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Difficulty: MediumTrauma and Burns

A 41-year-old man is brought to the emergency department after a motorcycle collision. He is unresponsive but opens his eyes to painful stimuli. Vital signs are temperature 36.2∘C36.2^\circ\text{C}, blood pressure 78/48 mm Hg78/48 \text{ mm Hg}, heart rate 132/min132/\text{min}, and respiratory rate 24/min24/\text{min}. The airway is patent, and breath sounds are equal bilaterally. A properly positioned pelvic binder was placed by emergency medical services. Extended focused assessment with sonography for trauma (eFAST) demonstrates no intraperitoneal fluid and no pericardial effusion. There is normal lung sliding bilaterally. An anteroposterior pelvic radiograph reveals a severe diastasis of the pubic symphysis and a right sacroiliac joint disruption. After receiving 1 L1\text{ L} of warmed intravenous crystalloids and 2 units2\text{ units} of uncrossmatched type O-negative blood, the patient's blood pressure is 82/50 mm Hg82/50 \text{ mm Hg} and heart rate is 128/min128/\text{min}. Which of the following is the most appropriate next step in management?

  1. A
    Computed tomography of the abdomen and pelvis
  2. B
    Diagnostic peritoneal lavage
  3. C
    Exploratory laparotomy
  4. Pelvic angiographyAnswer
  5. E
    Retrograde urethrography

Answer

Pelvic angiography
The patient has a hemodynamically unstable pelvic fracture with a negative eFAST, indicating that the source of his hemorrhagic shock is the retroperitoneum. In a patient who remains hypotensive despite volume resuscitation and application of a pelvic binder, the next most appropriate step is pelvic angiography with embolization to achieve hemostasis.

Step-by-Step Solution

1
Identify the patient's hemodynamic status
The patient is in hemorrhagic shock, evidenced by hypotension and tachycardia that are unresponsive to initial fluid and blood resuscitation.
Determining hemodynamic stability dictates the trauma algorithm pathway.
2
Localize the source of bleeding
The eFAST is negative, ruling out massive intraperitoneal and pericardial hemorrhage.
Identifying the hemorrhage source is critical before proceeding to definitive management.
3
Recognize the significance of the pelvic fracture
The radiograph shows an 'open book' fracture, indicating massive retroperitoneal bleeding.
Pelvic ring disruptions often cause severe hemorrhage from the venous plexus and internal iliac arterial branches.
4
Determine the definitive management
The patient requires pelvic angiography for embolization.
In unstable patients with a pelvic source of bleeding and a negative FAST, immediate hemostasis via angiography or preperitoneal packing is indicated.

Key Concept

Management of hemodynamically unstable patients with a pelvic fracture and a negative FAST examination requires pelvic angiography with embolization or preperitoneal pelvic packing.
Estimated Time:1m 15s
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Topics

Trauma and Burns

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