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Difficulty: MediumTrauma and Burns

A 38-year-old male construction worker is brought to the emergency department after falling approximately 25 feet from a scaffold. On arrival, his blood pressure is 72/40 mmHg, heart rate is 138/min, and respiratory rate is 24/min. He is lethargic but maintaining his airway. Bilateral breath sounds are clear and equal. The abdomen is soft, non-distended, and lacks rebound tenderness or guarding. Gentle anteroposterior compression of the iliac crests reveals abnormal outward mobility of the pelvis. Intravenous access is established, and resuscitation with uncrossmatched blood is initiated. A bedside focused assessment with sonography for trauma (FAST) examination demonstrates no free fluid in the pericardial, hepatorenal, splenorenal, or rectovesical spaces. Which of the following is the most appropriate next step in management?

  1. Application of a pelvic circumferential compression deviceAnswer
  2. B
    Computed tomography of the abdomen and pelvis
  3. C
    Immediate exploratory laparotomy
  4. D
    Diagnostic peritoneal lavage
  5. E
    Retrograde urethrography

Answer

The most appropriate next step is the application of a pelvic circumferential compression device (pelvic binder).
In a trauma patient with hemorrhagic shock, a mechanically unstable pelvis, and a negative FAST exam, the bleeding is localized to the retroperitoneum. The immediate next step in management is the application of a pelvic circumferential compression device (pelvic binder) or a tied bedsheet around the greater trochanters. This decreases the pelvic volume and provides a tamponade effect on the bleeding venous plexus and fractured bone surfaces, stabilizing the patient's hemodynamics. If the patient remains unstable after binder application, the subsequent step would be preperitoneal packing or pelvic angiography with embolization.

Step-by-Step Solution

1
Assess the patient's hemodynamic status and mechanism of injury.
The patient is in profound hemorrhagic shock (blood pressure 72/40 mmHg) following a high-altitude fall.
Identifying instability determines that immediate life-saving interventions must take precedence over definitive diagnostic imaging.
2
Localize the primary source of hemorrhage using physical exam and bedside diagnostics.
The chest is clear, the FAST exam is negative (ruling out massive intraperitoneal or pericardial bleeding), and the pelvis is mechanically unstable on exam.
This constellation of findings localizes the life-threatening hemorrhage to the retroperitoneal space due to a pelvic ring disruption.
3
Determine the appropriate intervention for retroperitoneal hemorrhage from a pelvic fracture.
Apply a pelvic binder.
A pelvic binder reduces the pelvic volume, apposing the fractured bone edges and creating a tamponade effect on the bleeding presacral venous plexus and pelvic arteries.

Key Concept

Hemodynamically unstable patients with pelvic fractures and negative FAST exams require immediate application of a pelvic binder to provide mechanical tamponade of retroperitoneal hemorrhage.
Estimated Time:1m 15s
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Topics

Trauma and Burns

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