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Difficulty: HardTrauma and Burns

A 2828-year-old man is brought to the emergency department by ambulance after being struck by a motor vehicle while crossing the street. On arrival, he is moaning in pain. His temperature is 36.5∘C36.5^\circ\text{C} (97.7∘F97.7^\circ\text{F}), pulse is 132/min132/\text{min}, respirations are 22/min22/\text{min}, and blood pressure is 78/40 mm Hg78/40\text{ mm Hg}. Pulse oximetry shows 97%97\% on room air. The patient's airway is patent, and breath sounds are equal bilaterally. A rigid cervical collar is in place. Physical examination reveals ecchymosis over the lower abdomen and perineum, as well as blood at the urethral meatus. Gentle anteroposterior compression of the iliac crests reveals mechanical instability of the pelvis. Intravenous access is established, and a massive transfusion protocol is initiated. A pelvic binder is applied in the emergency department, but the patient's blood pressure remains 80/42 mm Hg80/42\text{ mm Hg}. A focused assessment with sonography for trauma (FAST) examination shows no free fluid in the pericardial, perihepatic, perisplenic, or pelvic spaces. Which of the following is the most appropriate next step in management?

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

Answer

Pelvic angiography
In a hemodynamically unstable patient with a mechanically unstable pelvic fracture and a negative FAST examination, the primary source of hemorrhage is most likely retroperitoneal (from the presacral venous plexus or branches of the internal iliac artery). Because the FAST is negative, an exploratory laparotomy is contraindicated; opening the peritoneum will release the tamponade effect holding the retroperitoneal hematoma in check, potentially causing catastrophic exsanguination. The most appropriate next step is to address the pelvic bleeding directly via pelvic angiography with embolization (or preperitoneal pelvic packing).

Step-by-Step Solution

1
Evaluate the patient's hemodynamic status and mechanism of injury.
The patient is in class III/IV hemorrhagic shock (hypotension, marked tachycardia) following high-energy blunt trauma.
Identifying shock dictates the urgency and subsequent pathway of the ATLS algorithm.
2
Assess the source of hemorrhage based on physical exam and primary adjuncts.
The mechanically unstable pelvis indicates a pelvic fracture, while the negative FAST suggests the bleeding is not intraperitoneal.
A negative FAST in the setting of severe pelvic trauma implies that the life-threatening hemorrhage is retroperitoneal (typically from the presacral venous plexus or branches of the internal iliac artery).
3
Determine the definitive management for the identified source of shock.
Select pelvic angiography with embolization (or preperitoneal pelvic packing) as the next definitive intervention.
These interventions directly address retroperitoneal pelvic bleeding. Exploratory laparotomy is strictly contraindicated as it releases the natural retroperitoneal tamponade effect.

Key Concept

Management algorithm for hemodynamically unstable pelvic trauma
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Topics

Trauma and Burns

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