Unstable Open-Book Pelvis with a Negative FAST and No Interventional Radiology

Why the FAST is negative. FAST detects free fluid in the pericardium, hepatorenal recess, splenorenal recess and the dependent pelvis. It does not look at the retroperitoneum. An open-book pelvic fracture bleeds into the retroperitoneal space, which is invisible to the probe; the patient can exsanguinate with a completely normal FAST. The scan is also operator-dependent, and a large pelvic haematoma may not produce free fluid in the vesicouterine or rectovesical pouch. Therefore a negative FAST in an unstable patient with a clinical pelvic fracture does not exclude haemorrhage and must never downgrade the resuscitation.

First 15 minutes:

1. Airway and cervical spine; high-flow oxygen; two large-bore intravenous lines; warm the room and the fluids.
2. Apply or re-check the pelvic binder at the level of the greater trochanters - a binder at the iliac crests does nothing, and a well-placed binder can reduce an open-book fracture and reduce bleeding.
3. Activate the massive transfusion protocol now, on clinical grounds: 1:1:1 red cells, plasma and platelets, with calcium replacement.
4. Restrict crystalloid to avoid dilutional coagulopathy; target permissive hypotension (systolic about 80–90 mmHg) until surgical control, accepting that this is inappropriate if there is a coexisting head injury.
5. Complete tranexamic acid: 1 g over 10 minutes then 1 g over 8 hours.
6. Look for other bleeding sources: chest, abdomen, long bones, external wounds; log-roll with spinal precautions to examine the back and perineum.
7. Avoid urethral catheterisation if there is blood at the meatus or a high-riding prostate; use suprapubic or imaging instead.
8. Definitive haemorrhage control decision in parallel - this is the only intervention that stops the bleeding.

Running the protocol. Give red cells, plasma and platelets in a 1:1:1 ratio (or whole blood if the system has it), one 'pack' at a time, reassessing between packs with blood pressure, heart rate, temperature, ionised calcium, lactate and, if available, viscoelastic testing. Give 10 mL of 10% calcium gluconate per 2–4 units of blood. Keep the patient warm; a temperature below 35 °C is itself a coagulopathy. Add cryoprecipitate or fibrinogen concentrate if fibrinogen is below 1.5–2 g/L. Do not chase the haemoglobin - the endpoints are haemorrhage control, perfusion and correction of the lethal triad.

Choosing the haemorrhage-control strategy. The question is where the blood is going and what can be done about it locally.

• Retroperitoneal venous bleeding from an open-book pelvis is best controlled by reduction and stabilisation (binder, external fixator) plus preperitoneal packing. This is achievable in a district hospital with a general surgeon.
• Arterial bleeding needs angiography and embolisation, which is not available here.
• Intraperitoneal bleeding would have shown on FAST but a delayed or repeated scan is justified if the abdomen is distended; laparotomy is then indicated.

Practical plan here: keep the binder on, give the first pack, call the general surgeon in now rather than waiting 30 minutes for a routine arrival, and prepare theatre for examination under anaesthesia with preperitoneal packing and application of an external fixator by the orthopaedic team. If bleeding continues despite packing and fixation, and the patient can be stabilised enough for a road journey, transfer to a trauma centre with interventional radiology is reasonable - but transferring an actively bleeding, unpacked pelvis simply moves the death. A brief CT after the first pack, in a patient who responds, can localise an arterial blush and focus the transfer decision.

Futility is a clinical trajectory, not a single number. The indicators that resuscitation is failing are: ongoing massive bleeding despite packing, fixation and multiple packs (for example more than 10 units of red cells without haemodynamic improvement); persistent hypotension with no response to blood products and vasopressors; worsening acidosis (pH below 7.0 with a rising lactate despite resuscitation); core temperature below 32 °C; clinically evident coagulopathy; and the absence of any correctable source. Peri-arrest or cardiac arrest with a non-compressible pelvic haemorrhage and no interventional radiology is the clearest signal.

Before declaring futility, correct the reversible causes:

• Is the binder in the right place?
• Is there an untreated tension pneumothorax, tamponade or ongoing external haemorrhage?
• Has the patient been allowed to become cold, acidotic or hypocalcaemic?
• Is the tube in the right place, and is the ventilator stacking?
• Has the surgeon actually been called and given a clear request?

The conversation. Speak to the family in a private space, with a nurse present and, if possible, the most senior doctor. Be honest and specific: explain the injuries, what has been done, that bleeding cannot be stopped with the resources available, and that the patient is dying despite maximal treatment. Avoid jargon and false hope, allow silence and questions, and establish what the patient would have wanted if that is known. Agree a plan, including whether to attempt transfer or to focus on comfort, and document it. Debrief the team afterwards - a trauma death in a resource-limited hospital is a significant event for staff as well as family.