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Difficulty: MediumTrauma and Burns

A 27-year-old male pedestrian is brought to the emergency department after being struck by a motor vehicle. He complains of severe pelvic and lower abdominal pain. On arrival, his temperature is 36.8∘C36.8^\circ\text{C} (98.2∘F98.2^\circ\text{F}), blood pressure is 80/50 mmHg, heart rate is 132/min, and respiratory rate is 22/min. Oxygen saturation is 98% on room air. The patient's airway is patent, and breath sounds are equal bilaterally. A focused assessment with sonography for trauma (FAST) exam is negative for intraperitoneal fluid. Chest radiography reveals no abnormalities. Pelvic radiography demonstrates widening of the pubic symphysis and sacroiliac joints. An external pelvic binder is applied, and an institutional massive transfusion protocol is initiated. Reassessment 15 minutes later shows a blood pressure of 82/52 mmHg and a heart rate of 128/min. Which of the following is the most appropriate next step in management?

  1. A
    Computed tomography of the abdomen and pelvis with intravenous contrast
  2. Pelvic angiography with embolizationAnswer
  3. C
    Exploratory laparotomy
  4. D
    Diagnostic peritoneal lavage
  5. E
    Intravenous administration of norepinephrine

Answer

Pelvic angiography with embolization is the most appropriate next step in management.
The correct answer is pelvic angiography with embolization. This patient presents with hemorrhagic shock secondary to an open-book pelvic fracture. In pelvic trauma, life-threatening hemorrhage typically originates from the presacral venous plexus or branches of the internal iliac artery. Initial management requires mechanical stabilization with a pelvic binder to reduce pelvic volume and promote tamponade, alongside blood product resuscitation. If the patient remains hemodynamically unstable and the FAST exam is negative (ruling out major intraperitoneal bleeding), the next most appropriate step is definitive hemorrhage control. This is achieved via pelvic angiography with embolization (or alternatively, preperitoneal pelvic packing), which specifically targets the retroperitoneal arterial bleeding source without disrupting the protective retroperitoneal tamponade effect.

Step-by-Step Solution

1
Assess the patient's hemodynamic status and primary survey.
The patient is in hemorrhagic shock (BP 80/50 mmHg, HR 132/min) with a patent airway and normal breathing.
Identifying hemodynamic instability dictates whether the diagnostic pathway leans toward immediate operative intervention versus advanced imaging.
2
Evaluate the potential sources of hemorrhage based on initial bedside adjuncts.
FAST is negative (no intraperitoneal fluid), and chest x-ray is clear, but pelvic x-ray shows an open-book fracture.
This effectively isolates the pelvis and retroperitoneum as the primary source of life-threatening bleeding.
3
Determine the next step after initial stabilization efforts (pelvic binder and massive transfusion) have proven insufficient.
The patient remains hemodynamically unstable, requiring definitive hemorrhage control via pelvic angiography with embolization or preperitoneal packing.
A negative FAST precludes exploratory laparotomy, and persistent hemodynamic instability absolutely precludes a CT scan.

Key Concept

Management algorithm for pelvic trauma with persistent hemodynamic instability
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Topics

Trauma and Burns

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