Management of hemorrhagic shock in the trauma patient with severe pelvic fracture*

MTP: massive transfusion protocol; eFAST: extended focused assessment with sonography for trauma; OR: operating room; PRBCs: packed red blood cells; SBP: systolic blood pressure; PPP: preperitoneal pelvic packing; AE: angioembolization; ICU: intensive care unit; CT: computed tomography; HR: heart rate; RBCs: red blood cells; FFP: fresh frozen plasma; TXA: tranexamic acid; TEG: thromboelastography; REBOA: resuscitative endovascular balloon occlusion of the aorta; DPL: diagnostic peritoneal lavage.
* Ongoing hemorrhage is manifested as hypotension and tachycardia (SBP <90, HR >110). Bleeding from concomitant abdominal injury is included in this algorithm. If chest injury is suspected to be the cause of bleeding, chest exploration may be the appropriate first step. Higher grades of pelvic fractures (Young and Burgess classification) are associated with life-threatening hemorrhage, particularly anteroposterior compression, and vertical shear injuries.
¶ Notify the blood bank, attending trauma surgeon, attending orthopedic surgeon, operating room, and vascular intervention team.
Δ Transfuse RBCs, FFP, platelets. Transfuse cryoprecipitate and TXA based on TEG parameters. Appropriate transfusion ratios are discussed in topics on initial trauma management and resuscitation.
◊ If refractory shock unresponsive to transfusion is present (SBP <80), consider REBOA. REBOA placement should not delay definitive hemorrhage control. REBOA may improve resuscitation efforts, permit total body CT prior to transfer to OR (standard or hybrid), and facilitate pelvic angiography/AE in the OR. REBOA involves placing a vascular sheath into the femoral artery and advancing an aortic balloon above the level of suspected bleeding. If needed, the aortic balloon can be inflated to occlude the aorta. Prolonged REBOA can be associated with ischemic consequences.
§ If eFAST is equivocal, consider DPL.
¥ The relative severity of intra-abdominal injury versus pelvic fracture determines whether management of fracture-related bleeding is performed first or following abdominal exploration. Exploratory thoracotomy may also be required depending on the nature of the injuries.
‡ PPP involves placement of laparotomy sponges into the preperitoneal space to tamponade bleeding and reduce the available volume of the retroperitoneum.
† For suspected arterial bleeding, after PPP, AE will be necessary.
** Pelvic angiography with AE can be performed in a hybrid operating room or interventional suite (if immediately available).
¶¶ >4 units PRBCs in 12 hours from a pelvic source (ie, other sources excluded or treated) and normal coagulation parameters.