Examkin

Question

Difficulty: MediumTrauma and Burns

A 38-year-old male motorcyclist is brought to the emergency department after colliding with a guardrail. On presentation, he is awake but groggy. His temperature is 36.2°C (97.1°F), blood pressure is 78/45 mm Hg, pulse is 132/min, and respirations are 22/min. Oxygen saturation is 97% on a nonrebreather mask. Airway is patent. Breath sounds are equal bilaterally, and the trachea is midline. The abdomen is soft and non-distended without guarding. There is a scrotal hematoma, and blood is noted at the urethral meatus. Anteroposterior compression of the iliac crests reveals mechanical instability. Intravenous access is established, and a 1-liter bolus of warmed lactated Ringer solution is rapidly infused, but the blood pressure remains 80/48 mm Hg. A bedside focused assessment with sonography for trauma (FAST) demonstrates no free intraperitoneal or pericardial fluid. A pelvic binder is immediately applied. Which of the following is the most appropriate next step in management?

  1. Pelvic angiographyAnswer
  2. B
    Computed tomography of the abdomen and pelvis
  3. C
    Exploratory laparotomy
  4. D
    Retrograde urethrography
  5. E
    Transurethral placement of a Foley catheter

Answer

Pelvic angiography
The patient is experiencing hemorrhagic shock due to a pelvic fracture. The FAST exam is negative, indicating no significant intraperitoneal bleeding. Therefore, the source of blood loss is presumed to be retroperitoneal from the disrupted pelvic ring and its associated venous or arterial plexus. After applying a pelvic binder, the most appropriate next step in managing a hemodynamically unstable patient with a retroperitoneal pelvic hemorrhage is pelvic angiography to identify and embolize bleeding vessels. Preperitoneal pelvic packing is an acceptable alternative depending on institutional resources.

Step-by-Step Solution

1
Identify the patient's hemodynamic status and response to initial resuscitation.
The patient is in hemorrhagic shock (hypotension, tachycardia) and is a nonresponder to the initial fluid bolus.
Determining hemodynamic stability dictates whether the patient proceeds to definitive diagnostic imaging or requires immediate hemorrhage control.
2
Locate the primary source of life-threatening bleeding.
The FAST exam is negative, ruling out massive intraperitoneal hemorrhage. Mechanical instability of the pelvis indicates a pelvic fracture.
A mechanically unstable pelvis combined with a negative FAST strongly suggests that the life-threatening bleeding is located in the retroperitoneal space.
3
Determine the next priority in the ATLS protocol for a hemodynamically unstable pelvic fracture.
Following application of a pelvic binder, the most appropriate next step is pelvic angiography with embolization.
Since the bleeding is retroperitoneal, pelvic angiography (or preperitoneal packing) is required to identify and arrest the arterial hemorrhage.
4
Evaluate and defer management of secondary injuries.
Signs of urethral injury (blood at the meatus, scrotal hematoma) are noted but diagnostic evaluation is delayed.
Hemorrhage control takes precedence over the urologic evaluation in an unstable trauma patient. Blind Foley insertion is contraindicated.

Key Concept

Management of hemodynamically unstable pelvic fractures
Rate this question

Topics

Trauma and Burns

More questions from this topic