A patient with APC-III pelvic ring injury arrives in hemorrhagic shock with BP 70/40 mmHg after massive external pelvic binder application. Despite 4 units pRBC, she remains unstable. What is the next MOST appropriate intervention?

• A Emergency external fixator application in the operating room
• B Therapeutic pelvic angiography and embolization
• C Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) at Zone III with simultaneous preperitoneal pelvic packing ✓
• D Open book pelvic binder re-tightening and further fluid loading

Explanation

In hemodynamically unstable pelvic fractures refractory to binder application and initial resuscitation, the current damage control strategy involves REBOA (Zone III — infrarenal aorta) to reduce pelvic inflow, combined with preperitoneal pelvic packing via a midline incision to directly tamponade presacral and prevesical venous bleeding (which accounts for the majority of pelvic hemorrhage). Angioembolization targets arterial hemorrhage (only 10–15% of pelvic fracture bleeding) and is appropriate after packing if instability persists. External fixation alone is insufficient for APC-III vertical shear injuries.

Reference: Maheshwari Essential Orthopaedics, 6th ed.

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Written and medically reviewed by the StethoPrep medical team.