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Difficulty: MediumTrauma and Burns

A 42-year-old male construction worker is evaluated in the trauma center after a 15-foot fall from scaffolding. On arrival, his blood pressure is 75/40 mmHg75/40 \text{ mmHg} and heart rate is 132 /min132 \text{ /min}. His airway is patent, and breath sounds are present and equal bilaterally. A chest radiograph shows no abnormalities. The abdomen is soft and non-distended without guarding or rigidity. A focused assessment with sonography for trauma (FAST) reveals no free intraperitoneal or pericardial fluid. Gentle compression of the iliac crests reveals mechanical instability and crepitus. Which of the following is the most appropriate next step in management?

  1. Application of a pelvic binderAnswer
  2. B
    Computed tomography of the abdomen and pelvis
  3. C
    Exploratory laparotomy
  4. D
    Pelvic angiography with embolization
  5. E
    Diagnostic peritoneal lavage

Answer

Application of a pelvic binder
This patient is in hemorrhagic shock secondary to a pelvic fracture. The negative chest radiograph and negative FAST exam localize the life-threatening hemorrhage to the retroperitoneal space due to the mechanically unstable pelvic ring. The venous plexus and cancellous bone are the most common sources of bleeding in pelvic fractures. The immediate next step is the application of a pelvic binder (or sheet), which mechanically stabilizes the fracture, reduces pelvic volume, and promotes the tamponade of venous hemorrhage. Once the binder is applied and the patient receives balanced blood product resuscitation, further steps (such as pelvic angiography for arterial bleeding or preperitoneal packing) can be pursued if hemodynamic instability persists.

Step-by-Step Solution

1
Identify the patient's hemodynamic status.
The patient is in hemorrhagic shock (blood pressure 75/40 mmHg75/40 \text{ mmHg}, heart rate 132 /min132 \text{ /min}).
Vital signs dictate the immediate treatment pathway in trauma algorithms.
2
Localize the source of hemorrhage.
The chest radiograph is normal, and FAST is negative, ruling out massive hemothorax or intraperitoneal bleeding. Pelvic instability indicates a pelvic ring fracture.
Trauma evaluation systematically rules out sources of life-threatening bleeding (chest, abdomen, pelvis, long bones).
3
Determine the appropriate intervention for the identified bleeding source.
The patient requires immediate pelvic stabilization.
A pelvic binder reduces pelvic volume, promoting tamponade of venous bleeding, which is the most common source of hemorrhage in pelvic fractures.

Key Concept

Hemodynamically unstable patients with suspected pelvic fractures and a negative FAST exam should immediately undergo application of a pelvic binder to promote venous tamponade and reduce retroperitoneal hemorrhage.
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Topics

Trauma and Burns

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