Where rapid, appropriate transfusion fails to control the situation, the commonest cause is continued bleeding. In most cases the site is obvious.
1. External haemorrhage accompanying limb injuries should be readily controlled if this has not already been done.
2. Continuing blood loss from intrathoracic injuries should be obvious. Assuming that a haemothorax has been diagnosed and treated by the insertion of a chest drain, the quantity and rate of loss may be evaluated by monitoring the volumes in the collection bottle(s). This may be used to assess the need for exploration to control persisting haemorrhage.
3. Massive bleeding from within the abdominal cavity usually requires immediate laparotomy, but it is essential to be sure that the bleeding is not from the pelvis. (An unstable fracture of the pelvis and a negative abdominal ultrasound would be a contraindication for laparotomy.)
The commonest causes of intra-abdominal haemorrhage are tearing of the liver, spleen or mesentery, and all are potentially amenable to surgery.
4. Haemorrhage accompanying fractures of the pelvis. This is most common in unstable fractures involving the sacroiliac joints; the bleeding may be from the pelvic plexus of veins or from damage to the iliac arteries. In the first instance, especially if there is little sacroiliac disruption, an external pelvic fixator should be employed, and replacement efforts renewed. If the sacroiliac joint is disrupted and ihe situation fails to resolve, a (posterior) C-clamp should be applied. If circulatory instability persists, then exploration may be needed as a last resort. Diffuse bleeding from the pelvic venous plexus is generally best controlled by packing. On rare occasions selective embolisation or ligature of the iliac arteries may be necessary.
5. Haemorrhage from the urinary tract is seldom very severe, but nevertheless may be a problem. It should be suspected if there is a haematuria or some other indication (such as the presence of a fracture of the pelvis of appropriate pattern). The diagnosis may be clarified by an intravenous pyelogram, a cystogram. or a urethrogram.
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