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Zorluk: OrtaOrthopedic Surgery

A 42-year-old man is brought to the emergency department following a high-speed motor vehicle collision. He was the restrained driver. Upon arrival, he is confused and diaphoretic. His temperature is 36.5°C (97.7°F), blood pressure is 78/50 mm Hg, pulse is 132/min, and respiratory rate is 24/min. Pulse oximetry shows 97% on room air. The airway is patent, and breath sounds are clear and equal bilaterally. A focused assessment with sonography for trauma (FAST) examination reveals no free fluid in the peritoneal cavity or pericardial sac. Physical examination demonstrates marked ecchymosis over the lower abdomen and perineum, with severe instability of the pelvic ring on gentle anteroposterior compression. There is blood at the urethral meatus. Bilateral lower extremity pulses are palpable but weak. Motor and sensory examinations of the lower extremities are limited due to patient confusion, but there are no gross deformities of the legs. Two large-bore intravenous lines are placed, and fluid resuscitation with isotonic crystalloid is initiated. Which of the following is the most appropriate next step in management?

  1. A
    Computed tomography angiography of the abdomen and pelvis
  2. Application of a noninvasive pelvic binderCevap
  3. C
    Immediate exploratory laparotomy
  4. D
    Insertion of a urethral catheter to monitor urine output
  5. E
    Administration of broad-spectrum intravenous antibiotics

Cevap

Application of a noninvasive pelvic binder
The patient is in class III/IV hypovolemic shock due to major orthopedic trauma. In patients with severe pelvic ring instability and a negative FAST exam, the primary source of life-threatening bleeding is typically the retroperitoneal venous plexus. The immediate next step in management is the application of a noninvasive pelvic binder (or a firmly wrapped sheet) centered over the greater trochanters. This intervention mechanically stabilizes the pelvis, reduces the internal pelvic volume, and facilitates a tamponade effect to control venous hemorrhage, bridging the patient to definitive management such as preperitoneal pelvic packing or angioembolization.

Adım Adım Çözüm

1
Analyze the patient's hemodynamic status and trauma primary survey.
The patient is in hypovolemic shock (hypotension, tachycardia) with a negative FAST exam and normal breath sounds.
To rule out intrathoracic and intraperitoneal sources of bleeding as the cause of shock.
2
Correlate the physical exam findings with the shock state.
Severe pelvic instability and perineal ecchymosis indicate a major pelvic ring disruption (e.g., open-book fracture), which can cause massive retroperitoneal venous bleeding.
To identify the likely source of hemorrhage causing the patient's hemodynamic instability.
3
Determine the most immediate life-saving intervention.
Application of a pelvic binder is required immediately.
A binder reduces pelvic volume, promotes a tamponade effect on venous bleeding, and mechanically stabilizes the fracture, bridging the patient to definitive management.

Anahtar Kavram

In a hemodynamically unstable trauma patient with a pelvic ring fracture and a negative FAST exam, the immediate next step is mechanical stabilization with a pelvic binder to reduce pelvic volume and tamponade retroperitoneal venous hemorrhage.
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Orthopedic Surgery

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