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Difficulty: MediumSurgical and Procedural Interventions

Emergency medical services bring a 29-year-old man to the trauma bay 30 minutes after he fell from a 3-story scaffolding. He is confused and moaning in pain. His temperature is 36.5∘C36.5^{\circ}\text{C} (97.7∘F97.7^{\circ}\text{F}), blood pressure is 78/42 mmHg, pulse is 138/min, and respirations are 26/min. Oxygen saturation is 95% on a non-rebreather mask. The patient's airway is patent, and breath sounds are equal bilaterally. A portable chest radiograph reveals clear lung fields without evidence of pneumothorax or hemothorax. An anteroposterior pelvic radiograph demonstrates a widened pubic symphysis of 3 cm and a displaced right sacroiliac joint. A focused assessment with sonography for trauma (FAST) scan demonstrates a 2-cm anechoic stripe in the hepatorenal recess (Morison pouch). Intravenous access is established, a pelvic binder is applied, and a massive transfusion protocol is initiated. Ten minutes later, his blood pressure remains 80/40 mmHg. Which of the following is the most appropriate next step in the management of this patient?

  1. Immediate exploratory laparotomyAnswer
  2. B
    Computed tomography angiography of the abdomen and pelvis
  3. C
    Pelvic angiography with arterial embolization
  4. D
    Retrograde cystourethrography
  5. E
    Placement of an anterior external pelvic fixator

Answer

Immediate exploratory laparotomy
The correct answer is immediate exploratory laparotomy. This patient presents with hemorrhagic shock following blunt trauma. He has evidence of an 'open-book' pelvic fracture, which is known to cause massive retroperitoneal hemorrhage. However, his FAST scan is positive, confirming the presence of intraperitoneal blood. According to Advanced Trauma Life Support (ATLS) protocols, if a patient is hemodynamically unstable and has a positive FAST scan, an immediate exploratory laparotomy is mandatory to locate and control the intraperitoneal source of bleeding. Pelvic binding has already been appropriately performed to reduce pelvic volume and provide tamponade to the retroperitoneal space. Intraperitoneal hemorrhage takes surgical priority over definitive pelvic fracture management.

Step-by-Step Solution

1
Identify the patient's hemodynamic status.
The patient is in Class III/IV hemorrhagic shock with a blood pressure of 78/42 mmHg and a heart rate of 138/min, unresponsive to initial resuscitation.
Hemodynamic instability dictates the diagnostic and therapeutic algorithm in trauma.
2
Evaluate the identified sources of bleeding.
The patient has two potential sources of massive hemorrhage: retroperitoneal bleeding (indicated by the open-book pelvic fracture) and intraperitoneal bleeding (indicated by the positive FAST scan showing fluid in Morison's pouch).
Concurrent injuries require prioritization based on immediate lethality and accessibility.
3
Apply the ATLS algorithm for combined pelvic and abdominal trauma.
In the presence of a positive FAST and hemodynamic instability, intraperitoneal hemorrhage is the most immediate life threat and must be managed operatively first.
Intraperitoneal bleeding cannot be controlled with external compression or angioembolization; it requires definitive surgical exploration.

Key Concept

In a hemodynamically unstable trauma patient with concurrent pelvic fracture and a positive FAST scan, immediate exploratory laparotomy takes precedence over pelvic interventions to control intraperitoneal hemorrhage.
Estimated Time:1m 0s
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Topics

Surgical and Procedural Interventions

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