HEMORRHAGE CONTROL

1. All trauma patients should undergo a rapid trauma assessment according to TCCC, Advanced Trauma Life Support (ATLS), and Joint Trauma Systems (JTS) damage control resuscitation guidelines. Sources of hemorrhage should be rapidly identified and intervened upon in a systematic way. Please see JTS Damage Control Resuscitation and Whole Blood Transfusion CPGs for more information.

2. Patients in hemorrhagic shock should be appropriately treated with blood products, preferably whole blood. Blood product administration of either whole blood (preferably) or component blood products in a 1:1:1 ratio, based on available product, should be initiated for patients who remain hypotensive (SBP < 100, or 110 in patients with suspected traumatic brain injury). Initiation of massive transfusion protocol is often required.

3. During resuscitation, place a pelvic binder or sheet (if not already in place) centered over the greater trochanters with the buckle centered over the pubic symphysis. The pelvis should be manually reduced by internally rotating the hemipelves together, having one person press the greater trochanters together after which a second person tightens down the binder or tightly secure the sheet. Taping the knees and feet together can assist in internal rotation of the lower extremities to facilitate further reduction at the pelvis and help improve the pelvic reduction achieved with a sheet or binder.14 A multidisciplinary approach with early orthopedic surgery consultation (and trauma consultation if care is being rendered prior to a Role 2) is critical for the holistic management of these complex injuries.

4. As with all trauma patients, patients with concern for pelvic injuries and those with pelvic binders in place require a pelvic x-ray as an adjunct of the primary survey. If a pelvic binder is in place, obtain the x-ray with the binder/sheet cinched down. Only if the patient is hemodynamically stable, release the binder/sheet and repeat the x-ray to evaluate for major pelvic ring disruption – if the pelvic ring is unstable, reduce the pelvis again and retighten the binder/sheet; repeat the pelvis x-ray to confirm that the pelvis is radiographically reduced. Monitor hemodynamics continuously during this process and communicate with all members of the team when the pelvic binder is released and when it is re-applied.

5. Identify all areas of potential hemorrhage. A focused assessment with sonography for trauma (FAST exam) should be completed as another adjunct to the primary survey to assess for intra-abdominal hemorrhage. There should be a detailed examination of soft tissue disruptions with special attention paid to the perineal area. Digital rectal exams and vaginal exams should be performed for all open pelvic fractures or if there is evidence of perineal trauma.

6. Hypotensive patients with a positive FAST should proceed directly to the operating room for laparotomy. Be mindful when extending the laparotomy incision infra-umbilically. A patient with unstable pelvis and in hemorrhagic shock from this will likely have a large pre-peritoneal (or retroperitoneal) hematoma, incising into this hematoma will decompress it and release tamponade, worsening hemorrhage.

a. Visualize the infraumbilical area internally when extending the laparotomy incision, or alternatively, feel for a large hematoma in this region.

b. If there is a pre-peritoneal hematoma confirmed, AVOID EXTENDING THE LAPAROTOMY INCISION INFERIORLY AND AVOID INCISING THE HEMATOMA. This is the space you must preserve for your pre-peritoneal pelvic packing to be effective.

c. Pre-peritoneal packing (PPP) should be considered if the pelvis is thought to be the major contributor to hemorrhage, which is best completed via an infraumbilical midline incision separate from a laparotomy incision. (See below for details.)

7. If PPP is being utilized, it is strongly recommended that concomitant pelvis external fixation be performed, if possible. Binders should only be used in this setting if equipment or skills for pelvic external fixation are lacking.

8. Zone 3 Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) should be considered for temporary hemorrhage control if there is hemodynamic instability when providers are appropriately trained and have surgical capability. (See the JTS REBOA for Hemorrhagic Shock CPG for details.)

NOTE: Patients are rarely suitable for definitive fixation hours after presentation to surgical capability.

9. For patients with a negative FAST who are hypotensive (SBP < 90) despite pelvic binder placement, resuscitation with blood products should be continued on the way to the OR for PPP or interventional radiology (IR) angioembolization (if capability available) and external fixation. (Reminder: a FAST exam that is negative/non-diagnostic does not definitively rule out hemorrhage.) 13

10. Remove pelvic binders and perform surgical stabilization with an external fixator as soon as possible. If a binder is left in place for more than 6 hours, the patient will need periodic skin checks at a minimum of every 12 hours by holding the pelvis reduced and taking down the binder/sheet, assessing the skin for pressure wounds and reapplying after skin assessment. If there is concern for pressure wounds, external fixation should be performed so the binder/sheet can be discontinued. Binders/sheets should not be left in place for more than 24 hours if possible.

11. Post PPP patients will need continued ICU-level monitoring of hemodynamics and may require continued resuscitation. These patients should in in an ICU. These casualties will require transfer to a higher level or care when they are stable for transport. Pelvic fracture patients who require any type of surgical intervention will require evacuation out of the combat theater.

12. In patients who undergo PPP, packs should be removed when resuscitation is complete and they are hemodynamically stable. This should always be accomplished within 48 hours.

13. In patients who are hemodynamically unstable despite adequate pelvic packing, bleeding is then likely from an arterial source. The treatment options include: temporizing uni/bilateral internal iliac artery occlusion (with vessel loops/Rommel tourniquets, atraumatic clamps) or evacuation to a higher level of care with IR capability. These are temporizing measures only. Bilateral internal iliac artery ligation should only be performed in extreme circumstances as the risk for necrosis and severe infection increase mortality. Unilateral internal iliac artery ligation can be used with less morbidity. Ideally selective vessel ligation (branches from internal iliac) is preferred but more technically challenging.

14. Definitive pelvic surgery should be deferred to a Role 4 facility with orthopaedic trauma surgery support and capabilities. There are circumstances where this could be done at a Role 3 MTF if the adequate expertise, imaging, and adjunct capabilities are present. During the GWOT these cases were performed at either Landstuhl or at a CONUS Role 4 MTF.