Unstable pelvic fracture with positive FAST and no CT scanner
A 34-year-old motorcyclist is brought in 40 minutes after a high-speed collision with a truck. He is awake, confused, and complaining of pelvic and right thigh pain. A pelvic binder has been applied by the ambulance crew. Observations: blood pressure 76/42 mmHg, pulse 138/min, respiratory rate 30/min, SpO2 96% on 15 L oxygen, temperature 35.1°C, GCS 14 (E4 V4 M6). There is bruising over the lower abdomen and perineum, a rigid abdomen, and an open right femoral fracture. FAST shows fluid in Morison's pouch and the pelvis. Pelvic radiograph shows a Tile C fracture; chest radiograph is normal. Bloods: haemoglobin 92 g/L, base deficit −11 mmol/L, lactate 6.2 mmol/L, international normalised ratio 1.4. The massive transfusion protocol has been activated. There is no CT scanner available for 30 minutes because of a breakdown.
1. What are your priorities in the first 20 minutes, and what resuscitation targets would you set before haemorrhage control?
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I would use a catastrophic-haemorrhage-first approach within the primary survey. The pelvic binder must be checked for position at the greater trochanters, and the open femoral fracture controlled with direct pressure and traction splinting. I would secure two large-bore intravenous lines, start the massive transfusion protocol, give tranexamic acid 1 g within 3 hours of injury, warm the patient and give calcium. The rigid abdomen and positive FAST make intra-abdominal haemorrhage likely; the pelvic fracture may also be bleeding.
The resuscitation targets are permissive hypotension with a systolic blood pressure of about 80–90 mmHg until haemorrhage is controlled, accepting a transient period of reduced cerebral perfusion only if there is no head injury. His GCS of 14 and confusion make a brain injury possible, so I would aim higher, around a systolic pressure of 100–110 mmHg, and avoid repeated hypotensive episodes. I would give blood products rather than crystalloid, aim for a 1:1:1 ratio initially, keep the patient warm, and avoid delaying surgery for CT or for a full set of results.
2. He remains hypotensive after 4 units of red cells. Which haemorrhage-control manoeuvre would you choose first, and why: immediate laparotomy, preperitoneal pelvic packing, angioembolisation, REBOA or external fixation?
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Immediate laparotomy is my first manoeuvre, because FAST shows fluid in Morison's pouch in an unstable patient and his abdomen is rigid. That combination suggests intraperitoneal haemorrhage, likely from liver or spleen, which can only be controlled at laparotomy. Preperitoneal pelvic packing alone would leave that source uncontrolled.
I would apply an external fixator or maintain the pelvic binder, and at the same operation I could perform preperitoneal packing if pelvic bleeding persists after the abdomen is packed. Angioembolisation is appropriate for persistent pelvic arterial bleeding once the patient is stabilised or if laparotomy shows no intraperitoneal source, but transferring an unstable patient to the angiography suite is hazardous. REBOA zone III can be an adjunct for pelvic bleeding, but it does not control intraperitoneal haemorrhage, may worsen abdominal bleeding if placed in the wrong zone, and should not delay laparotomy. The sequence should be: laparotomy and packing, pelvic stabilisation and packing, then angiography for persistent pelvic bleeding.
3. How does his GCS of 14 alter your blood pressure target and choice of resuscitation? What about tranexamic acid and calcium?
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A GCS of 14 after trauma is a brain injury until proven otherwise, even if the confusion could be due to hypoperfusion. I would therefore avoid a strictly permissive hypotensive strategy and target a systolic blood pressure of at least 110 mmHg, avoiding any episode below 90 mmHg. This reduces the risk of secondary brain injury, although it may increase bleeding. I would prioritise rapid haemorrhage control and early head CT once the patient is stable enough to leave the resuscitation area.
Tranexamic acid should be given as 1 g intravenously within 3 hours of injury, followed by 1 g over 8 hours, unless there is a specific contraindication. It reduces mortality in bleeding trauma patients and is not a substitute for haemorrhage control. Calcium should be checked and replaced, because citrate in stored blood causes hypocalcaemia, which impairs coagulation and cardiac contractility. He is already hypothermic at 35.1°C, so active warming and avoidance of large-volume crystalloid are essential parts of the resuscitation, as is correction of acidosis after bleeding is controlled.