Trauma haemorrhage
Uncontrolled bleeding is a major preventable cause of early trauma death. Management combines rapid recognition, mechanical control of bleeding and balanced resuscitation.
Immediate approach
- identify external haemorrhage and control it directly
- suspect concealed bleeding in chest, abdomen, pelvis, long bones and retroperitoneum
- activate a major-haemorrhage protocol early when appropriate
- avoid preventable hypothermia
- monitor acid-base status, lactate, haemoglobin, coagulation and ionised calcium
- involve interventional radiology and surgical teams early when definitive haemostasis may be required
Pelvic binder
In a haemodynamically unstable patient with a suspected mechanically unstable pelvic-ring injury, a pelvic binder is applied at the level of the greater trochanters, not around the iliac crests.
Potential benefits:
- reduces pelvic volume in some open-book patterns
- improves tamponade
- reduces painful motion during initial resuscitation
A binder is a temporary resuscitation device. Prolonged application carries a risk of skin pressure injury and does not replace definitive fixation or haemorrhage control.
A binder reduces pelvic volume and stabilises some unstable patterns. It should be positioned at the greater trochanters, not around the iliac crests.
Prolonged application requires skin monitoring and a plan for definitive stabilisation.
Tranexamic acid
Tranexamic acid reduces fibrinolysis by blocking lysine-binding sites on plasminogen. In bleeding trauma patients, benefit is time dependent; it is used early according to major-trauma protocols.
Do not delay mechanical control of bleeding to administer medication.
Tranexamic acid is an antifibrinolytic. In major bleeding trauma it is most useful when given early within the accepted treatment window.
It inhibits activation/binding of plasminogen and reduces fibrin breakdown. It does not replace mechanical haemorrhage control.
Massive transfusion
Modern major-haemorrhage pathways aim to prevent the self-reinforcing cycle of:
- haemorrhage
- hypothermia
- acidosis
- coagulopathy
- hypocalcaemia
Blood-component therapy is guided by protocol and, where available, point-of-care coagulation testing.
Pelvic haemorrhage options
Depending on local resources and the bleeding source, definitive strategies may include:
- pelvic stabilisation
- preperitoneal packing
- angiographic embolisation
- operative control of associated intra-abdominal bleeding
The sequence is determined by physiology and local trauma pathways rather than by radiographic classification alone.
Haemorrhage control in trauma
Major trauma resuscitation prioritises rapid control of haemorrhage while maintaining oxygen delivery and preventing the lethal interaction of:
- hypothermia
- acidosis
- coagulopathy
Source control and resuscitation must occur in parallel.
Pelvic fracture
A mechanically unstable pelvic-ring injury can produce severe haemorrhage from:
- venous plexus
- cancellous bone surfaces
- arterial injury
Initial measures may include:
- pelvic binder placed correctly over the greater trochanters
- haemostatic resuscitation
- urgent imaging/intervention according to haemodynamic state
Repeated pelvic “springing” is unnecessary and can disturb clot.
Source control
Depending on local systems and bleeding source, options include:
- preperitoneal packing
- angioembolisation
- external fixation
- definitive pelvic stabilisation
- aortic balloon occlusion in selected specialist settings
The haemodynamic state determines urgency and sequencing.
Damage-control resuscitation
Principles include:
- rapid control of bleeding
- balanced blood-component strategy where indicated
- prevention of hypothermia
- correction of significant coagulopathy
- calcium monitoring/replacement during massive transfusion
- avoidance of excessive crystalloid
Pelvic-associated injuries
Look for:
- urethral injury
- bladder injury
- rectal/vaginal injury
- lumbosacral nerve injury
- open pelvic fracture
Open pelvic fractures carry particularly high infection and haemorrhage risk and need coordinated multidisciplinary management.
FRCS synthesis
For a shocked patient with an unstable pelvic injury, state the sequence clearly: binder + haemostatic resuscitation + rapid identification/control of bleeding source + definitive stabilisation when physiology permits.