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Zorluk: OrtaOrthopedic Surgery

A 45-year-old man is brought to the emergency department via ambulance after falling approximately 20 feet from a roof. Upon arrival, he is moaning in pain and appears confused. His temperature is 36.1°C (97.0°F), blood pressure is 78/40 mmHg, pulse is 135/min, and respirations are 26/min. The airway is patent, and breath sounds are equal bilaterally. Physical examination reveals severe ecchymosis over the lower abdomen and perineum. The pelvis is mechanically unstable to gentle anteroposterior compression. The right lower extremity is shortened and externally rotated. A focused assessment with sonography for trauma (FAST) examination reveals no intraperitoneal or pericardial fluid. An anteroposterior radiograph of the pelvis demonstrates a 4-cm diastasis of the pubic symphysis and widening of the right sacroiliac joint. A pelvic binder is immediately applied, and a massive transfusion protocol is initiated. After receiving 2 units of uncrossmatched packed red blood cells and 1 unit of fresh frozen plasma, his blood pressure remains 80/42 mmHg and pulse is 130/min. Which of the following is the most appropriate next step in management?

  1. A
    Exploratory laparotomy
  2. B
    Computed tomography scan of the abdomen and pelvis
  3. Pelvic angiography with embolizationCevap
  4. D
    Retrograde urethrography
  5. E
    Placement of a right femoral traction pin

Cevap

The most appropriate next step in management is pelvic angiography with embolization.
The patient presents with an open-book pelvic fracture and hemorrhagic shock. Initial management correctly included the application of a pelvic binder, which reduces pelvic volume and helps tamponade venous bleeding, alongside aggressive resuscitation. However, he remains hemodynamically unstable despite these measures. A negative FAST examination indicates there is no major intraperitoneal hemorrhage, confirming that the ongoing bleeding is localized to the retroperitoneal space. The most appropriate next step to achieve hemostasis in this scenario is pelvic angiography with embolization to control arterial bleeding (typically from branches of the internal iliac artery). Preperitoneal pelvic packing is an alternative definitive intervention.

Adım Adım Çözüm

1
Assess the patient's hemodynamic status and trauma primary survey.
The patient is in hemorrhagic shock (blood pressure 80/42 mmHg) and is not responding adequately to mechanical stabilization and massive transfusion.
To determine the acuity and prioritize life-saving interventions over secondary diagnostic adjuncts.
2
Interpret the results of the FAST examination and pelvic radiograph.
The FAST is negative, ruling out massive intraperitoneal hemorrhage. The radiograph confirms an unstable open-book pelvic fracture.
To localize the source of shock, which in this case is retroperitoneal bleeding originating from the disrupted pelvic ring.
3
Determine the algorithmic next step for refractory pelvic bleeding.
Because the bleeding is retroperitoneal and unresponsive to mechanical stabilization (pelvic binder), arterial hemostasis is required.
Venous bleeding is often controlled by the binder; persistent shock implies arterial injury requiring angiography or preperitoneal packing.

Anahtar Kavram

In a hemodynamically unstable patient with a pelvic fracture and a negative FAST examination, the most appropriate next step after placing a pelvic binder and initiating resuscitation is pelvic angiography with embolization to control retroperitoneal arterial hemorrhage.
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