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Soru

Zorluk: ZorSurgical and Procedural Interventions

A 29-year-old male is brought to the trauma center following a severe crush injury at a construction site. He is confused and pale. Vital signs are HR 142/min, BP 70/40 mm Hg, and RR 26/min. The airway is intact, and breath sounds are equal bilaterally. A focused assessment with sonography for trauma (FAST) exam shows no pericardial or intraperitoneal fluid. A portable chest radiograph is normal. A portable pelvic radiograph reveals a severe diastasis of the pubic symphysis and disruption of the right sacroiliac joint. A pelvic binder is immediately applied, and a massive transfusion protocol is initiated. After receiving 4 units of packed red blood cells, 4 units of fresh frozen plasma, and 1 unit of platelets over the next 20 minutes, the patient's blood pressure remains 72/42 mm Hg. The interventional radiology suite is currently occupied with another emergency, and the team will not be available for at least an hour. Which of the following is the most appropriate next step in the management of this patient?

  1. Immediate open preperitoneal pelvic packingCevap
  2. B
    Exploratory laparotomy
  3. C
    Computed tomography angiography of the pelvis
  4. D
    Transfer to the surgical intensive care unit for continued volume resuscitation
  5. E
    Diagnostic peritoneal lavage

Cevap

Immediate open preperitoneal pelvic packing is the correct management step for this actively exsanguinating patient.
The patient is in profound hemorrhagic shock secondary to an unstable pelvic fracture, which typically causes massive retroperitoneal venous bleeding. Because the FAST exam is negative (ruling out major intraperitoneal bleeding) and the patient remains hypotensive despite an appropriately placed pelvic binder and aggressive massive transfusion, definitive mechanical hemostasis is immediately required. With interventional radiology unavailable for angioembolization, open preperitoneal pelvic packing is the standard, life-saving surgical intervention to directly tamponade the bleeding retroperitoneal venous plexus.

Adım Adım Çözüm

1
Identify the primary source of hemorrhagic shock.
The source is retroperitoneal bleeding from an unstable pelvic fracture.
The patient is hypotensive with a negative FAST exam and normal chest x-ray, making the severe pelvic ring disruption the definitive source of blood loss.
2
Evaluate the response to initial stabilization measures.
The patient remains in refractory shock despite the application of a pelvic binder and massive transfusion.
Ongoing venous plexus or arterial bleeding in the retroperitoneum has not been controlled by non-invasive external compression alone.
3
Determine the optimal definitive procedural intervention based on resource availability.
Proceed with open preperitoneal pelvic packing in the operating room.
Because interventional radiology is unavailable for an hour, surgical packing is the only immediate option to mechanically tamponade the retroperitoneal bleeding and prevent lethal exsanguination.

Anahtar Kavram

In a hemodynamically unstable patient with an isolated pelvic fracture and negative FAST, retroperitoneal hemorrhage is the primary concern. If angioembolization is unavailable or delayed, open preperitoneal pelvic packing is the immediate life-saving surgical intervention.
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Surgical and Procedural Interventions

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