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Difficulty: HardTrauma and Burns

Paramedics transport a 55-year-old male pedestrian to the trauma center after he was struck by a moving delivery van. He complains of excruciating pain in his lower abdomen and hips. On primary assessment, his airway is patent, and breath sounds are equal bilaterally. His blood pressure is 78/42 mm Hg, and his pulse is 135/min. Physical examination demonstrates marked bruising over the suprapubic region. Gentle lateral compression of the iliac crests reveals a mechanically unstable pelvic ring. A pelvic binder is immediately applied, and 1 liter of intravenous Lactated Ringer's solution is infused rapidly. A bedside ultrasound (FAST) examination reveals an anechoic stripe in the hepatorenal recess. Repeat vital signs show a blood pressure of 82/46 mm Hg and a pulse of 128/min. Which of the following is the most appropriate next step in management?

  1. Exploratory celiotomyAnswer
  2. B
    CT imaging of the abdomen and pelvis
  3. C
    Pelvic angiography with embolization
  4. D
    Diagnostic peritoneal lavage
  5. E
    Retrograde urethrography

Answer

The most appropriate next step is exploratory celiotomy (laparotomy) to address the active intraperitoneal hemorrhage.
This patient presents with hemorrhagic shock due to blunt force trauma, characterized by hypotension and tachycardia that do not normalize after initial fluid resuscitation. He has two major potential sources of blood loss: an unstable pelvic fracture (which typically causes retroperitoneal venous or arterial bleeding) and intraperitoneal injury (evidenced by the positive FAST). According to ATLS guidelines, when a patient with a pelvic fracture is hemodynamically unstable and has a positive FAST, the intra-abdominal source is presumed to be the most immediate life threat. The most appropriate next step is exploratory celiotomy (laparotomy). If the patient remains unstable after intra-abdominal bleeding is controlled, pelvic angiography or preperitoneal packing can then be performed.

Step-by-Step Solution

1
Assess the patient's hemodynamic status following initial resuscitation.
The patient remains hemodynamically unstable with a blood pressure of 82/46 mm Hg and a pulse of 128/min after receiving intravenous fluids.
Hemodynamic instability dictates the treatment algorithm, separating patients who can safely undergo imaging from those who require immediate intervention.
2
Evaluate the source of hemorrhagic shock using physical exam and bedside ultrasound.
The patient has two potential sources of major bleeding: a mechanically unstable pelvic fracture (retroperitoneal) and a positive FAST exam (intraperitoneal).
Identifying the primary compartment of bleeding determines which specialist and intervention is required first.
3
Apply the Advanced Trauma Life Support (ATLS) algorithm for multiple sources of hemorrhage.
The correct priority is to address the intraperitoneal bleeding via exploratory celiotomy.
In the setting of a pelvic fracture and hemodynamic instability, a positive FAST indicates that intraperitoneal hemorrhage is a major contributor to the patient's shock and must be surgically controlled before addressing the pelvic bleeding with angiography or preperitoneal packing.

Key Concept

In an unstable patient with a pelvic fracture, a positive FAST exam mandates immediate exploratory laparotomy (celiotomy) to control intraperitoneal hemorrhage before addressing the retroperitoneal pelvic bleeding.
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Topics

Trauma and Burns

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