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Difficulty: MediumInitial Stabilization and Triage

A construction worker is transported to the trauma center by helicopter after falling approximately 30 feet from scaffolding. On arrival, the patient is obtunded but groans to painful stimuli. Vital signs demonstrate a blood pressure of 68/40 mm Hg, a heart rate of 148/min, and a respiratory rate of 28/min. Oxygen saturation is 95% on a non-rebreather mask. The airway is patent, and breath sounds are symmetric bilaterally. The abdomen is distended, and gentle lateral compression of the iliac crests reveals profound mechanical instability. A bedside focused assessment with sonography for trauma (FAST) reveals no free intraperitoneal fluid. Which of the following simultaneous initial management steps are most appropriate for this patient? (Select exactly 2 options)

  1. Application of a noninvasive pelvic circumferential compression deviceAnswer
  2. Initiation of a massive transfusion protocol with uncrossmatched blood productsAnswer
  3. C
    Immediate transport to the radiology suite for a computed tomography scan of the abdomen and pelvis
  4. D
    Initiation of a continuous intravenous norepinephrine infusion
  5. E
    Performance of a retrograde urethrogram

Answer

The correct simultaneous initial steps are the application of a noninvasive pelvic circumferential compression device and the initiation of a massive transfusion protocol with uncrossmatched blood products.
This patient presents with profound hemorrhagic shock following a high-altitude fall, exhibiting a mechanically unstable pelvis. A negative FAST exam in this context highly suggests massive retroperitoneal hemorrhage resulting from a pelvic ring disruption. In unstable patients with suspected severe pelvic fractures, immediate mechanical stabilization using a pelvic binder reduces pelvic volume, promoting the tamponade of venous bleeding and bony surfaces. Simultaneously, aggressive volume resuscitation using balanced blood products via a massive transfusion protocol is critical to restore intravascular volume, improve oxygen-carrying capacity, and prevent the trauma-induced coagulopathy that worsens with large-volume crystalloid administration.

Step-by-Step Solution

1
Assess the patient's hemodynamic status and mechanism of injury.
The patient is in profound shock (BP 68/40, HR 148) following a high-impact fall with an unstable pelvis.
Identifying the severity of shock establishes the immediate need for aggressive resuscitation over diagnostic imaging.
2
Interpret the negative FAST exam in the context of an unstable pelvis.
The absence of intraperitoneal fluid suggests the source of massive hemorrhage is likely retroperitoneal, originating from the disrupted pelvic ring.
This localizes the primary source of bleeding and guides specific mechanical interventions.
3
Determine the optimal simultaneous stabilization interventions.
Select mechanical tamponade (pelvic binder) and optimal fluid replacement (massive transfusion protocol) as the dual life-saving measures.
These interventions simultaneously control the rate of bleeding and restore oxygen-carrying capacity.

Key Concept

Initial stabilization of suspected massive pelvic hemorrhage requires simultaneous mechanical volume reduction (pelvic binder) and hemodynamic resuscitation with blood products.
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Topics

Initial Stabilization and Triage

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