Abdominal, Pelvic & Extremity Trauma

Catastrophic Hemorrhage (<C>):
• Extremity: Apply CoTCCC Windlass Tourniquet (CAT Gen 7) 5–8 cm proximal to wound directly over bare skin (never over a joint).
• Pelvis: Apply commercial pelvic binder (SAM Sling II / T-POD) centered strictly over the greater trochanters with internal rotation taping of the ankles [1,2].

Supradiaphragmatic Vascular Access:
• Insert 2 × 14G–16G short peripheral IVs in antecubital fossae OR 15G humeral head IO + 8.5 Fr trauma sheath (Cordis/MAC) in subclavian or internal jugular vein.
• Strict Contraindication: Never rely on femoral venous access in suspected pelvic/abdominal vascular trauma [1].

• Tourniquet: Exceed systolic intraluminal pressure to compress the main conduit artery against the cortical bone shaft.
• Pelvic Binder: Reduce pelvic radius (r) to collapse retroperitoneal volume (V = ⁴⁄₃πr³), achieving mechanical tamponade of the presacral venous plexus and cancellous bone [2].

Primary Survey (A-B-C) & eFAST:
• Maintain inline cervical spine immobilization.
• Perform 5-view eFAST (3.5–5.0 MHz curvilinear probe): RUQ (Morison’s pouch + right hemithorax), LUQ (splenorenal + subdiaphragmatic), Suprapubic (Pouch of Douglas/rectovesical), Subxiphoid pericardial, and bilateral anterior pleural sliding [1,3].

Activate Massive Transfusion Protocol (MTP):
• Infuse uncrossmatched O-Negative (childbearing-age females) or O-Positive (males) PRBCs, FFP, and Platelets in a balanced 1:1:1 ratio via Belmont/Level 1 rapid infuser warmed to 39°C [1,4].
• Target: Permissive hypotension (SBP 80–90 mmHg, MAP 50–60 mmHg) if no concurrent severe TBI (GCS ≤ 8 mandates SBP ≥ 110 mmHg) [1].

• Balanced 1:1:1 Ratio: Prevent dilutional coagulopathy, shed glycocalyx endotheliopathy, and crystalloid-induced clot disruption (“popping the clot”) [4].
• eFAST: Detect ≥ 200 mL of free intraperitoneal fluid within 90 seconds to triage unstable patients directly to the OR [3].

Antifibrinolytic & Calcium Rescue:
• Draw baseline VBG/ABG (lactate, base deficit, ionized calcium iCa²⁺), CBC, Type & Cross, PT/INR, fibrinogen, and viscoelastic testing (TEG/ROTEM).
• Apply active forced-air warming blanket (Bair Hugger at 43°C) to prevent the lethal triad [1].

• Tranexamic Acid (TXA): 1 g IV in 100 mL 0.9% NaCl infused over 10 minutes (must be given within ≤ 3 hours of injury), followed by 1 g IV over 8 hours (125 mg/hr) [5].
• Calcium Chloride 10%: 1 g (10 mL) (= 13.6 mEq elemental Ca²⁺) IV slow push over 3–5 min via central/large line (or Calcium Gluconate 10% 3 g / 30 mL via peripheral IV) [1].

• TXA: Competitively blocks lysine-binding sites on plasminogen, preventing plasmin-mediated degradation of fibrin polymers [5].
• Calcium: Reverses citrate toxicity from banked PRBC/FFP, restoring Factor IV-dependent coagulation steps and myocardial excitation-contraction coupling (target iCa²⁺ > 1.15 mmol/L).

Neurovascular & Open Fracture Assessment:
• Perform portable AP Pelvis and AP Chest radiographs in the resuscitation bay.
• Assess distal pulses, capillary refill, and Ankle-Brachial Index (ABI < 0.90 indicates arterial injury) [6].
• Reduce gross long-bone deformities with inline traction and splint; cover open fractures with sterile saline-soaked gauze [7].

Open Fracture Antibiotic Prophylaxis (≤ 60 min):
• Gustilo Type I/II: Cefazolin 2 g IV over 5 min (3 g if weight ≥ 120 kg) [7].
• Gustilo Type III: Ceftriaxone 2 g IV q24h (or Cefazolin 2 g IV + Gentamicin 5 mg/kg IV) [7,8].
• Fecal/Clostridial Soil: Add Penicillin G 4 million units IV q4h (or Metronidazole 500 mg IV) [7].
• Tetanus: Tdap 0.5 mL IM + TIG 250–500 IU IM (if dirty wound and unknown/< 3 prior doses) [1].

• Immediate Reduction: Unkinks tethered arterial vessels (e.g., popliteal artery in knee dislocation) and reduces soft-tissue tension.
• Early Antibiotics (< 60 min): Achieves bactericidal bone and hematoma tissue concentrations before bacterial glycocalyx biofilm formation occurs on exposed cortical bone [7,8].

Hemodynamic Branching (OR vs. IR vs. REBOA):
• SBP < 90 + eFAST (+): Immediate exploratory laparotomy [1].
• SBP < 90 + eFAST (−) + Unstable Pelvis: Preperitoneal pelvic packing (PPP) in OR, Angioembolization, or Zone 3 REBOA via common femoral artery [2].

Zone 1 vs. Zone 3 REBOA (ER-REBOA Plus 7 Fr):
• Zone 1 (Supraceliacal): Insert to 46 cm (sternal notch landmark) for subdiaphragmatic abdominal exsanguination; inflate with 0.9% NaCl until distal waveform dampens (max occlusion ≤ 30 min).
• Zone 3 (Infrarenal): Insert to 28 cm (xiphoid/umbilicus landmark) for isolated pelvic/junctional hemorrhage (max occlusion ≤ 60 min) [2].

• REBOA: Increases central aortic afterload, augmenting coronary and cerebral perfusion pressures (CPP = DBP − RAP and MAP − ICP) while arresting distal arterial inflow to the shattered mesentery, solid organs, or internal iliac branches [2].