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Difficulty: MediumTrauma and Burns

A 3333-year-old construction worker is brought to the emergency department after a 2020-foot fall from a scaffold. On arrival, he is lethargic and diaphoretic. His temperature is 36.5∘C36.5^\circ\text{C} (97.7∘F97.7^\circ\text{F}), blood pressure is 78/45 mm Hg78/45\text{ mm Hg}, and pulse is 132/min132\text{/min}. Oxygen saturation is 96%96\% on room air. Primary survey reveals a patent airway and bilaterally equal breath sounds. The abdomen is soft, non-distended, and without guarding. Inspection of the pelvis shows a scrotal hematoma and blood at the urethral meatus. Gentle lateral compression of the iliac crests elicits crepitus and abnormal mobility. A bedside focused assessment with sonography for trauma (FAST) shows no free fluid in the peritoneal cavity or pericardial sac. An anteroposterior pelvic radiograph reveals a 4.5-cm4.5\text{-cm} pubic symphysis diastasis and widening of the left sacroiliac joint. Intravenous access is established, and aggressive crystalloid resuscitation is initiated. Which of the following is the most appropriate next step in management?

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

Answer

Application of a noninvasive pelvic binder is the most appropriate next step to mechanically stabilize the fracture and promote retroperitoneal tamponade.
The most appropriate next step in management is the application of a noninvasive pelvic binder. This patient is in profound hypovolemic shock following a high-energy fall, and his clinical examination and radiographs are consistent with an 'open book' pelvic fracture (anteroposterior compression injury). These fractures tear the anterior sacroiliac ligaments and disrupt the presacral venous plexus and branches of the internal iliac artery, leading to massive retroperitoneal hemorrhage. The negative FAST scan indicates that the bleeding is not intraperitoneal. In a hemodynamically unstable patient with a severe pelvic ring disruption, immediate application of a pelvic binder (centered over the greater trochanters) is indicated. This intervention reduces pelvic volume, apposes the fracture ends, and promotes the tamponade of venous bleeding, buying crucial time for definitive procedures such as preperitoneal packing or angiographic embolization.

Step-by-Step Solution

1
Assess the patient's hemodynamic status and mechanism of injury.
The patient is in profound hypovolemic shock (blood pressure 78/45 mm Hg78/45\text{ mm Hg}, pulse 132/min132\text{/min}) following a high-energy fall.
Identifying hemodynamic instability is the first step in trauma management, dictating immediate interventions for life-threatening hemorrhage.
2
Evaluate the source of bleeding using the primary survey and adjuncts.
The FAST scan is negative, ruling out major intraperitoneal or pericardial bleeding. The pelvic radiograph confirms a severe 'open book' pelvic fracture.
A negative FAST in a hypotensive trauma patient directs attention to other major sources of blood loss, particularly the retroperitoneum associated with the pelvic fracture.
3
Determine the most appropriate immediate intervention to control the hemorrhage.
Application of a noninvasive pelvic binder is selected to address the mechanical source of the bleeding.
A pelvic binder reduces the pelvic volume, apposes the fracture ends, and promotes the tamponade of life-threatening retroperitoneal venous bleeding before considering definitive management.

Key Concept

Hemodynamically unstable patients with severe pelvic fractures and a negative FAST exam require immediate application of a pelvic binder to tamponade retroperitoneal bleeding.
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Topics

Trauma and Burns

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