Pelvic fracture haemorrhage for angioembolisation24-year-old man, 78 kg, after a 6-metre fall; unstable pelvic fracture

The patient

The examiner asks

Answer aloud, then press Show.

1. Consider

   What are your considerations?

   Show the answerHide the answer

   • A 24-year-old in haemorrhagic shock from a pelvic fracture, for emergency angioembolisation then external fixation. Patient
   • As a trauma patient, I start xABCDE; alcohol and GCS 14 can mask a head injury.
   • Pelvic fractures can bleed fatally into the retroperitoneum; open ones carry up to 32% mortality. Disease
   • He's already 35.4 °C; cold, acidosis, clotting failure and low calcium feed each other.
   • The angiography suite is remote: less help, less space and kit, far from theatre. Surgery

2. Prepare

   Take me through your primary survey.

   Show the answerHide the answer

   • x: no external bleeding; binder checked, since pelvic compression stabilises the ring and cuts bleeding. Crisis
   • A: he's talking, so patent; I don't intubate now, because induction could crash his pressure. Airway
   • B: eFAST shows no pneumothorax or haemothorax. Disease
   • C: blood, not crystalloid; massive transfusion activated at 1:1:1. Crisis
   • He's within 3 hours: tranexamic acid 1 g over 10 minutes, then 1 g over 8 hours.
   • D and E: GCS 14 with alcohol on board, glucose checked; he's cold, so warm him now. Disease

3. Plan

   How will you manage him in the angiography suite?

   Show the answerHide the answer

   • Head CT clear, so permissive hypotension: small boluses only if systolic falls below 80–90. Disease
   • Rapid infuser with warmed products; ionised calcium checked, aiming above 1.15 mmol/L. Crisis
   • Fibrinogen kept at 150 mg/dL or more with cryoprecipitate.
   • If he needs GA: ketamine in reduced dose and rocuronium 1.2 mg/kg, with blood running. Airway
   • Remote site: second anaesthetist, transfusion runner, defibrillator and emergency drugs in the room. Surgery
   • External fixation follows the embolisation; ICU afterwards. After surgery

4. Crisis

   After 8 units of red cells and 4 of plasma, he oozes from every line; ionised calcium 0.82 mmol/L, fibrinogen 120 mg/dL, temperature 34.6 °C, BP 76/44, HR 138. What do you do?

   Show the answerHide the answer

   • Massive haemorrhage algorithm: he's coagulopathic, and his ratio has drifted to 2:1. (Crisis)
   • Plasma and platelets brought back up to 1:1:1 with the red cells.
   • Calcium 0.82 is severe, bound by citrate: calcium chloride 10 mL of 10% over 10 minutes.
   • Fibrinogen 120, below the 150 mg/dL target: cryoprecipitate.
   • At 34.6 °C: forced-air warming, warmed products, theatre heated; hypothermia is degrading his clotting.
   • Viscoelastic testing guides the next products; the radiologist keeps embolising.

5. Crisis

   Mid-embolisation the arterial trace goes flat; ECG shows sinus tachycardia at 140 with no pulse. What do you do?

   Show the answerHide the answer

   • Adult arrest algorithm, PEA in a bleeding trauma patient: hypovolaemia is the cause until proven otherwise. Crisis
   • Compressions can't fill an empty heart; blood through the rapid infuser is my priority.
   • Adrenaline 1 mg every 3–5 minutes, but volume comes first.
   • His causes: hypovolaemia, low calcium and high potassium from transfusion, acidosis and cold.
   • I still decompress both sides of his chest, without waiting for imaging.
   • Ultrasound his pericardium for tamponade.
   • With a pulse back: ICU, damage control surgery and a trauma surgeon at the bedside. After surgery