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Difficulty: HardOrthopedic Surgery

A 65-year-old man with a history of congestive heart failure is brought to the emergency department via ambulance after being involved in a high-speed motor vehicle collision. He was an unrestrained driver and required a prolonged extrication from the vehicle. Upon arrival, he is lethargic and confused. Vital signs show a heart rate of 142/min, blood pressure of 72/40 mmHg, and a respiratory rate of 28/min. The airway is patent, and breath sounds are clear and equal bilaterally. A Focused Assessment with Sonography in Trauma (FAST) examination reveals no intraperitoneal free fluid or pericardial effusion. Inspection of the perineum demonstrates severe scrotal ecchymosis and a drop of blood at the urethral meatus. Gentle inward compression of the iliac crests reveals profound mechanical instability of the pelvic ring. Dorsalis pedis pulses are faint bilaterally, and the lower extremities are cool to the touch. Which of the following is the most appropriate next step in management?

  1. A
    Transport to the radiology suite for a computed tomography scan of the abdomen and pelvis
  2. B
    Immediate transfer to the operating room for an exploratory laparotomy
  3. Application of a circumferential pelvic binder at the level of the greater trochantersAnswer
  4. D
    Intravenous administration of furosemide and noninvasive positive pressure ventilation
  5. E
    Delay interventions until a legally appointed healthcare proxy can be located to provide informed consent

Answer

Application of a circumferential pelvic binder at the level of the greater trochanters.
This patient presents with hemorrhagic shock due to an unstable pelvic ring fracture, evidenced by mechanical instability, scrotal ecchymosis, and a negative FAST exam. The majority of bleeding in pelvic fractures originates from the presacral venous plexus. The immediate next best step is noninvasive mechanical stabilization using a circumferential pelvic binder applied at the level of the greater trochanters. This maneuver closes the pelvic ring, reduces the potential volume of the retroperitoneal space, and promotes the tamponade of venous hemorrhage. Once stabilized with a binder, the patient may undergo further resuscitation and potentially pelvic angiography with embolization if arterial bleeding is suspected.

Step-by-Step Solution

1
Assess the patient's hemodynamic status and trauma primary survey.
The patient is in class IV hypovolemic shock (HR 142/min, BP 72/40 mmHg) with a negative FAST exam, effectively ruling out massive intra-abdominal hemorrhage.
Establishing the presence of shock and ruling out the most common cavities for massive hemorrhage directs the search to the retroperitoneum.
2
Analyze the physical exam findings of the pelvis.
Scrotal ecchymosis, blood at the meatus, and profound mechanical instability indicate a major pelvic ring disruption (e.g., an 'open-book' fracture).
These signs confirm that the source of the patient's profound hemorrhagic shock is retroperitoneal bleeding originating from the presacral venous plexus or pelvic arterial injury.
3
Determine the most immediate life-saving intervention.
Apply a circumferential pelvic binder.
A pelvic binder reduces the pelvic volume, creating a tamponade effect on the bleeding retroperitoneal venous plexus, which is the essential first step before considering angiography or preperitoneal packing.

Key Concept

Acute management of hemodynamically unstable pelvic ring fractures involves immediate application of a pelvic binder to tamponade retroperitoneal venous bleeding.
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Topics

Orthopedic Surgery

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