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Difficulty: MediumSurgical and Procedural Interventions

A 34-year-old man is brought to the emergency department after a high-speed motor vehicle collision. He is pale, diaphoretic, and minimally responsive. Vital signs show a temperature of 36.2°C (97.2°F), blood pressure of 72/40 mm Hg, heart rate of 135/min, and respiratory rate of 24/min. The airway is patent, and breath sounds are equal bilaterally. A focused assessment with sonography for trauma (FAST) examination is negative for intraperitoneal fluid. Pelvic examination reveals significant instability to gentle anteroposterior compression. Intravenous access is established, and a massive transfusion protocol is initiated. Which of the following are the most appropriate immediate procedural and surgical interventions for this patient? (Select all that apply)

  1. Application of a noninvasive pelvic circumferential compression deviceAnswer
  2. Pelvic angiography with targeted arterial embolizationAnswer
  3. C
    Emergent exploratory laparotomy
  4. D
    Computed tomography imaging of the abdomen and pelvis
  5. E
    Immediate transurethral placement of a Foley catheter

Answer

The correct procedural interventions are the application of a noninvasive pelvic circumferential compression device and pelvic angiography with targeted arterial embolization.
The patient is in hemorrhagic shock due to an unstable pelvic fracture. In the setting of a negative FAST examination, the life-threatening bleeding is located in the retroperitoneal space, originating from either the presacral venous plexus or pelvic arterial branches. The first critical procedural step is the application of a pelvic circumferential compression device, which reduces the pelvic volume, aligns the fractured bone ends, and promotes tamponade of venous bleeding. Because the patient remains hemodynamically unstable, he requires definitive management of potential arterial hemorrhage. Pelvic angiography with targeted arterial embolization (or preperitoneal pelvic packing) is the most appropriate concurrent or immediate subsequent step for achieving definitive arterial hemostasis.

Step-by-Step Solution

1
Identify the primary physiologic derangement.
The patient is in severe hemorrhagic shock (hypotension, tachycardia) following blunt trauma.
Recognizing the severity of shock guides the urgency of interventions.
2
Determine the source of bleeding based on physical exam and adjuncts.
The FAST exam is negative (no intraperitoneal bleeding), but the pelvis is mechanically unstable.
This localizes the life-threatening hemorrhage to the retroperitoneal space associated with the pelvic fracture.
3
Select the appropriate immediate stabilizing procedures.
Application of a pelvic binder and transfer for pelvic angiography are chosen.
A binder tamponades venous bleeding by reducing pelvic volume, while angiography identifies and embolizes arterial bleeders. Exploratory laparotomy must be avoided.

Key Concept

Management of hemodynamically unstable pelvic fractures involves immediate mechanical stabilization with a pelvic binder to control venous bleeding, followed by pelvic angiography (or preperitoneal packing) for arterial hemorrhage control, while avoiding laparotomy unless intraperitoneal bleeding is confirmed.
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Surgical and Procedural Interventions

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