Unstable Pelvic Fracture and Positive FAST in a Rural ED
A 29-year-old woman is brought to a rural emergency department after being struck by a car while walking. She is awake but anxious. Vital signs: blood pressure 82/50 mmHg, heart rate 132/min, respiratory rate 30/min, SpO2 94% on 15 L nonrebreather, temperature 35.6°C. There is a pelvic binder in place, a large left thigh hematoma, and the abdomen is distended and tender. The trauma team has placed two large-bore IVs. FAST shows free fluid in Morison's pouch and the splenorenal recess. Pelvic radiograph shows a widened symphysis and suspected posterior ring disruption. The local hospital has 2 units of packed red blood cells, no massive transfusion protocol pack, no interventional radiology, and one general surgeon who is 20 minutes away. Ground transfer to the level I trauma center takes 45 minutes; helicopter is grounded by weather. Her GCS is 14, and she is becoming more confused.
1. Outline damage-control resuscitation in the first 30 minutes.
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Damage-control resuscitation. Activate the massive transfusion protocol or, if unavailable, use a balanced 1:1:1 approach with the 2 units of PRBC plus plasma and platelets if obtainable; do not wait for crossmatch in exsanguinating hemorrhage. Limit crystalloid to avoid dilutional coagulopathy and hypothermia. Give tranexamic acid 1 g IV within 3 hours of injury, followed by 1 g over 8 hours. Warm the patient, check ionized calcium and give calcium replacement, and use pelvic binder plus thigh splint. Permissive hypotension to a palpable radial pulse or SBP around 80-90 mmHg is reasonable until hemorrhage control, but not in traumatic brain injury; her confusion mandates avoiding prolonged hypotension. The reasoning is that this is hemorrhagic shock with pelvic and abdominal bleeding, so blood products and rapid hemostasis, not large crystalloid boluses, improve survival.
2. How do you prioritize pelvic stabilization, laparotomy, and transfer?
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Priority sequence. Pelvic binder and thigh stabilization first, because pelvic ring disruption can bleed massively. The positive FAST and distension make intra-abdominal hemorrhage likely; with hemodynamic instability, the general surgeon should proceed to laparotomy rather than CT. If the surgeon is 20 minutes away, call immediately and prepare the OR; do not delay with imaging. Transfer to the level I center should occur after initial hemorrhage control or if the local surgeon cannot control the source. Interventional radiology for pelvic bleeding is not available locally, so the receiving center must be told about the pelvic fracture and need for angiography. The reasoning is that unstable pelvic fracture plus positive FAST is a surgical emergency; the order is stabilization, laparotomy for abdominal hemorrhage, then transfer for pelvic angioembolization.
3. What is the role of tranexamic acid and balanced blood product resuscitation?
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TXA and blood products. TXA should be given as soon as possible, ideally within 1 hour and no later than 3 hours after injury; beyond 3 hours it may be harmful. Use a 1 g loading dose over 10 minutes then 1 g over 8 hours. For blood products, a 1:1:1 ratio of PRBC to plasma to platelets approximates whole blood and reduces dilutional coagulopathy. The local 2 units of PRBC are not enough; call the blood bank for emergency release and consider activating a regional protocol. Monitor calcium because citrate causes hypocalcemia, and check fibrinogen; cryoprecipitate or fibrinogen concentrate may be needed. The reasoning is that trauma-induced coagulopathy is multifactorial, and early balanced products plus antifibrinolytic therapy address both bleeding and clot instability.