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Zorluk: OrtaTrauma and Burns

A 28-year-old man is brought to the emergency department via ambulance after being struck by a sport utility vehicle while crossing the street. He complains of severe lower abdominal and groin pain. His airway is patent, and breath sounds are equal bilaterally. Temperature is 36.5°C (97.7°F), heart rate is 135/min, blood pressure is 78/40 mm Hg, and respiratory rate is 24/min. Physical examination reveals a soft, non-distended abdomen with no rebound tenderness or guarding. There is prominent ecchymosis over the suprapubic and scrotal regions, and a small amount of blood is present at the urethral meatus. Gentle anteroposterior compression of the iliac crests reveals mechanical instability. A focused assessment with sonography for trauma (FAST) examination shows no free fluid in the pericardial, right upper quadrant, left upper quadrant, or suprapubic spaces. A pelvic binder is immediately applied, and the patient receives 2 units of uncrossmatched packed red blood cells. Fifteen minutes later, his heart rate is 128/min and blood pressure is 82/45 mm Hg. Which of the following is the most appropriate next step in management?

  1. A
    Computed tomography of the abdomen and pelvis
  2. B
    Diagnostic peritoneal lavage
  3. C
    Immediate exploratory laparotomy
  4. Pelvic angiographyCevap
  5. E
    Retrograde urethrography

Cevap

Pelvic angiography is the most appropriate next step to achieve hemostasis in this hemodynamically unstable patient with a pelvic fracture and a negative FAST.
This patient has a mechanically unstable pelvic fracture and remains in hemorrhagic shock despite the application of a pelvic binder and transfusion of blood products. The focused assessment with sonography for trauma (FAST) is negative, which essentially rules out significant intraperitoneal or pericardial hemorrhage. Therefore, the source of this patient's shock is presumed to be retroperitoneal hemorrhage originating from the fractured pelvis (often the presacral venous plexus or branches of the internal iliac artery). For hemodynamically unstable patients with a pelvic fracture and a negative FAST, the definitive next step is to achieve hemostasis via pelvic angiography with embolization or preperitoneal pelvic packing.

Adım Adım Çözüm

1
Assess the patient's hemodynamic status.
The patient is in persistent hemorrhagic shock (tachycardia, hypotension) despite initial fluid and blood resuscitation and placement of a pelvic binder.
Hemodynamic instability dictates the trauma algorithm, shifting the focus from comprehensive diagnostics to immediate life-saving interventions.
2
Localize the likely source of hemorrhage.
The FAST exam is negative, ruling out major intraperitoneal and pericardial bleeding. The unstable pelvis and scrotal ecchymosis indicate a severe pelvic fracture with retroperitoneal bleeding.
Identifying the anatomic compartment of hemorrhage determines the specific definitive intervention needed.
3
Determine the definitive management for the identified source.
Pelvic angiography with embolization (or preperitoneal pelvic packing) is selected.
Because the bleeding is retroperitoneal, laparotomy is contraindicated as it releases the natural tamponade. Angiography targets the bleeding pelvic vessels directly.

Anahtar Kavram

In a hemodynamically unstable patient with a pelvic fracture and a negative FAST examination, the bleeding is assumed to be retroperitoneal, and the appropriate next step is pelvic angiography with embolization or preperitoneal pelvic packing.
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