A 45-year-old man is brought to the emergency department after a heavy concrete pipe rolled over his lower torso at a construction site. On arrival, his airway is patent, and breath sounds are equal bilaterally. His blood pressure is 78/45 mmHg and his pulse is 132/min. There is no visible external hemorrhage. Physical examination reveals ecchymosis over the perineum and severe instability of the pelvic ring upon gentle lateral compression. A focused assessment with sonography for trauma (FAST) examination reveals no intraperitoneal free fluid. Which of the following is the most appropriate next step in management?
- Application of a circumferential pelvic binderAnswer
- BComputed tomography (CT) scan of the abdomen and pelvis
- CExploratory laparotomy
- DIntravenous administration of broad-spectrum antibiotics
- EDiagnostic peritoneal lavage (DPL)
Answer
Application of a circumferential pelvic binder
The correct answer is the application of a circumferential pelvic binder. This patient presents with class III/IV hemorrhagic shock (hypotension, marked tachycardia) and signs of an unstable pelvic ring fracture following a crush injury. In the setting of blunt trauma, a negative focused assessment with sonography for trauma (FAST) examination indicates that there is no significant intraperitoneal free fluid. Therefore, the source of bleeding is most likely retroperitoneal, arising directly from the fractured cancellous bone and the disrupted presacral venous plexus. The immediate priority in managing a hemodynamically unstable patient with a pelvic fracture is mechanical stabilization. A circumferential pelvic binder (or a firmly wrapped sheet centered over the greater trochanters) reduces the internal volume of the pelvis. This volume reduction promotes the tamponade of venous bleeding and prevents the disruption of early hemostatic clots by limiting bone motion, effectively addressing the 'Circulation' component of the Advanced Trauma Life Support (ATLS) protocol.
Step-by-Step Solution
Key Concept
Mechanical stabilization with a pelvic binder is the initial management step for hemodynamically unstable patients with unstable pelvic ring fractures.