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Question

Difficulty: MediumTrauma and Burns

A 42-year-old male is transported to the emergency department via helicopter after a high-speed motorcycle collision. Upon arrival, his airway is patent, and breath sounds are vesicular and equal bilaterally. His blood pressure is 75/40 mmHg, and his heart rate is 132/min. The abdomen is soft, non-distended, and without rebound tenderness. Examination of the lower half of the body reveals a shortened and externally rotated right lower extremity, as well as significant ecchymosis over the scrotum and perineum. Gentle palpation of the iliac crests reveals abnormal mobility. A focused assessment with sonography for trauma (FAST) examination demonstrates no free intraperitoneal or pericardial fluid. Intravenous access is established, and administration of uncrossmatched blood is initiated. Which of the following is the most appropriate next step in management?

  1. Application of a noninvasive pelvic binderAnswer
  2. B
    Computed tomography of the abdomen and pelvis
  3. C
    Immediate exploratory laparotomy
  4. D
    Pelvic angiography with embolization
  5. E
    Retrograde urethrography

Answer

Application of a noninvasive pelvic binder
The correct answer is application of a noninvasive pelvic binder. This patient presents with profound hemorrhagic shock (hypotension, marked tachycardia) and physical exam findings highly concerning for an open-book pelvic ring disruption (scrotal/perineal ecchymosis, abnormal mobility of iliac crests). In patients with severe pelvic trauma, the primary source of life-threatening hemorrhage is often the presacral venous plexus or branches of the internal iliac artery. Because the FAST exam is negative, the bleeding is retroperitoneal rather than intraperitoneal. Therefore, the immediate next step in management is mechanical stabilization of the pelvis using a commercial pelvic binder (or a sheet wrapped around the greater trochanters). This critical maneuver reduces pelvic volume, promotes a tamponade effect on venous bleeding, and stabilizes the fracture ends to prevent further hemorrhage.

Step-by-Step Solution

1
Identify the primary physiologic derangement.
The patient is in class III/IV hemorrhagic shock (BP 75/40 mmHg, HR 132/min).
Recognizing shock determines the immediate need for aggressive resuscitation and source control over non-emergent diagnostics.
2
Localize the source of life-threatening hemorrhage.
The bleeding is retroperitoneal, originating from an unstable pelvic fracture (abnormal iliac mobility, perineal ecchymosis, negative FAST).
A negative FAST in the setting of shock and an unstable pelvis points to the presacral venous plexus or internal iliac arteries as the source.
3
Select the immediate intervention for source control.
Application of a pelvic binder.
Mechanical stabilization decreases pelvic volume and creates a tamponade effect to control retroperitoneal venous hemorrhage while preparing for potential definitive procedures.

Key Concept

In a hemodynamically unstable patient with an open-book pelvic fracture and a negative FAST exam, the most appropriate immediate next step after fluid/blood resuscitation is mechanical stabilization with a pelvic binder to tamponade retroperitoneal bleeding.
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Topics

Trauma and Burns

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