding in a coagulopathic patient.
Options in order
- Preperitoneal pelvic packing - through a lower midline incision, pack the pelvis from below the peritoneum, three packs on each side, without opening the haematoma. Rapid, feasible in theatre, and buys time.
- Temporary abdominal closure and transfer for angioembolisation of the internal iliac branches. Packing controls venous bleeding; angio controls arterial. Ideally both.
- If unstable with no interventional radiology available, pelvic packing plus external fixation and continued balanced resuscitation, with a low threshold for transfer.
Adjuncts
- Do not explore the haematoma; do not heparinise or give blind thrombolysis.
- Avoid the temptation to perform a "total" retroperitoneal exploration; the mortality is well described as a result of the moment the peritoneum is opened.
- Consider REBOA only as a bridge in a patient with a suspected non-compressible source below the diaphragm, and only with a team familiar with it.
- Continue blood products, calcium and warming throughout.
3. The patient leaves theatre after packing, still at 35 °C with a pH of 7.18. What are your endpoints before definitive closure, and how do you manage the open abdomen?
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Recognise damage control physiology Temperature 34.8 °C, pH 7.18, INR 1.8 and platelets 88 - the lethal triad is established. The correct decision is to stop operating and resuscitate in ICU.
Endpoints before returning to theatre
- Temperature >35.5–36 °C with active warming.
- pH >7.25 and lactate falling; a lactate that is not clearing means ongoing bleeding or ischaemic bowel.
- INR <1.5, fibrinogen >1.5 g/L, platelets >50 × 10⁹/L, ionised calcium normal.
- Noradrenaline requirement falling and urine output restored.
- These are guides, not absolute thresholds; the clinical trajectory matters more than any single number.
Open abdomen management
- Negative-pressure temporary abdominal closure with a protective visceral drape, not a simple pack.
- Measure intra-abdominal pressure; the abdomen is at risk of compartment syndrome once the packs are removed and the bowel oedematises.
- Planned relook in 24–48 hours to remove packs, check bowel viability, and wash out; close the fascia only if there is no tension.
- If closure is not possible by day 5–7, plan for mesh-mediated traction or a deliberate ventral hernia with later reconstruction, rather than forcing closure under tension and causing necrosis of the fascia.
- Remember the pelvic fracture itself needs stability: external fixation, or internal fixation once physiology allows, and early mobilisation with physiotherapy.