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Difficulty: HardTrauma and Burns

A 35-year-old male is brought to the emergency department after a high-speed motorcycle collision. He complains of severe lower abdominal and pelvic pain.

Vital signs on arrival are:
Temperature: 36.5∘C36.5^\circ\text{C} (97.7∘F97.7^\circ\text{F})
Blood pressure: 76/40 mmHg76/40\text{ mmHg}
Heart rate: 135/min135/\text{min}
Respiratory rate: 24/min24/\text{min}
Oxygen saturation: 96%96\% on room air

The primary survey reveals a clear airway and bilaterally equal breath sounds. The abdomen is soft and non-distended without guarding or rebound tenderness. Emergency medical services placed a commercial pelvic binder prior to arrival. A portable anteroposterior pelvic radiograph reveals an "open-book" pelvic fracture with a 4 cm4\text{ cm} diastasis of the pubic symphysis.

A FAST (Focused Assessment with Sonography for Trauma) examination demonstrates no free fluid in the pericardial, perisplenic, perihepatic, or pelvic views.

Two large-bore intravenous lines are established, and he receives 1 L1\text{ L} of warmed lactated Ringer solution and 1 unit1\text{ unit} of uncrossmatched type O-negative blood. A repeat blood pressure is 82/45 mmHg82/45\text{ mmHg} with a heart rate of 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
    Exploratory laparotomy
  3. Pelvic angiographyAnswer
  4. D
    Diagnostic peritoneal lavage
  5. E
    Retrograde cystourethrography

Answer

Pelvic angiography
This patient is in hemorrhagic shock following blunt trauma, with an 'open-book' pelvic fracture. The initial management for a hemodynamically unstable patient with a mechanically unstable pelvic fracture is the application of a pelvic binder to reduce pelvic volume and promote tamponade of venous bleeding. Despite the binder and initial fluid and blood resuscitation, the patient remains hypotensive. The FAST exam is negative, which essentially rules out massive intra-abdominal hemorrhage as the primary cause of shock. Therefore, the ongoing hemorrhage is originating from the retroperitoneal pelvic venous plexus or pelvic arterial branches. The most appropriate next step in management for a hemodynamically unstable patient with a pelvic fracture and a negative FAST is pelvic angiography with embolization (or preperitoneal pelvic packing) to definitively control the retroperitoneal hemorrhage.

Step-by-Step Solution

1
Assess hemodynamic status and primary survey findings.
The patient is in persistent hemorrhagic shock (hypotension, tachycardia) following blunt trauma despite initial fluid and blood resuscitation.
Determines the urgency of intervention and categorizes the patient into the unstable trauma treatment algorithm.
2
Evaluate the results of the FAST examination in the context of known injuries.
The FAST is negative, effectively ruling out massive intraperitoneal or pericardial hemorrhage as the cause of shock.
Differentiates between intra-abdominal bleeding (which would require laparotomy) and retroperitoneal bleeding (which requires angiography or packing).
3
Identify the remaining source of hemorrhage and select the definitive intervention.
With a negative FAST and an unstable pelvic fracture despite a previously applied binder, the bleeding is retroperitoneal. Pelvic angiography is selected.
Angiography allows for the rapid identification and embolization of actively bleeding pelvic arterial branches, achieving definitive hemorrhage control.

Key Concept

In hemodynamically unstable patients with pelvic fractures and a negative FAST exam, the source of bleeding is retroperitoneal; the appropriate next step is pelvic angiography with embolization or preperitoneal pelvic packing.
Estimated Time:1m 30s
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Topics

Trauma and Burns

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