A 22-year-old man is brought to the emergency department after sustaining multiple injuries in a fall. His airway is intact, he is breathing spontaneously (RR 20/min), and his GCS is 15. His BP is 80/50 mmHg despite 2 litres of crystalloid. FAST is negative. Pelvic X-ray shows an open-book pelvic fracture. What is the most important immediate intervention to control haemorrhage?

• A Emergency exploratory laparotomy
• B External fixator application in the operating theatre
• C Apply a pelvic binder to reduce pelvic volume ✓
• D Retroperitoneal packing via Pfannenstiel incision

Explanation

An open-book pelvic fracture disrupts the pubic symphysis and posterior sacroiliac ligaments, dramatically increasing pelvic volume and allowing massive venous (and sometimes arterial) haemorrhage into the retroperitoneum. Application of a pelvic binder (or improvised sheet binding) at the level of the greater trochanters reduces pelvic volume, tamponades venous bleeding, and can be done immediately in the trauma bay before any further imaging or operative intervention. External fixation is a more definitive mechanical control but requires the operating theatre. Laparotomy is not indicated when FAST is negative. Retroperitoneal packing is used as an adjunct after initial binder application in patients failing to respond.

Reference: Bailey & Love's Short Practice of Surgery, 27th ed.

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Written and medically reviewed by the StethoPrep medical team.