A 32-year-old man is brought to the emergency department after a high-speed motor vehicle collision. He reports severe pain in his hips and lower back. Vital signs show a temperature of 37.0°C (98.6°F), blood pressure of 82/50 mmHg, pulse of 134/min, and respiratory rate of 22/min. Physical examination reveals an ecchymotic and unstable pelvis upon gentle anterior-posterior compression. A focused assessment with sonography for trauma (FAST) is negative for free intra-abdominal fluid, and a chest x-ray is clear. There are no obvious external sources of bleeding. Large-bore intravenous access is established, and aggressive fluid resuscitation is initiated. Which of the following is the most appropriate next step in management?
- Application of a pelvic binderAnswer
- BCT scan of the abdomen and pelvis
- CImmediate exploratory laparotomy
- DIntravenous administration of broad-spectrum antibiotics
- EPerform a retrograde urethrogram
Answer
Application of a pelvic binder
This patient is in hemorrhagic shock following blunt trauma. The combination of a negative FAST exam, a clear chest x-ray, no external bleeding, and an unstable pelvis strongly indicates life-threatening retroperitoneal hemorrhage from a pelvic fracture. The most appropriate immediate next step is mechanical stabilization with a pelvic binder (or a firmly tied sheet), which decreases pelvic volume and provides a tamponade effect on the bleeding presacral venous plexus. This is a critical, life-saving maneuver that must be performed before any further diagnostic imaging or secondary surveys.
Step-by-Step Solution
Key Concept
Hemodynamically unstable patients with pelvic fractures and negative FAST exams require immediate application of a pelvic binder to control retroperitoneal hemorrhage.