A 42-year-old male construction worker is evaluated in the trauma center after a 15-foot fall from scaffolding. On arrival, his blood pressure is and heart rate is . His airway is patent, and breath sounds are present and equal bilaterally. A chest radiograph shows no abnormalities. The abdomen is soft and non-distended without guarding or rigidity. A focused assessment with sonography for trauma (FAST) reveals no free intraperitoneal or pericardial fluid. Gentle compression of the iliac crests reveals mechanical instability and crepitus. Which of the following is the most appropriate next step in management?
- Application of a pelvic binderCevap
- BComputed tomography of the abdomen and pelvis
- CExploratory laparotomy
- DPelvic angiography with embolization
- EDiagnostic peritoneal lavage
Cevap
Application of a pelvic binder
This patient is in hemorrhagic shock secondary to a pelvic fracture. The negative chest radiograph and negative FAST exam localize the life-threatening hemorrhage to the retroperitoneal space due to the mechanically unstable pelvic ring. The venous plexus and cancellous bone are the most common sources of bleeding in pelvic fractures. The immediate next step is the application of a pelvic binder (or sheet), which mechanically stabilizes the fracture, reduces pelvic volume, and promotes the tamponade of venous hemorrhage. Once the binder is applied and the patient receives balanced blood product resuscitation, further steps (such as pelvic angiography for arterial bleeding or preperitoneal packing) can be pursued if hemodynamic instability persists.
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Anahtar Kavram
Hemodynamically unstable patients with suspected pelvic fractures and a negative FAST exam should immediately undergo application of a pelvic binder to promote venous tamponade and reduce retroperitoneal hemorrhage.