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Arterial pelvic haemorrhage with a concurrent abdominal injury requiring emergency laparotomy — MRCEM SBA MCQ

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HardTraumaArterial pelvic haemorrhage with a concurrent abdominal injury requiring emergency laparotomyMRCEM SBA

A 42-year-old pedestrian is brought to a major trauma centre after being struck by a van. A pelvic binder is in place and blood-component resuscitation is under way. His blood pressure rises from 78/48 mmHg to 108/68 mmHg, allowing immediate CT. This shows a mechanically unstable pelvic ring fracture with active contrast extravasation from an internal iliac artery branch. It also shows jejunal wall discontinuity, free intraperitoneal gas and fluid. He has increasing abdominal tenderness, and the trauma surgeon is preparing an emergency laparotomy. Interventional radiology and pelvic surgery are immediately available. Which is the most appropriate first-line invasive treatment of the pelvic haemorrhage?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: E — Preperitoneal pelvic packing

The CT contrast extravasation identifies active arterial pelvic bleeding. Although interventional radiology is generally the first-line invasive treatment for this finding, the jejunal discontinuity and free intraperitoneal gas establish a separate abdominal injury requiring emergency laparotomy. That need changes the sequence: NICE recommends pelvic packing as the first-line invasive treatment of arterial pelvic bleeding when emergency laparotomy is needed for abdominal injuries. The binder and blood-component resuscitation remain part of care while definitive haemorrhage control is organised. ([nice.org.uk](https://www.nice.org.uk/guidance/ng37/chapter/recommendations)) A is attractive because embolisation is recommended for arterial pelvic bleeding when emergency laparotomy is *not* needed; here, proceeding to radiology first would delay surgery for the bowel injury. B and C can stabilise a mechanically unstable pelvic ring, but neither is the specified first-line invasive treatment for arterial haemorrhage in this operative context. Their use for skeletal stabilisation can be determined with the pelvic surgeon. D may appear efficient during laparotomy, but bilateral internal iliac ligation is not NICE’s recommended first-line approach; pelvic packing is. ([nice.org.uk](https://www.nice.org.uk/guidance/ng37/chapter/recommendations))

Reference: NICE NG37, Fractures (complex): assessment and management, recommendation 1.2.16 (Published 17 February 2016; last updated 23 November 2022) — https://www.nice.org.uk/guidance/ng37/chapter/recommendations NICE NG39, Major trauma: assessment and initial management, recommendation 1.5.40 (Published 17 February 2016) — https://www.nice.org.uk/guidance/ng39/chapter/recommendations