Examkin

Question

Difficulty: HardSurgical and Procedural Interventions

A 3434-year-old man is brought to the emergency department via ambulance after being struck by a high-speed vehicle as a pedestrian. On arrival, he is confused and visibly diaphoretic. His blood pressure is 72/40 mmHg72/40 \text{ mmHg}, heart rate is 142 /min142 \text{ /min}, and respiratory rate is 28 /min28 \text{ /min}. Pulse oximetry shows 94%94\% on a non-rebreather mask. The airway is patent, and breath sounds are equal bilaterally. The abdomen is tense and distended. Physical examination reveals an unstable pelvic ring upon gentle medial compression of the iliac crests. Two large-bore peripheral intravenous lines are established, and balanced blood product resuscitation is initiated.

Arrange the following procedural and diagnostic steps in the most appropriate chronological sequence for managing this patient's condition:

  1. 1Application of a noninvasive circumferential pelvic binder
  2. 2Performance of a focused assessment with sonography for trauma (FAST)
  3. 3Emergent exploratory laparotomy
  4. 4Pelvic angiography with potential arterial embolization

Answer

The correct sequence is: Application of a pelvic binder, followed by a FAST examination, then emergent exploratory laparotomy, and finally pelvic angiography.
The algorithm for a hemodynamically unstable patient with an unstable pelvic fracture requires immediate application of a pelvic binder to reduce pelvic volume and control venous bleeding (which accounts for most pelvic hemorrhage). Concurrently, a FAST exam is performed to assess for intraperitoneal bleeding. A patient with a tense, distended abdomen and shock will likely have a positive FAST, necessitating an emergent exploratory laparotomy to control intra-abdominal solid organ or mesenteric bleeding. Because laparotomy does not adequately address bleeding within the deep pelvic retroperitoneum, pelvic angiography with embolization is the definitive subsequent step for persistent instability due to arterial injury.

Step-by-Step Solution

1
Stabilize the pelvic ring mechanically.
Application of a noninvasive circumferential pelvic binder.
Reduces pelvic volume and tamponades venous bleeding from the presacral plexus, which is the most common source of hemorrhage in pelvic fractures.
2
Evaluate for coexisting intraperitoneal hemorrhage.
Performance of a focused assessment with sonography for trauma (FAST).
Crucial to determine if the patient's profound shock is driven by intra-abdominal bleeding, which dictates the surgical approach.
3
Control intraperitoneal hemorrhage surgically.
Emergent exploratory laparotomy.
A positive FAST in a hemodynamically unstable patient requires immediate operative intervention to stop active intra-abdominal bleeding.
4
Address residual retroperitoneal arterial hemorrhage.
Pelvic angiography with potential arterial embolization.
Used after laparotomy if the patient remains unstable or if an expanding pelvic hematoma is identified during surgery, to control arterial bleeding.

Key Concept

In hemodynamically unstable patients with major pelvic fractures, the sequence of management prioritizes immediate mechanical stabilization (pelvic binder), rapid exclusion of intra-abdominal hemorrhage (FAST), surgical control of intraperitoneal bleeding (laparotomy), and subsequent control of retroperitoneal arterial bleeding (angiography).
Rate this question

Topics

Surgical and Procedural Interventions

More questions from this topic