Haemorrhagic shock from pelvic fracture — FFICM MCQ

Correct answer: D — Activate pelvic haemorrhage control with interventional radiology or surgery

The correct answer is D, activate pelvic haemorrhage control with interventional radiology or surgery. This patient has ongoing haemorrhagic shock (tachycardia, hypotension, lactate 7.2 mmol/L) despite tranexamic acid, a correctly applied binder and balanced blood product resuscitation, with FAST and chest X-ray excluding intra-abdominal and thoracic sources, so the pelvis is the presumed bleeding focus. Per UK trauma standards, active pelvic bleeding that does not respond to resuscitation requires definitive source control by surgical pelvic packing or interventional radiology embolisation, and major trauma centres must have a clear protocol for this. A binder is a temporising measure, not definitive haemostasis, so persistence of shock mandates escalation to angioembolisation or theatre without delay. Why the other options are wrong: E. Give 3 litres crystalloid before transfusion: large-volume crystalloid causes dilutional coagulopathy, hypothermia and clot disruption, and is contrary to damage control resuscitation principles favouring early blood products. C. Remove the pelvic binder to assess deformity: removing the binder in an unstable patient releases the tamponade effect on the pelvic venous plexus and fracture site, worsening haemorrhage; binders should stay in situ until haemodynamically stable. A. Transfer directly to ward for traction: an unstable, shocked patient with a suspected ongoing bleeding source needs immediate haemorrhage control in theatre or interventional radiology, not ward-based traction, which does not achieve source control. B. Start vasodilators to reduce afterload: the problem is hypovolaemic haemorrhagic shock, not cardiac afterload; vasodilators would worsen hypotension and end-organ perfusion. Key point: persistent shock after binder and blood products in pelvic fracture means the bleeding is ongoing and demands immediate definitive source control via interventional radiology or surgery, not more crystalloid or binder manipulation.

Reference: British Orthopaedic Association Standards for Trauma (BOAST): The Management of Patients with Pelvic Fractures, boa.ac.uk/resource/boast-3-pdf.html