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Concurrent splenic and pelvic haemorrhage after blunt trauma — MRCEM SBA MCQ

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HardTraumaConcurrent splenic and pelvic haemorrhage after blunt traumaMRCEM SBA

A 42-year-old driver is brought to a major trauma centre after a high-speed collision. A pelvic binder is in place and the major haemorrhage protocol has been activated. His blood pressure initially improves with blood-component resuscitation, allowing immediate CT. This shows a shattered spleen with active contrast extravasation and a large haemoperitoneum. It also shows an unstable pelvic ring fracture with active arterial extravasation into a retroperitoneal haematoma. On leaving CT, his blood pressure falls to 76/44 mmHg despite continuing transfusion. A trauma surgeon and interventional radiologist are immediately available. Which is the most appropriate immediate haemorrhage-control pathway?

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

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Correct answer: C — Operative splenic haemostasis with pelvic packing.

This patient has two demonstrated sources of major haemorrhage. The large haemoperitoneum, actively bleeding spleen and recurrent shock despite transfusion make emergency laparotomy necessary. The pelvic arterial blush is important, but it does not take priority over operative control of the intra-abdominal bleeding. NICE recommends pelvic packing as the first-line invasive treatment for active arterial pelvic bleeding when emergency laparotomy is needed for abdominal injuries; interventional radiology is first-line when laparotomy is not needed. Operative splenic haemostasis with pelvic packing is therefore the best immediate pathway. ([nice.org.uk](https://www.nice.org.uk/guidance/ng37/chapter/recommendations)) A delays control of the splenic haemorrhage while pelvic embolisation is performed. B addresses the pelvis first but likewise delays the necessary laparotomy. D is attractive because embolisation targets the demonstrated pelvic arterial bleeding; it may be needed later if bleeding persists, but it omits the recommended first-line pelvic packing during this emergency operation. E addresses splenic bleeding and pelvic mechanical stability, but external fixation does not replace packing as first-line invasive haemorrhage control in this setting. The earlier response to resuscitation explains why CT was reasonable; the subsequent deterioration determines the immediate treatment priority. ([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 (17 February 2016) — https://www.nice.org.uk/guidance/ng39/chapter/recommendations NICE NG39, Major trauma: assessment and initial management, recommendation 1.5.31 (17 February 2016) — https://www.nice.org.uk/guidance/ng39/chapter/recommendations