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Difficulty: HardTrauma and Burns

A 52-year-old woman is evaluated in the emergency department after a severe motor vehicle collision. She was the restrained driver of a vehicle that struck a concrete retaining wall at highway speeds. Upon arrival, she is lethargic but her airway is patent. She appears pale and diaphoretic. Vital signs are a temperature of 36.6°C (97.9°F), a pulse of 135/min, a blood pressure of 78/48 mmHg, and a respiratory rate of 28/min. Oxygen saturation is 96% on supplemental oxygen.

Breath sounds are clear and equal bilaterally, and the trachea is midline. Heart sounds are normal. The abdomen is soft, nondistended, and mildly tender to deep palpation in the lower quadrants. There is marked ecchymosis over the suprapubic region. Anteroposterior pelvic radiography performed in the trauma bay demonstrates a symphyseal diastasis of 4 cm4 \text{ cm} and a displaced fracture of the left sacroiliac joint. A pelvic binder is immediately applied, and she receives rapid intravenous transfusion of uncrossmatched blood products and crystalloid.

Following initial resuscitation, her blood pressure is 82/50 mmHg and pulse is 128/min. A bedside focused assessment with sonography for trauma (FAST) exam demonstrates no pericardial effusion and no intraperitoneal free fluid.

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. D
    Retrograde cystourethrography
  5. Pelvic angiographyAnswer

Answer

Pelvic angiography
The correct answer is pelvic angiography. This patient has sustained high-energy blunt trauma and remains hemodynamically unstable despite initial resuscitation, including the application of a pelvic binder. The FAST exam is negative, which effectively rules out significant intraperitoneal or pericardial bleeding as the cause of her shock. In the setting of an unstable pelvic fracture with persistent hemorrhagic shock and no evidence of intraperitoneal bleeding, the hemorrhage is located in the retroperitoneum. The most appropriate next step to control retroperitoneal arterial bleeding is pelvic angiography with embolization (or preperitoneal pelvic packing). Opening the abdomen (exploratory laparotomy) is contraindicated in this specific scenario because it would release the tamponading effect of the intact retroperitoneum and exacerbate the bleeding.

Step-by-Step Solution

1
Identify the patient's hemodynamic status.
The patient is in hemorrhagic shock (hypotension, marked tachycardia) and remains hemodynamically unstable despite the application of a pelvic binder and initial fluid/blood resuscitation.
Hemodynamic instability dictates the trauma treatment algorithm, precluding time-consuming diagnostic tests like CT scans.
2
Evaluate the source of bleeding based on the primary survey and bedside adjuncts.
The FAST exam is negative, ruling out massive intraperitoneal or pericardial hemorrhage. Chest auscultation is normal, reducing the likelihood of massive hemothorax.
A negative FAST in an unstable patient indicates that the abdomen is not the primary source of life-threatening bleeding.
3
Correlate the physical findings and imaging with the ongoing shock.
The patient has an 'open book' pelvic fracture (symphyseal diastasis and SI joint disruption), which can cause massive retroperitoneal hemorrhage from the presacral venous plexus or internal iliac arterial branches.
Pelvic fractures are a major source of hidden, extra-abdominal blood loss.
4
Determine the definitive intervention.
Since mechanical stabilization (pelvic binder) has failed to restore hemodynamic stability, pelvic angiography with embolization (or preperitoneal packing) is required.
Angiography is the standard next step to identify and occlude bleeding pelvic arteries when mechanical stabilization is insufficient.

Key Concept

In a hemodynamically unstable blunt trauma patient with a pelvic fracture and a negative FAST exam, the next appropriate step for persistent hemorrhagic shock after applying a pelvic binder is pelvic angiography with embolization or preperitoneal pelvic packing.
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Topics

Trauma and Burns

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