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Difficulty: MediumInitial Stabilization and Triage

A 42-year-old construction worker is brought to the trauma resuscitation bay following a 20-foot fall from a scaffold. On arrival, he is pale and lethargic but moans in response to painful stimuli. His airway is patent, and breath sounds are vesicular and equal bilaterally.

Vital signs are:
Temperature: 36.4°C (97.5°F)
Blood pressure: 72/40 mmHg
Heart rate: 135 /min
Respiratory rate: 24 /min
Oxygen saturation: 97% on high-flow oxygen.

A primary survey reveals a mechanically unstable pelvis that demonstrates mobility on gentle anterior-posterior compression. There are severe abrasions over the lower abdomen and flanks, but no obvious sources of external hemorrhage are identified. Two large-bore peripheral intravenous lines are immediately established.

Which of the following are the most appropriate immediate next steps in management? (Select two)

  1. Application of a pelvic circumferential compression deviceAnswer
  2. Administration of uncrossmatched blood productsAnswer
  3. C
    Computed tomography angiography of the pelvis
  4. D
    Urgent magnetic resonance imaging of the lumbosacral spine
  5. E
    Immediate transfer to the general orthopedic ward

Answer

The most appropriate immediate next steps are the application of a pelvic circumferential compression device and the administration of uncrossmatched blood products.
The correct sequence for managing this hemodynamically unstable patient with a suspected pelvic fracture relies on immediate life-saving interventions. The application of a pelvic circumferential compression device reduces the intrapelvic volume, which helps to tamponade venous bleeding and stabilize the fractured bone ends. Concurrently, because the patient is in Class IV hemorrhagic shock (hypotension, severe tachycardia, altered mental status), the immediate administration of uncrossmatched blood products is essential to rapidly restore intravascular volume and oxygen-carrying capacity. These steps must occur simultaneously in the trauma bay before any advanced diagnostic imaging or definitive disposition is considered.

Step-by-Step Solution

1
Assess the patient's hemodynamic status based on vital signs and physical examination.
The patient has a blood pressure of 72/40 mmHg, a heart rate of 135 /min, and lethargy, indicating severe (Class IV) hypovolemic shock.
Recognizing the severity of shock dictates the urgency and type of fluid resuscitation required.
2
Identify the likely source of hemorrhage.
The primary survey reveals a mechanically unstable pelvis without obvious external bleeding, suggesting massive retroperitoneal hemorrhage from a pelvic ring disruption.
Identifying the hemorrhage source directs specific mechanical stabilization measures.
3
Select the appropriate stabilization interventions.
A pelvic binder must be applied to reduce pelvic volume and tamponade bleeding, while uncrossmatched blood products must be administered to treat the hemorrhagic shock.
In unstable trauma patients, immediate mechanical stabilization and volume replacement with blood take absolute precedence over advanced diagnostic imaging.

Key Concept

In patients with severe hemorrhagic shock due to an unstable pelvic fracture, initial management must focus on immediate mechanical stabilization (pelvic binder) and balanced hemostatic resuscitation (uncrossmatched blood products) before transporting the patient for advanced imaging.
Estimated Time:1m 30s
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Topics

Initial Stabilization and Triage

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