Outline the initial management of a 62-year-old male presenting with haemorrhagic shock secondary to pelvic fractures following a fall from a ladder.
Life-threatening situation and management involves a multi-disciplinary approach following EMST guidelines.
- Obtain large-bore IV access (2 x 14G IV cannulae in ACFs) and send blood for cross-match and appropriate investigation
- Resuscitation fluids – crystalloid / colloid / blood (group specific or cross-matched dependent on urgency) administered to resuscitation end-points (MAP 60-70) in ratio of packed cells to FFP and platelets 1:1
- Avoid excessive movement of the pelvis and stabilize with sheet or commercial external pelvic stabilizer device
- CXR and secondary survey to look for other sources of bleeding
- Investigate for associated intra-abdominal or intra-pelvic injuries with FAST scan and/or CT scan if patient has stabilized with resuscitation
- Urgent consultation with interventional radiologist for angiography and embolization if other sources of bleeding excluded and if interventional radiology service available
- Urgent consultation with orthopaedic surgeon for external fixation
- Urgent consultation with general surgeon if intra-abdominal blood or evidence of intestinal perforation
- Aortic balloon occlusion also described as temporizing measure for patients in extremis from pelvic bleeding
- Antibiotics if suspected / proven disruption of bowel or urinary tract
This question would benefit from a systematic approach.
A) Assessment of the airway and of the need for immediate intubation, while maintaining C-spine precautions
B) Ventilation with high FiO2; investigation of possible aspiration with CXR and ABG.
C) Establishment of IV access and correction of hypovolemia;
urgent collection of a sample for a crossmatch of blood and urgent administration of available uncrossmatched blood.
Assess for retroperitoneal and pelvic bleeding with FAST +/- CT
D) Investigate causes of fall related to intracranial events, eg. ICH,
intoxication, seizure, etc.
E)Correct hypothermia, hypocalcemia and acidosis
Ensure haemostasis; the following options are available
- Blood product replacement to ensure normal coagulation function
- Pelvic binder
- Tranexamic acid and/or Factor VIIa
- Direct external compression of the aorta
- Intra-aortic balloon occlusion
- Reduction of acetabular fracture by lower limb traction
- Angioembolisation by interventional radiologist
- Surgical exploration / external fixation
What say the literature? This 2007 article essentially echoes the suggestions made by the college.
ATLS student course manual, 8th edition (Chapter 5) - American College of Surgeons Committee on Trauma
Geeraerts, Thomas, et al. "Clinical review: initial management of blunt pelvic trauma patients with haemodynamic instability." Critical Care 11.1 (2007): 204.
Heetveld, Martin J., et al. "Hemodynamically unstable pelvic fractures: recent care and new guidelines." World journal of surgery 28.9 (2004): 904-909.
Martinelli, Thomas, et al. "Intra-aortic balloon occlusion to salvage patients with life-threatening hemorrhagic shocks from pelvic fractures." Journal of Trauma and Acute Care Surgery 68.4 (2010): 942-948.
Douma, Matthew, Katherine E. Smith, and Peter G. Brindley. "Temporization of Penetrating Abdominal-Pelvic Trauma With Manual External Aortic Compression: A Novel Case Report." Annals of emergency medicine (2013).