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Zorluk: ZorTrauma and Burns

A 28-year-old male warehouse worker is brought to the emergency department after being crushed laterally against a wall by a moving forklift. Upon arrival, he is confused and diaphoretic. Vital signs are temperature 36.2°C, heart rate 132/min, blood pressure 78/50 mmHg, and respiratory rate 22/min. Oxygen saturation is 96% on room air. Primary survey reveals a patent airway and equal breath sounds bilaterally. The abdomen is soft and non-distended with no peritoneal signs. Palpation of the pelvis reveals gross mechanical instability. Genitourinary examination shows marked scrotal ecchymosis, and digital rectal examination reveals a high-riding prostate. An anteroposterior pelvic radiograph confirms a severely displaced open-book pelvic ring fracture. A pelvic binder is immediately applied, and the patient is resuscitated with 2 units of uncrossmatched packed red blood cells. Following this intervention, his blood pressure remains 80/52 mmHg. A focused assessment with sonography for trauma (FAST) scan is performed and shows no free intraperitoneal or pericardial fluid. Which of the following is the most appropriate next step in management?

  1. A
    Computed tomography of the abdomen and pelvis
  2. B
    Exploratory laparotomy
  3. C
    Retrograde urethrography
  4. D
    Transurethral placement of a Foley catheter
  5. Pelvic angiographyCevap

Cevap

Pelvic angiography
The correct answer is pelvic angiography. This patient presents with hemorrhagic shock and a mechanically unstable pelvic ring fracture. The initial management for an unstable pelvic fracture involves placing a pelvic binder to reduce pelvic volume and promote the tamponade of venous bleeding, alongside blood product resuscitation. If the patient remains hemodynamically unstable, a FAST examination is critical to determine if there is concurrent intra-abdominal bleeding. A positive FAST would mandate an exploratory laparotomy. However, in this patient, the FAST is negative, indicating that the source of the persistent hemorrhage is retroperitoneal, likely from disrupted pelvic arterial vessels (e.g., branches of the internal iliac artery). The most appropriate definitive next step to control retroperitoneal arterial hemorrhage is pelvic angiography with embolization. Preperitoneal pelvic packing is an alternative in some institutional protocols, but it is not listed among the choices.

Adım Adım Çözüm

1
Identify the patient's hemodynamic status.
The patient is in class III/IV hemorrhagic shock (confused, BP 80/52 mmHg, HR 132/min) that is unresponsive to initial volume resuscitation and placement of a pelvic binder.
Determining hemodynamic stability dictates whether the patient can safely undergo cross-sectional imaging (CT) or requires immediate intervention.
2
Localize the primary source of the life-threatening hemorrhage.
The FAST scan is negative, ruling out massive intraperitoneal or pericardial bleeding. The physical exam and radiograph confirm an unstable pelvic fracture.
A negative FAST in the presence of an unstable pelvis localizes the severe bleeding to the retroperitoneal space, which is typically venous (venous plexus) but can be arterial in cases of severe instability.
3
Determine the next appropriate intervention in the ATLS pathway.
Since the bleeding is localized to the retroperitoneum and the patient remains hypotensive despite a binder, pelvic angiography with embolization (or preperitoneal pelvic packing) is required.
Exploratory laparotomy is avoided here because opening the peritoneum releases the tamponade effect, potentially accelerating retroperitoneal blood loss.

Anahtar Kavram

Management of hemodynamically unstable pelvic fractures
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Trauma and Burns

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