Pelvic fractures may cause significant bleeding. The
superior gluteal artery is responsible for the majority of bleeding in pelvic
fractures with an arterial injury. Most of the bleeding in pelvic fractures is
from the veins and the fracture itself. Hemorrhage is the most life-threatening
complication associated with pelvic injuries and will typically occur at the
Superior Gluteal Artery. Hemorrhage of the Superior Gluteal Artery can be
fatal. Approximately 10% of patients will have severe bleeding. Severe bleeding
usually occurs in fracture patterns that are highly unstable to both rotational
and vertical forces.
APC III (open book like type) is the complete disruption of
anterior SI, sacrotuberous, and sacrospinous ligaments; disrupted posterior SI
ligaments.
Vertical Shear Fractures are very bad fractures as they
cause the complete disruption of the anterior and posterior ligaments;
cephaloposterior displacement. Anteroposterior compression or vertical shear
injuries are consistently associated with a higher risk of mortality from bleeding.
The mortality rate is directly related to the amount of shock the patient is in
at the time of presentation.
When treating patients with pelvic fractures and massive
bleeding, it is important to remember that the patient will lose approximately
35% of their blood volume with acute hemorrhage before a sustained decrease in
systolic blood pressure occurs. Immediate application of a pneumatic anti-shock
garment is absolutely contraindicated in patients with a rupture of the
diaphragm. Ringer’s lactate is the preferred initial fluid replacement used to
resuscitate hypovolemic trauma patients in shock. A hypotensive blunt trauma
patient will be given an initial fluid push with 2,000mL of Ringer’s lactate. A
patient with bleeding and in shock will probably require O negative blood. If
the patient is given 4 units of blood but remains hemodynamically unstable,
then angiography and embolization is needed. Immediate application of an
external fixator is another method to control bleeding, especially if the
pelvis is unstable in external rotation. An abdominal and pelvic CT scan will
clearly define the bony injury as well as the extent and source of the
bleeding.
The best treatment for pelvic fractures with bleeding is a
blood transfusion with correction of hypothermia and coagulopathy.
