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Refractory pelvic fracture-associated hemorrhage after preperitoneal packing: now what?
  1. Gretchen Floan1,2,
  2. Matthew J Martin1,2
  1. 1Department of Trauma Surgery, Scripps Mercy Hospital San Diego, San Diego, California, USA
  2. 2Department of Surgery, Naval Medical Center San Diego, San Diego, California, USA
  1. Correspondence to Dr Matthew J Martin; traumadoc22{at}

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Case description

A male patient in his 50s presented after a high-speed motorcycle crash. On arrival to the trauma bay, his primary survey was intact with normal vital signs. He had an obvious deformity of his left forearm secondary to a closed radius/ulnar fracture. He had anterior pelvic tenderness but no perineal/scrotal bruising. A pelvic X-ray and CT scan of his torso showed severe diastasis of the pubic symphysis with associated posterior disruption of the sacroiliac joint (figure 1A). He had a small associated extraperitoneal pelvic hematoma extending into the left rectus sheath with trace arterial blush and mild hemorrhage into the urinary bladder. He remained hemodynamically stable with a Glasgow Coma Scale score of 15 and with the main complaint of pain from the left forearm fracture.

Figure 1

(A) Initial pelvic X-ray showing severe pubic symphysis diastasis and posterior disruption of the left sacroiliac joint, and (B) immediate postoperative X-ray showing the QuikClot Control+ pads in the preperitoneal space and adequate pelvic reduction obtained via placement of an external pelvic binder.

The patient was taken immediately to the operating room (OR) for planned external pelvic fixation and fixation of his left forearm. On anesthetic induction, he became acutely hypotensive and went into pulseless electrical activity cardiac arrest. He required a brief period of cardiopulmonary resuscitation and responded to 1 mg epinephrine with return of spontaneous circulation. Massive transfusion protocol …

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