I report the case of a 55-year-old pedestrian woman who was transferred to our emergency department by the prehospital care team after being hit by a car in a zebra crossing, with the diagnosis of polytrauma.

As medical records she suffered from paroxistic atrial fibrillation, mitral insufficiency, poliomyelitis sequala in the right inferior limb, and was under Ribaroxaban and Flecainide. She had previously signed and advance healthcare directive document refusing blood transfusion as the patient is Jehovah´s witness.

Upon arrival at the hospital emergency she was treated in the shock room and the initial assessment scheme can summarize as follows:

A: Intubated, cervical collar.

B: Symmetric and preserved vesicular murmur, symmetric mobilization of both hemithorax, no wounds or bruises or other lesions, 100% saturation with supplemental oxygen.

C: Electrocardiogram shows paroxistic atrial fibrillation, blood pressure 110/50 and 115 beats per minute.

D: Unconscious, Glasgow 3/15, arreactive pupils.

E: Abdomen: Soft, compressible, no signs of peritoneal irritation. Carrier of a pelvic binder. Impress of pelvic fracture and bilateral tibial fractures. Distal pulses preserved.

In the blood test we found hemoglobin 12.1g/dl, pH 7,29, pCO2 46 and lactate 1,5 milimoles/L.

ECO-FAST is obtained which is negative and simple thorax and pelvis anteroposterior X-rays.

The patient was resuscitated as per the advance trauma life support (ATLS) protocol in the emergency room without using blood derivates.

CT scan investigation showed a left lateral and floor orbital wall fracture, left lateral maxillary sinus wall fracture, spleen laceration grade 2, right adrenal contusion, left retroperitoneal hematoma, pelvic paravesical hematoma and B3 pelvic fracture (Video 1).

Inferior limbs X-rays showed tibial and peroneal fractures. In the right tibia there were seven cortical screws owing to a previous surgery (Figure 1).

The Injury Severity Score of this patient was 29 points and we considered her as borderline, deciding to apply the damage control management. The patient was transfer to the operating theater and a supraacetabular external fixator was applied to the pelvis, left tibia was fixed using a circular external fixator with hydroxyapatite pins and a splint immobilization was applied in order con maintained the right tibia alignment (Video 2).

The day after admission we started treatment with intravenous iron in combination with subcutaneous erythropoietin. Prophylaxis with low molecular weight heparin was initiated 48 hours after the admission.

Owing to the residual symphysis incongruence we decided to do open reduction and internal fixation of the pelvic fracture (Video 3). In this case we should respect as much as possible the risk of bleeding so we were forced to adapt our surgical planning to this circumstance.

3 weeks after the initial trauma, once the hemoglobin levels were recovered, we performed the osteosynthesis thru percutaneous and a Pfannenstiel approach (Video 4).

Blood sample tests are graphically summarized (Figure 2).

In the follow up, 6 weeks after the initial trauma the left tibial alignment was not maintained, thus (Figure 3), as the hemoglobin levels were optimal, we removed the circular external fixator, we placed the tibia in a splint for 1 week and, once the pins entrances were healed,  we fixed the fracture with a reamed tibial nail using a suprapatellar approach (Video 5).

All the fractures were clinically and radiographically healed within the 6 months and no blood transfusions were required following the autonomy right written down the living will of the patient (Figure 4). The patient recovered the autonomy level previous to the knocking down car accident and didn´t require any pain treatment.