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Difficulty: MediumInitial Stabilization and Triage

A 47-year-old female pedestrian is struck by a commercial delivery truck and brought directly to the trauma resuscitation bay. On arrival, she is lethargic, diaphoretic, and pale. Vital signs include a heart rate of 145/min, blood pressure of 65/35 mmHg, and respiratory rate of 28/min. Pulse oximetry is currently unreadable due to poor peripheral perfusion. The primary survey reveals clear, equal breath sounds bilaterally and no obvious source of external hemorrhage. The pelvis is highly unstable to gentle anteroposterior compression, and the right thigh is significantly swollen and deformed. Two large-bore peripheral intravenous lines are immediately established. Which of the following are the most appropriate immediate next steps in the stabilization of this patient? (Select all that apply)

  1. Activate the massive transfusion protocol and administer uncrossmatched blood productsAnswer
  2. Apply a noninvasive pelvic circumferential compression deviceAnswer
  3. C
    Transfer the patient to the radiology suite for a computed tomography scan of the abdomen and pelvis
  4. D
    Initiate a continuous intravenous infusion of norepinephrine
  5. E
    Perform a retrograde urethrogram to evaluate for potential lower urinary tract injury

Answer

The most appropriate immediate steps are to activate the massive transfusion protocol for uncrossmatched blood products and to apply a noninvasive pelvic circumferential compression device.
The patient is in extremis from hemorrhagic shock, likely secondary to a severe pelvic fracture and femur fracture. In this scenario, simultaneous mechanical stabilization and aggressive volume resuscitation are the absolute highest priorities. Applying a pelvic circumferential compression device rapidly reduces pelvic volume, promoting tamponade of venous bleeding and preventing further displacement of fracture fragments. Concurrently, activating the massive transfusion protocol provides balanced, uncrossmatched blood products (red blood cells, plasma, and platelets) which are essential for restoring intravascular volume, oxygen delivery, and correcting trauma-induced coagulopathy.

Step-by-Step Solution

1
Assess the patient's hemodynamic and clinical status.
The patient is in class IV hypovolemic (hemorrhagic) shock, evidenced by profound hypotension, marked tachycardia, and lethargy.
Identifying the type and severity of shock dictates the urgency and specific type of resuscitation required.
2
Identify the likely sources of major hemorrhage.
The highly unstable pelvis and swollen thigh point to massive retroperitoneal and femoral bleeding.
In blunt trauma with clear breath sounds and no external bleeding, the abdomen, pelvis, and long bones are the primary suspected sources of occult life-threatening blood loss.
3
Initiate immediate life-saving stabilization maneuvers.
Hemorrhage control is achieved mechanically via a pelvic binder, while intravascular volume and coagulation factors are restored using massive transfusion.
Definitive stabilization of hemorrhagic shock requires simultaneously stopping the bleeding and replacing lost oxygen-carrying capacity.

Key Concept

In severe hemorrhagic shock due to blunt pelvic trauma, initial stabilization must prioritize immediate mechanical hemorrhage control (e.g., pelvic binding) and volume resuscitation with blood products over diagnostic imaging or vasopressor administration.
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Topics

Initial Stabilization and Triage

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