Abstract text (incl. references and figure legends)
Traumatic pelvic injuries contribute to the mortality rate in polytrauma patients.
A 66-year-old male cyclist had a traumatic collision with a tram. In the prehospital phase, he was responsive and treated as per local EMS-protocol. Upon admission to the ED, he was conscious, tachypneic, tachycardic, hypotensive and deteriorating. Polytrauma CT showed ribs and sternum fractures, bilateral pneumothorax, numerous unstable pelvic fractures, paraspinal muscles blunt injury and retroperitoneal bleeding. An external pelvic stabilization splint was established. Rescue transfusion for hemorrhage as well as external heating was initiated. The patient was first qualified for an orthopedic external pelvic stabilization surgery. Due to the worsening shock with the unclear focus of bleeding resulting in the patient falling into transient cardiac arrest, plans for surgery were abandoned. The repeated FAST-USG was negative for any visible intraperitoneal bleeding, cardiac tamponade or other cardiac injuries. Priority was switched to radiological intervention. Three arteries: right obturator artery, left internal iliac artery, and the right intercostal artery were found actively bleeding and embolized 3 hours after ED admission. The patient was then admitted in the ICU where he continued to deteriorate with signs of irreversible phase of shock with multiple organ failure. The patient died the day after the accident.
In case of traumatic pelvic fractures, it is crucial to suspect bleeding from adjacent vessels since shock symptoms can be occult on the onset. The "golden hour" rule in the prehospital phase is cardinal. Once haemorrhagic shock is suspected, it is critical to prevent "the death triad"- coagulopathy, acidosis and hypothermia. If the patient hemodynamically deteriorates with negative POCUS/CT, suspect retroperitoneal/GI bleeding. Endovascular intervention in high-energy pelvic trauma patients with shock can be life saving as the late phase of shock is irreversible.
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