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Zorluk: ZorTrauma and Burns

A 54-year-old female pedestrian is transported to the trauma bay after being struck by a public transit bus. Upon arrival, she is lethargic and pale. Her blood pressure is 75/40 mmHg, heart rate is 138/min, and respiratory rate is 26/min. The airway is patent, and breath sounds are equal bilaterally. Physical examination reveals extensive ecchymoses over the lower abdomen and flanks. There is a palpable diastasis of the pubic symphysis, and the pelvis is mechanically unstable to anteroposterior compression. An initial point-of-care ultrasound of the chest and abdomen shows no evidence of pericardial, pleural, or intraperitoneal fluid. An anteroposterior pelvic radiograph confirms a severely displaced open-book pelvic fracture. A circumferential non-invasive pelvic binder is promptly placed over the greater trochanters. Following the administration of two units of uncrossmatched type O-negative packed red blood cells, her blood pressure remains 78/42 mmHg and heart rate is 135/min. Which of the following is the most appropriate next step in the management of this patient?

  1. Fluoroscopic percutaneous arterial embolizationCevap
  2. B
    Contrast-enhanced cross-sectional imaging of the torso
  3. C
    Surgical exploration of the peritoneal cavity
  4. D
    Placement of a pelvic external orthopedic fixator
  5. E
    Percutaneous aspiration of the peritoneal space

Cevap

The correct answer is fluoroscopic percutaneous arterial embolization (or preperitoneal pelvic packing).
The correct answer is fluoroscopic percutaneous arterial embolization. This patient is experiencing hemorrhagic shock secondary to a severe pelvic ring disruption. In the setting of an unstable pelvic fracture, initial management dictates mechanical stabilization with a non-invasive pelvic binder to reduce pelvic volume and tamponade venous bleeding. If the patient remains hemodynamically unstable despite binding and initial blood product resuscitation, and intraperitoneal hemorrhage has been ruled out (via a negative point-of-care ultrasound), the most likely source of ongoing blood loss is arterial (e.g., branches of the internal iliac artery). The appropriate next intervention is pelvic angiography with embolization (or preperitoneal pelvic packing, depending on institutional protocol and resources). Proceeding to this step provides definitive hemorrhage control for bleeding that is refractory to mechanical compression.

Adım Adım Çözüm

1
Assess the primary survey and hemodynamic status.
The patient is in class III/IV hemorrhagic shock.
Vital signs demonstrate severe hypotension and tachycardia following high-energy blunt trauma.
2
Identify the source of hemorrhage.
Point-of-care ultrasound is negative for intracavitary bleeding; however, clinical and radiographic findings confirm a mechanically unstable pelvic fracture.
In blunt trauma, major blood loss typically occurs in the chest, abdomen, pelvis, or long bones. A negative ultrasound effectively points to the retroperitoneal pelvis as the source.
3
Institute initial hemorrhage control.
A non-invasive pelvic binder is applied to reduce pelvic volume and promote tamponade.
The majority of pelvic hemorrhage is venous and responds well to mechanical volume reduction.
4
Determine the subsequent step for refractory shock.
Arterial embolization (or preperitoneal packing) is indicated.
Persistent instability after pelvic binding and initial blood product resuscitation suggests ongoing arterial hemorrhage, which requires targeted definitive control.

Anahtar Kavram

Management of hemodynamically unstable pelvic fractures
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Konular

Trauma and Burns

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