SAQ 415 – Trauma – unstable pelvic fracture with haemorrhagic shock

Trauma – unstable pelvic fracture with haemorrhagic shock.

a. Important positive findings

• High-risk mechanism with haemodynamic instability, consistent with haemorrhagic shock.
• Unstable right-sided pelvic ring injury, including right acetabular and iliac/alar fractures.
• Right superior pubic ramus fracture, with possible additional sacral or neck-of-femur injury.
• Right femoral shaft fracture, with a traction splint likely in situ.
• GCS 13 raises concern for head injury or poor cerebral perfusion from shock.

b. Treatment priorities

• Give urgent volume resuscitation with O-negative packed red cells and activate massive transfusion; minimise crystalloid and consider permissive hypotension until haemorrhage control.
• Apply pelvic binder and maintain spinal precautions; immobilise associated long-bone injuries.
• Seek and control bleeding: EFAST, laparotomy if intraperitoneal bleeding is present, and pelvic angiography or embolisation if pelvic bleeding is likely.
• Give analgesia such as titrated fentanyl or ketamine.
• Give tranexamic acid if within the appropriate trauma window.
• Involve trauma surgery, orthopaedics, interventional radiology, anaesthetics, and blood bank early.
• Prepare for transfer if definitive haemorrhage control is unavailable.

c. Massive transfusion protocol

• Clear activation triggers and early communication with blood bank and haematology.
• Balanced blood product delivery, for example packed red cells, FFP, and platelets in an institution-defined ratio such as 1-2:1:1.
• Monitoring and treatment of complications including coagulopathy, hypocalcaemia, hypothermia, acidosis, and hyperkalaemia.
• Defined endpoints for stopping or de-escalating the protocol.
• Adjuncts such as tranexamic acid where indicated.
• Safety and governance elements: product checks, documentation, audit, and case review.