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Haemodynamic Response to Pelvic Stabilization

A pelvic binder is applied to splint the pelvis and reduce bleeding from bone ends and
provide some fracture stability to allow clot to form at sites of venous haemorrhage. The
binder will not control arterial haemorrhage. The haemodynamic response to the binder can
aid decision-making as to the nature of the underlying vascular injury. Those patients who
remain haemodynamically unstable following application of the binder probably have a
significant arterial haemorrhage which will need operative or endovascular control. (This
may be in the pelvis or another body cavity).
Conversely those patients whose cardiovascular status becomes normal following binder
placement probably do not have a major arterial injury and can proceed to definitive imaging
by CT scan. If an arterial blush is identified on the CT, patients can proceed to angioembolisation in a more controlled manner.

Concurrent Resuscitation
Patients who are in shock, actively bleeding and have not responded to the above simple
manoeuvres are in extremis and need expert care while haemorrhage control is being
achieved. This includes:

Intubation and ventilation

Activation of a massive transfusion protocol with aggressive administration of
coagulation factors (and minimal crystalloid)

Permissive hypotension prior to haemorrhage control

No investigations or interventions that delay or compromise early haemorrhage

Operating Room or Angiography Suite?
Haemorrhage from branches of the internal iliac artery are best managed by endovascular
techniques such as angiographic embolisation or coil placement. Immediate transfer of the
patients to an endovascular suite is therefore the ideal for these patients. However in certain
situations, patients must be transferred immediately to the operating room prior to
1. The patient has co-existant major thoracic or abdominal haemorrhage.
Thoracic haemorrhage is usually readily identified following chest examination, chest
X-ray and chest tube drainage. Major intraperitoneal haemorrhage must be excluded
before transfer for angio-embolization. Again, CT is not possible due to the patient's
haemodynamic status and so FAST ultrasound or Diagnostic Peritoneal Aspiration
(DPA) must be used. In both cases, the aim is to exclude major intraperitoneal
haemorrhage of significant volume to account for the degree of cardiovascular
derangement. A small amount of intraperitoneal fluid is likely in patients with massive

the operating room is a safer bet than the angiography suite for initial haemorrhage control manoeuvres. The patient is exsanguinating from an open pelvic fracture. Minimal and significant free fluid on FAST Caution should be exercised when interpreting the results of both FAST and DPA. common iliacs etc). If there is any doubt. Similarly a weakly blood-stained peritoneal lavage is not significant but easy aspiration of frank blood from the peritoneal cavity is. Patients with open pelvic fractures that are bleeding externally should be taken to the operating room for packing of the external haemorrhage as well as extraperitoneal pelvic packing. A repeat scan may be of value. FAST has a high false-negative rate in the presence of pelvic fracture and retroperitoneal haematoma. but not 'positive enough' to warrant a laparotomy prior to embolisation.retroperitoneal haematoma. Neither FAST nor DPA can exclude a major abdominal retroperitoneal vascular injury (aorta. 2. Thus a FAST may be positive. .