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Difficulty: HardTrauma and Burns

A 48-year-old male construction worker is brought to the emergency department after being crushed between a concrete barrier and a moving vehicle at the level of his hips. On arrival, he is pale, diaphoretic, and confused. Vital signs are blood pressure 75/40 mm Hg, heart rate 138/min, and respiratory rate 24/min. The airway is patent, and breath sounds are clear and equal bilaterally. A portable chest radiograph shows no abnormalities. The abdomen is soft, non-distended, and mildly tender to deep palpation. Anteroposterior compression of the pelvis reveals severe mechanical instability, and a pelvic binder is immediately applied in the trauma bay. A focused assessment with sonography for trauma (FAST) exam demonstrates no anechoic free fluid in the pericardium, hepatorenal recess, splenorenal recess, or retrovesical space. The patient receives 2 units of uncrossmatched type O-negative packed red blood cells and 1 L of isotonic crystalloid. Reassessment reveals a blood pressure of 78/42 mm Hg and a heart rate of 135/min. Which of the following is the most appropriate next step in management?

  1. Pelvic angiographyAnswer
  2. B
    Computed tomography of the abdomen and pelvis
  3. C
    Immediate exploratory laparotomy
  4. D
    Diagnostic peritoneal lavage
  5. E
    Deferral of invasive interventions until next-of-kin provides informed consent

Answer

The correct step is to proceed with pelvic angiography (or preperitoneal pelvic packing) to control the retroperitoneal arterial hemorrhage.
The correct management for this patient is pelvic angiography (or preperitoneal pelvic packing). This patient is in profound hemorrhagic shock following a crush injury. The physical examination confirms an unstable pelvic ring, which is a major source of blood loss via the presacral venous plexus and internal iliac arterial branches. The initial management of an unstable pelvic fracture includes mechanical stabilization with a pelvic binder to reduce pelvic volume and promote tamponade, alongside aggressive blood product resuscitation. Because the patient remains hemodynamically unstable despite these measures, definitive hemorrhage control is required. Crucially, the FAST exam is negative, which effectively rules out massive intraperitoneal hemorrhage. In this algorithmic scenario (Hemodynamically Unstable + Unstable Pelvis + Negative FAST), the bleeding is assumed to be retroperitoneal. The standard of care is immediate pelvic angiography with embolization to control arterial bleeding. Preperitoneal pelvic packing is an accepted alternative, particularly in centers without immediate interventional radiology capabilities.

Step-by-Step Solution

1
Assess the patient's hemodynamic status and injury mechanism.
The patient is in hemorrhagic shock (hypotension, marked tachycardia) following a severe crush injury to the pelvis.
Identifying shock dictates the urgency of the trauma algorithm and precludes time-consuming diagnostic tests like CT scans.
2
Integrate the physical exam and initial diagnostic findings.
The patient has a mechanically unstable pelvis (indicating pelvic fracture) and a definitively negative FAST exam.
A negative FAST in the setting of severe shock points away from intraperitoneal hemorrhage and toward extraperitoneal (retroperitoneal) bleeding associated with the pelvic ring disruption.
3
Determine the algorithmic next step for a hemodynamically unstable pelvic fracture.
After the initial mechanical stabilization with a pelvic binder, the patient remains unstable, requiring definitive control of the retroperitoneal bleeding.
According to ATLS protocols, an unstable pelvic fracture with a negative FAST requires pelvic angiography with embolization or preperitoneal pelvic packing to halt ongoing arterial blood loss.

Key Concept

Management algorithm for hemodynamically unstable pelvic fractures
Estimated Time:1m 30s
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Topics

Trauma and Burns

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