Question 21

Outline the initial management of a 62-year-old male presenting with haemorrhagic shock secondary to pelvic fractures following a fall from a ladder.

College Answer

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

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 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

This question would benefit from a systematic approach.

Supportive management:

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

Specific management:

Ensure haemostasis; the following options are available

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

Heetveld, Martin J., et al. "Hemodynamically unstable pelvic fractures: recent care and new guidelines." World journal of surgery 28.9 (2004): 904-909.