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Difficulty: MediumTrauma and Burns

A 26-year-old male is brought to the emergency department after being struck by a motor vehicle while riding an electric scooter. On arrival, his airway is patent and he is breathing spontaneously. Vital signs are temperature 36.5°C (97.7°F), blood pressure 80/50 mm Hg, pulse 130/min, and respirations 20/min. Physical examination reveals a pale, diaphoretic man who is drowsy but arousable. Breath sounds are clear and equal bilaterally. His abdomen is soft and non-distended, without guarding or rebound tenderness. Gentle anteroposterior compression of the iliac crests reveals abnormal mobility and elicits a groan of pain from the patient. There is a hematoma over the perineum, and blood is visible at the urethral meatus. A focused assessment with sonography for trauma (FAST) examination shows no fluid in the hepatorenal, splenorenal, or rectovesical spaces, and no pericardial effusion. Two large-bore intravenous lines are placed, and fluid resuscitation is initiated. Which of the following is the most appropriate next step in management?

  1. Application of a pelvic binderAnswer
  2. B
    Computed tomography scan of the abdomen and pelvis
  3. C
    Exploratory laparotomy
  4. D
    Retrograde urethrography
  5. E
    Diagnostic peritoneal lavage

Answer

Application of a pelvic binder is the immediate next step for a hemodynamically unstable patient with a suspected pelvic fracture and a negative FAST exam.
This patient has a mechanically unstable pelvic fracture and hemorrhagic shock following blunt trauma. Pelvic fractures can cause massive, life-threatening retroperitoneal bleeding, typically originating from the presacral venous plexus or branches of the internal iliac artery. When a hemodynamically unstable patient has a negative FAST exam (which rules out massive intraperitoneal hemorrhage) and evidence of an unstable pelvis, the immediate next step is the application of a pelvic binder. A pelvic binder or sheet reduces pelvic volume, which promotes the tamponade of venous bleeding and stabilizes the fractured bone ends to limit further vascular injury. It is a rapid, non-invasive, life-saving intervention performed directly in the trauma bay while resuscitation continues.

Step-by-Step Solution

1
Identify the patient's hemodynamic status.
The patient is hemodynamically unstable with a blood pressure of 80/50 mm Hg and a heart rate of 130/min.
Determining hemodynamic stability dictates the algorithm path in acute trauma management.
2
Evaluate the primary source of hemorrhage using physical exam and FAST findings.
FAST is definitively negative (no intraperitoneal fluid). Physical exam shows signs of severe pelvic trauma (instability, perineal hematoma).
A negative FAST in an unstable blunt trauma patient points toward extraperitoneal sources of bleeding, primarily the pelvis or long bones.
3
Determine the immediate intervention for suspected life-threatening pelvic hemorrhage.
Application of a pelvic binder.
A pelvic binder reduces pelvic volume, promoting tamponade of massive retroperitoneal venous bleeding and stabilizing the fracture ends.

Key Concept

In a hemodynamically unstable patient with a pelvic fracture and a negative FAST exam, the immediate next step is application of a pelvic binder to reduce pelvic volume and tamponade retroperitoneal bleeding.
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Topics

Trauma and Burns

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