Following a high-speed motorcycle collision, a male patient in his mid-twenties arrives at… — USMLE Step 2 CK

Following a high-speed motorcycle collision, a male patient in his mid-twenties arrives at the trauma resuscitation bay. He is lethargic and responds only to painful stimuli. Vital signs include a blood pressure of $76/40\text{ mmHg}$ , heart rate of $135/\text{min}$ , respiratory rate of $26/\text{min}$ , and temperature of $36.5^\circ\text{C}$ ( $97.7^\circ\text{F}$ ). Physical assessment reveals profound ecchymosis over the suprapubic and perineal areas, accompanied by visible blood at the urethral meatus. Gentle anteroposterior compression of the iliac crests demonstrates gross mechanical instability of the pelvic ring. A bedside focused assessment with sonography for trauma (FAST) shows no anechoic fluid in the peritoneal spaces. Massive transfusion protocol is initiated via two large-bore peripheral intravenous catheters. Which of the following is the most appropriate next step in the management of this patient?

Application of a circumferential pelvic compression deviceAnswer
B
Transport for computed tomography of the abdomen and pelvis
C
Transfer to the operating room for exploratory laparotomy
D
Pelvic angiography with embolization
E
Performance of a retrograde urethrography

Answer

Application of a circumferential pelvic compression device

The correct answer is application of a circumferential pelvic compression device. This patient presents in severe hemorrhagic shock due to a mechanically unstable pelvic fracture. The major source of bleeding in pelvic fractures is the retroperitoneal venous plexus (up to

90\%

of cases) and cancellous bone surfaces. Because the FAST exam is negative, major intraperitoneal bleeding is ruled out, confirming the retroperitoneum as the likely source. The immediate priority is to reduce the pelvic volume and mechanically stabilize the fracture with a pelvic binder (or a tightly wrapped bedsheet around the greater trochanters). This decreases the pelvic volume, promotes the tamponade effect, and limits further venous hemorrhage.

Step-by-Step Solution

Identify the primary life-threatening condition.

The patient is in class III/IV hemorrhagic shock (hypotension, marked tachycardia) secondary to a mechanically unstable pelvic ring fracture.

Recognizing hemorrhagic shock dictates the immediate prioritization of the trauma ABCDEs (Circulation).

Interpret the FAST exam results in the context of the injury.

The FAST exam is negative, indicating no significant intraperitoneal hemorrhage.

A negative FAST in an unstable patient with a pelvic fracture suggests the primary source of bleeding is the retroperitoneal presacral venous plexus and fractured cancellous bone.

Determine the appropriate intervention for retroperitoneal pelvic bleeding.

Mechanical stabilization using a pelvic binder or sheet is selected.

Reducing the pelvic volume applies direct pressure and tamponades venous retroperitoneal bleeding, serving as a critical bridge to definitive management.

Key Concept

In a hemodynamically unstable patient with a pelvic fracture and a negative FAST exam, the immediate next step in management is mechanical stabilization with a circumferential pelvic compression device to tamponade retroperitoneal venous bleeding.

Estimated Time:1m 15s

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