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Difficulty: MediumSurgical and Procedural Interventions

An industrial worker is brought to the emergency department after a heavy steel pipe rolled onto his lower torso. Upon arrival, he is pale, diaphoretic, and confused. His temperature is 36.5°C (97.7°F), blood pressure is 78/42 mm Hg, pulse is 138/min, and respirations are 24/min. The airway is patent, and breath sounds are equal bilaterally. Inspection reveals extensive ecchymosis over the suprapubic and perineal areas. There is gross blood visible at the urethral meatus. Gentle anteroposterior pressure on the iliac crests reveals mechanical instability. Intravenous access is established, a pelvic binder is applied immediately, and a massive transfusion protocol is initiated. A focused assessment with sonography for trauma (FAST) shows no fluid in the pericardial sac or peritoneal cavity. Despite the administration of 2 units of uncrossmatched packed red blood cells and 1 liter of crystalloid, his blood pressure remains 80/45 mm Hg. Which of the following is the most appropriate next step in management?

  1. Proceed with pelvic angiography and embolizationAnswer
  2. B
    Transfer the patient for a computed tomography scan of the abdomen and pelvis
  3. C
    Perform an emergent exploratory laparotomy
  4. D
    Perform a retrograde urethrogram
  5. E
    Attempt placement of a transurethral Foley catheter

Answer

The most appropriate next step is to proceed with pelvic angiography and embolization to control the massive retroperitoneal hemorrhage.
The correct intervention is pelvic angiography and embolization. This patient presents with hemorrhagic shock due to an unstable pelvic fracture. In the setting of severe pelvic trauma, profound hypotension unresponsive to initial fluid and blood resuscitation indicates ongoing massive hemorrhage. The negative FAST examination effectively rules out major intraperitoneal bleeding, localizing the blood loss to the retroperitoneum (commonly from the presacral venous plexus or branches of the internal iliac artery). For hemodynamically unstable patients with pelvic fractures and a negative FAST, the standard procedural intervention is either pelvic angiography with embolization or preperitoneal pelvic packing to achieve definitive hemostasis.

Step-by-Step Solution

1
Assess the patient's hemodynamic status and response to initial resuscitation.
The patient remains in hemorrhagic shock (BP 80/45 mm Hg, HR 138/min) despite a pelvic binder, 2 units of blood, and crystalloid fluids.
Determines whether the patient requires immediate life-saving intervention or can tolerate further diagnostic imaging.
2
Identify the primary source of bleeding using physical exam and FAST.
FAST is negative (no intraperitoneal fluid), while the pelvis is mechanically unstable with overlying ecchymosis.
Localizes the hemorrhage to the retroperitoneal space (pelvic venous plexus or arterial branches) rather than the abdominal cavity.
3
Select the definitive procedural intervention for the identified source.
Pelvic angiography with embolization (or preperitoneal pelvic packing) is chosen.
It is the gold standard intervention to control life-threatening arterial hemorrhage from pelvic fractures in a hemodynamically unstable patient with a negative FAST.

Key Concept

Management of hemodynamically unstable pelvic fractures
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Topics

Surgical and Procedural Interventions

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