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Difficulty: MediumSurgical and Procedural Interventions

A 28-year-old man is brought to the emergency department 30 minutes after falling approximately 25 feet from a scaffold. He complains of excruciating pelvic and lower back pain. He has no significant past medical history. His temperature is 36.8°C (98.2°F), blood pressure is 80/40 mmHg, heart rate is 134/min, and respiratory rate is 24/min. Physical examination reveals blood at the urethral meatus. There is marked instability of the pelvic ring in response to gentle manual compression. A cervical spine collar is in place. Intravenous access is established with two large-bore peripheral lines, and a massive transfusion protocol is initiated. A bedside Focused Assessment with Sonography for Trauma (FAST) examination shows no intraperitoneal free fluid. A portable chest radiograph is unremarkable. An anteroposterior pelvic radiograph demonstrates widening of the pubic symphysis to 4.5 cm and disruption of the right sacroiliac joint. Despite receiving 2 liters of warmed crystalloid and 2 units of uncrossmatched packed red blood cells, his blood pressure remains 82/45 mmHg and heart rate is 130/min.

Which of the following are appropriate next steps in the procedural management of this patient? (Select all that apply)

  1. Application of a pelvic circumferential compression device at the level of the greater trochantersAnswer
  2. Pelvic angiography with transcatheter arterial embolizationAnswer
  3. C
    Immediate exploratory laparotomy and retroperitoneal exploration
  4. D
    Transport to the radiology suite for a computed tomography (CT) scan of the abdomen and pelvis
  5. E
    Diagnostic peritoneal lavage to evaluate for occult intra-abdominal hemorrhage

Answer

The appropriate procedural interventions for this patient are the application of a pelvic circumferential compression device (pelvic binder) and pelvic angiography with transcatheter arterial embolization.
This patient presents with hemorrhagic shock secondary to a severe 'open-book' pelvic fracture, evidenced by the widened pubic symphysis and sacroiliac joint disruption. The FAST exam is negative, indicating that the life-threatening bleeding is confined to the retroperitoneal space rather than the peritoneal cavity. The immediate priority in procedural management is to stabilize the pelvic ring to decrease pelvic volume, which promotes tamponade of the actively bleeding presacral venous plexus. This is most rapidly achieved by applying a pelvic circumferential compression device (pelvic binder) centered over the greater trochanters. Because the patient remains hemodynamically unstable despite aggressive volume resuscitation and mechanical stabilization, definitive control of arterial hemorrhage is additionally required. The standard of care for identifying and halting ongoing arterial bleeding (typically from branches of the internal iliac artery) in this setting is pelvic angiography with transcatheter arterial embolization.

Step-by-Step Solution

1
Evaluate the patient's hemodynamic status and trauma primary survey findings.
The patient is in persistent hemorrhagic shock (BP 82/45 mmHg) with an unstable 'open-book' pelvic fracture and a negative FAST exam.
Identifying the severity of shock and accurately localizing the bleeding source is essential to direct life-saving therapeutic interventions.
2
Determine the most likely source of the life-threatening hemorrhage.
The combination of a massive pelvic ring disruption and a negative FAST localizes the primary bleeding to the retroperitoneal space.
Pelvic fractures cause massive retroperitoneal bleeding originating from the presacral venous plexus and internal iliac arterial branches, without necessarily causing intraperitoneal bleeding.
3
Select the procedures that provide immediate mechanical stabilization and definitive vascular control.
Application of a pelvic binder and subsequent pelvic angiography with embolization (or preperitoneal packing) are indicated.
The binder immediately reduces pelvic volume to promote venous tamponade, while angiography provides definitive control of arterial hemorrhage.

Key Concept

Hemodynamically unstable patients with severe pelvic ring disruptions and no evidence of intraperitoneal hemorrhage on FAST require immediate application of a pelvic binder for mechanical tamponade, followed by pelvic angiography with embolization (or preperitoneal packing) to control retroperitoneal bleeding.
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Topics

Surgical and Procedural Interventions

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