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Difficulty: HardTrauma and Burns

A 48-year-old construction worker arrives at the emergency department via helicopter after being crushed by a steel beam across his hips. He is confused, pale, and diaphoretic. Vital signs demonstrate a heart rate of 138/min and a blood pressure of 72/40 mm Hg. His airway is patent and lungs are clear to auscultation bilaterally. Emergency medical personnel placed a circumferential pelvic sheet prior to transport. On evaluation, his abdomen is non-distended and soft to palpation. Inspection of the perineum reveals a scrotal hematoma and blood at the urethral meatus. Point-of-care ultrasound of the abdomen and pericardium shows no abnormal fluid collections. A portable chest radiograph is normal. Anteroposterior pelvic radiograph reveals an open-book pubic symphysis diastasis and a right sacroiliac joint disruption. Despite the rapid infusion of 2 units of uncrossmatched packed red blood cells, his blood pressure remains 75/42 mm Hg. Which of the following is the most appropriate next step in management?

  1. Pelvic angiography with embolizationAnswer
  2. B
    Intravenous contrast-enhanced computed tomography of the pelvis
  3. C
    Emergent exploratory laparotomy
  4. D
    Retrograde urethrography
  5. E
    Diagnostic peritoneal lavage

Answer

Pelvic angiography with embolization
This patient has an unstable pelvic fracture and remains in hemorrhagic shock despite blood resuscitation. A negative FAST exam and a soft abdomen indicate that the source of bleeding is not intraperitoneal, but rather retroperitoneal (typically from the presacral venous plexus or branches of the internal iliac artery). For hemodynamically unstable patients with pelvic fractures and negative intraperitoneal evaluations, the next most appropriate step is pelvic angiography with embolization (or preperitoneal pelvic packing) to achieve definitive hemostasis. The previously placed pelvic binder provides temporary mechanical stabilization and helps reduce pelvic volume, but active bleeding must still be stopped.

Step-by-Step Solution

1
Identify the patient's primary life-threatening condition.
The patient is in hemorrhagic shock (blood pressure 75/42 mm Hg) despite ongoing fluid and blood resuscitation.
According to advanced trauma life support protocols, addressing the cause of hemodynamic instability takes absolute precedence over all other non-life-threatening injuries (such as the suspected urethral injury).
2
Localize the source of the hemorrhage.
Chest radiograph and FAST are negative. The pelvis is fractured (open-book diastasis).
A negative FAST in a hypotensive patient with an unstable pelvic fracture indicates that the bleeding is retroperitoneal rather than intraperitoneal.
3
Determine the definitive management for retroperitoneal pelvic hemorrhage.
Pelvic angiography with embolization is indicated.
This intervention directly addresses arterial bleeding in the pelvic retroperitoneum without releasing the natural tamponade effect of the intact peritoneum.

Key Concept

In a hemodynamically unstable patient with an open-book pelvic fracture and a negative FAST exam, the source of bleeding is retroperitoneal. The next best step is pelvic angiography with embolization (or preperitoneal pelvic packing). Investigation of suspected urethral injuries must be delayed until hemodynamic stability is achieved.

Alternative Method

Preperitoneal pelvic packing is an equally valid alternative to angiography for definitive hemorrhage control in this scenario, depending on institutional resources and the immediate availability of an interventional radiologist.
Estimated Time:1m 15s
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Topics

Trauma and Burns

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