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Difficulty: MediumTrauma and Burns

A 2727-year-old male construction worker is brought to the trauma bay after falling approximately 20 feet20\text{ feet} from scaffolding. On arrival, he is confused and profusely diaphoretic. His temperature is 36.2∘C36.2^\circ\text{C}, heart rate is 128 /min128\text{ /min}, blood pressure is 82/50 mm Hg82/50\text{ mm Hg}, and respiratory rate is 26 /min26\text{ /min}. A rigid cervical collar is in place. The airway is patent, and breath sounds are vesicular and equal bilaterally. The trachea is midline. Heart sounds are rapid but regular without murmurs. The abdomen is flat, soft, and non-distended. Anteroposterior compression of the anterior superior iliac spines reveals abnormal mobility and elicits crepitus. A focused assessment with sonography for trauma (FAST) exam demonstrates no intraperitoneal free fluid and no pericardial effusion. Two large-bore intravenous lines are established, and 1 L1\text{ L} of warmed crystalloid is rapidly infusing. Which of the following is the most appropriate next step in management?

  1. Application of a pelvic circumferential compression deviceAnswer
  2. B
    Computed tomography scan of the abdomen and pelvis
  3. C
    Immediate exploratory laparotomy
  4. D
    Pelvic angiography with embolization
  5. E
    Diagnostic peritoneal aspiration

Answer

Application of a pelvic circumferential compression device (pelvic binder)
The correct answer addresses the immediate need to control massive retroperitoneal bleeding originating from a mechanically unstable pelvic fracture. When a patient in hemorrhagic shock has a negative FAST exam and normal chest findings, the pelvis or long bones are the primary sources of blood loss. Bedside application of a pelvic circumferential compression device (or a tightly wrapped bedsheet around the greater trochanters) rapidly reduces the pelvic volume, opposing the fractured bony surfaces and tamponading venous plexus bleeding. This buys critical time for resuscitation and mobilization of definitive resources like angiography or preperitoneal packing.

Step-by-Step Solution

1
Identify hemodynamic instability following blunt trauma.
The patient is in class III/IV hemorrhagic shock, evidenced by a blood pressure of 82/50 mm Hg, heart rate of 128 /min, and confusion.
Recognizing shock dictates adherence to the Advanced Trauma Life Support (ATLS) primary survey protocol, where resuscitation and identifying the bleeding source occur simultaneously.
2
Localize the primary source of hemorrhage using physical exam and bedside diagnostics.
The chest is clear, ruling out massive hemothorax. The FAST exam is negative, making massive intraperitoneal bleeding unlikely. The mechanically unstable pelvis indicates a severe pelvic ring disruption.
In blunt trauma, life-threatening hemorrhage typically occurs in the chest, abdomen, pelvis, or long bones. Eliminating the chest and abdomen leaves the retroperitoneum (pelvis) as the primary suspect.
3
Determine the most appropriate immediate intervention for the identified injury.
Application of a pelvic binder is the critical next step.
Pelvic fractures cause massive blood loss primarily from the presacral venous plexus and cancellous bone. A binder reduces pelvic volume, splinting the fracture and providing a tamponade effect to slow venous bleeding before definitive operative or angiographic management.

Key Concept

In hemodynamically unstable patients with a severe pelvic fracture and a negative FAST exam, the immediate next step in management is noninvasive pelvic stabilization (e.g., pelvic binder or sheet) to tamponade retroperitoneal venous hemorrhage.
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Topics

Trauma and Burns

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