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Difficulty: HardTrauma and Burns

A 34-year-old male construction worker is brought to the emergency department via ambulance after being crushed by a heavy concrete pipe. On arrival, he is confused and agitated. His temperature is 36.5°C (97.7°F), blood pressure is 78/40 mm Hg, pulse is 135/min, and respirations are 24/min. Pulse oximetry shows 96% on room air. Primary survey reveals a patent airway and equal breath sounds bilaterally. Heart sounds are rapid but normal in intensity. The abdomen is soft, nondistended, and without guarding. The pelvis is mechanically unstable to gentle lateral compression. A prominent scrotal hematoma and blood at the urethral meatus are noted. Intravenous access is established, a pelvic binder is applied, and a massive transfusion protocol with uncrossmatched blood products in a 1:1:11:1:1 ratio is initiated. Ten minutes later, his blood pressure is 80/42 mm Hg and pulse is 132/min. A focused assessment with sonography for trauma (FAST) exam demonstrates no fluid in the pericardial sac, hepatorenal recess, splenorenal recess, or rectovesical pouch. Anteroposterior chest radiograph is unremarkable. Which of the following is the most appropriate next step in management?

  1. A
    Computed tomography angiography of the abdomen and pelvis
  2. B
    Diagnostic peritoneal lavage
  3. C
    Exploratory laparotomy
  4. Pelvic angiography with embolizationAnswer
  5. E
    Retrograde urethrography

Answer

Pelvic angiography with embolization
The correct answer identifies that the patient is suffering from life-threatening retroperitoneal hemorrhage due to a pelvic fracture. The absence of fluid on the FAST exam and normal chest imaging means the bleeding is not in the chest or abdominal cavity. According to standard trauma protocols, a hemodynamically unstable patient with a pelvic fracture and a negative FAST must undergo immediate pelvic angiography with embolization (or preperitoneal pelvic packing) to stop the arterial bleeding.

Step-by-Step Solution

1
Evaluate the patient's hemodynamic status.
The patient remains in hemorrhagic shock (BP 80/42 mm Hg, HR 132/min) despite the application of a pelvic binder and initiation of massive transfusion protocol.
Hemodynamic instability dictates that the patient cannot undergo time-consuming diagnostic imaging like CT scans and requires immediate intervention.
2
Analyze the FAST exam and chest radiograph results.
FAST is completely negative and chest radiograph is normal.
This effectively rules out major intrathoracic, pericardial, and intraperitoneal hemorrhage as the primary causes of the patient's profound shock.
3
Identify the primary source of blood loss.
The bleeding source is localized to the retroperitoneum, secondary to the mechanically unstable pelvic fracture.
Pelvic fractures cause massive retroperitoneal bleeding from the presacral venous plexus and internal iliac arterial branches.
4
Determine the definitive management step.
Pelvic angiography with embolization (or preperitoneal pelvic packing) is indicated.
According to ATLS guidelines, unstable patients with pelvic fractures and negative FAST exams require emergent pelvic angiography or packing to halt retroperitoneal bleeding.

Key Concept

In a hemodynamically unstable patient with a pelvic ring fracture and a negative FAST exam, the next best step is pelvic angiography with embolization or preperitoneal pelvic packing to control retroperitoneal hemorrhage.
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Topics

Trauma and Burns

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