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Difficulty: MediumTrauma and Burns

Emergency medical services bring a 32-year-old male warehouse worker to the trauma center 30 minutes after he was pinned between a forklift and a concrete loading dock. He is awake, diaphoretic, and complains of agonizing pain in his hips and lower back.

Vital signs on arrival are temperature 36.8°C (98.2°F), blood pressure 76/40 mmHg, heart rate 138/min, and respiratory rate 24/min. The airway is patent, and breath sounds are equal bilaterally. The trachea is midline. Two large-bore intravenous catheters are placed, and 1 L of warmed lactated Ringer solution is administered rapidly. Following fluid resuscitation, his blood pressure remains 74/42 mmHg.

Physical examination reveals a rapidly expanding scrotal hematoma and a small amount of blood at the urethral meatus. Gentle anteroposterior compression of the iliac crests demonstrates gross mechanical instability, and a pelvic binder is immediately applied.

A bedside focused assessment with sonography for trauma (FAST) demonstrates no free fluid in the pericardial, pleural, or peritoneal cavities. A portable chest radiograph is normal. A portable anteroposterior pelvic radiograph confirms a 4-cm diastasis of the pubic symphysis and disruption of the left sacroiliac joint.

Which of the following is the most appropriate next step in management?

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

Answer

Pelvic angiography
The correct answer is pelvic angiography. This patient presents with hemorrhagic shock secondary to a severe crush injury. A pelvic binder was appropriately placed for the mechanically unstable pelvic fracture (open-book fracture). In the setting of ongoing hemodynamic instability despite fluid resuscitation, a negative FAST exam indicates that the life-threatening hemorrhage is located in the retroperitoneal space (typically from the presacral venous plexus or internal iliac artery branches), rather than the intraperitoneal cavity. The standard of care for identifying and stopping retroperitoneal hemorrhage from a pelvic fracture is pelvic angiography with embolization (or alternatively, surgical preperitoneal packing).

Step-by-Step Solution

1
Identify the primary physiological derangement.
The patient is in hemorrhagic shock (severe hypotension, tachycardia) and is a non-responder to initial crystalloid resuscitation.
Establishing the severity and trajectory of shock dictates the urgency of intervention.
2
Synthesize the bedside diagnostic findings.
The FAST is negative (ruling out major intraperitoneal bleeding), but the pelvic radiograph shows a mechanically unstable open-book fracture.
A negative FAST in a hypotensive pelvic fracture patient localizes the life-threatening hemorrhage to the retroperitoneum.
3
Determine the definitive therapeutic intervention based on the bleeding location.
Select pelvic angiography (or preperitoneal packing).
Retroperitoneal venous or arterial bleeding from a pelvic fracture cannot be controlled via a standard laparotomy and requires angiographic embolization or mechanical packing.

Key Concept

In hemodynamically unstable trauma patients with severe pelvic ring disruptions and a negative FAST exam, the bleeding is presumed to be retroperitoneal. The most appropriate next step is pelvic angiography with embolization or preperitoneal packing.
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Topics

Trauma and Burns

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