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Difficulty: HardOrthopedic Surgery

A 38-year-old man is brought to the emergency department after being struck by a motor vehicle while crossing the street. On arrival, he is confused but protecting his airway. His temperature is 36.5∘C36.5^\circ\text{C}, blood pressure is 78/40 mmHg78/40\text{ mmHg}, pulse is 135/min135/\text{min}, and respiratory rate is 26/min26/\text{min}. Oxygen saturation is 96%96\% on room air. Primary survey reveals equal and bilateral breath sounds. The abdomen is soft and non-distended. Examination of the pelvis reveals gross instability to anteroposterior compression. There is a large scrotal hematoma and a prominent drop of blood at the urethral meatus. An extended focused assessment with sonography for trauma (E-FAST) reveals no free fluid in the pericardial, pleural, or peritoneal spaces. A pelvic binder is immediately applied, and the patient is resuscitated with 2 liters of isotonic crystalloid and 2 units of uncrossmatched type O-negative packed red blood cells. Re-evaluation 15 minutes later shows a blood pressure of 82/45 mmHg82/45\text{ mmHg} and a pulse of 130/min130/\text{min}. Which of the following is the most appropriate next step in management?

  1. Pelvic angiography with embolizationAnswer
  2. B
    CT scan of the abdomen and pelvis with intravenous contrast
  3. C
    Immediate exploratory laparotomy
  4. D
    Retrograde urethrography
  5. E
    Placement of a transurethral Foley catheter

Answer

Pelvic angiography with embolization is the correct immediate intervention to control ongoing retroperitoneal hemorrhage in a hemodynamically unstable patient with a pelvic fracture and a negative E-FAST.
The correct answer addresses the immediate life-threatening issue: ongoing hemorrhage from a pelvic fracture. The patient remains in shock despite appropriate initial interventions (pelvic binder and blood products). Because the E-FAST is negative, the hemorrhage is isolated to the retroperitoneum (a space not adequately visualized by FAST). The standard algorithm for an unstable pelvic fracture with a negative E-FAST is to proceed directly to pelvic angiography with embolization (or preperitoneal pelvic packing) to arrest the bleeding.

Step-by-Step Solution

1
Assess the patient's hemodynamic status and identify life-threatening injuries.
The patient is in hemorrhagic shock (hypotension, tachycardia) and has a mechanically unstable pelvic fracture, which is a major source of blood loss.
Prioritizing ABCs and hemorrhage control is the foundation of trauma management.
2
Evaluate the results of the E-FAST exam and the initial resuscitative efforts.
The E-FAST is negative (ruling out massive intraperitoneal or intrathoracic bleeding), and the patient remains hemodynamically unstable despite a pelvic binder and blood transfusions.
Determining the source of bleeding dictates the surgical or endovascular approach.
3
Select the definitive intervention for ongoing pelvic hemorrhage.
Pelvic angiography with embolization (or preperitoneal pelvic packing) is chosen.
Since the bleeding is localized to the retroperitoneal space, angiographic embolization directly targets the bleeding pelvic vessels without opening the abdomen and disrupting the natural tamponade effect.

Key Concept

Management algorithm for hemodynamically unstable pelvic fractures
Estimated Time:2m 0s
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Topics

Orthopedic Surgery

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