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Zorluk: Çok zorTrauma and Burns

A 45-year-old man is brought to the emergency department 30 minutes after falling from a 3-story building. He is confused and moaning in pain. His temperature is 36.2°C (97.2°F), blood pressure is 75/40 mm Hg, heart rate is 135/min, and respiratory rate is 24/min. The airway is patent, and breath sounds are clear and equal bilaterally. A portable chest radiograph is unremarkable. A portable pelvic radiograph demonstrates a 4.5-cm diastasis of the pubic symphysis. A pelvic binder is immediately applied and secured appropriately. Focused assessment with sonography for trauma (FAST) demonstrates a large volume of anechoic fluid in the hepatorenal and splenorenal recesses. The patient receives 2 units of uncrossmatched packed red blood cells and 2 units of fresh frozen plasma via a rapid infusion device. Following the transfusion, his blood pressure is 78/42 mm Hg and heart rate is 130/min. Which of the following is the most appropriate next step in management?

  1. Immediate exploratory laparotomyCevap
  2. B
    Computed tomography of the abdomen and pelvis
  3. C
    Pelvic angiography with embolization
  4. D
    Immediate preperitoneal pelvic packing
  5. E
    Diagnostic peritoneal lavage

Cevap

Immediate exploratory laparotomy
The most appropriate next step in management is immediate exploratory laparotomy. This patient is in severe hemorrhagic shock due to blunt trauma and is a non-responder to initial damage-control resuscitation (pelvic binder application and massive transfusion protocol initiation). The unequivocally positive FAST scan indicates significant intra-abdominal hemorrhage. According to Advanced Trauma Life Support (ATLS) guidelines, a hemodynamically unstable patient with a positive FAST requires an emergent exploratory laparotomy to surgically control the bleeding. Although the patient has a concurrent life-threatening 'open-book' pelvic fracture, the intra-abdominal bleeding takes immediate surgical priority. During the laparotomy, if the patient remains hemodynamically unstable from suspected retroperitoneal pelvic bleeding, concurrent preperitoneal pelvic packing can be performed in the operating room.

Adım Adım Çözüm

1
Identify the patient's hemodynamic status.
The patient is in Class III/IV hemorrhagic shock (BP 75/40 mm Hg, HR 135/min) and is a non-responder to initial damage-control resuscitation (binder and blood products).
Establishing hemodynamic instability dictates the urgency and type of subsequent interventions.
2
Assess the sources of hemorrhage.
There are two major sources identified: severe pelvic fracture (diastasis of the pubic symphysis) and intra-abdominal injury (positive FAST).
Multiple sources of hemorrhage require prioritization based on ATLS guidelines.
3
Determine the priority of intervention.
Immediate exploratory laparotomy is chosen as the next step.
In the presence of a positive FAST and hemodynamic instability, intra-abdominal hemorrhage control takes absolute precedence over isolated pelvic interventions.

Anahtar Kavram

In hemodynamically unstable blunt trauma patients with multiple sources of hemorrhage (e.g., severe pelvic fracture and positive FAST), exploratory laparotomy is the mandatory next step to control intra-abdominal bleeding.
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Trauma and Burns

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