A 25-year-old man is brought to the emergency department following a high-speed motorcycle collision. The patient is alert and in distress due to pain. Blood pressure is 84/52 mm Hg and pulse is 130/min. The airway is patent, the trachea is midline, and breath sounds are present bilaterally. Heart sounds are normal. There is bruising across the left chest wall, the lower abdomen, and the left flank. The abdomen is soft and mildly tender to palpation diffusely, without rebound tenderness. The bony pelvis is unstable to gentle downward pressure. The left lower leg is visibly deformed but distal lower extremity capillary refill is symmetric. There is blood present at the urethral meatus. Chest x-ray reveals multiple rib fractures without pneumothorax. Focused Assessment with Sonography for Trauma reveals no pericardial effusion or intraperitoneal free fluid. Portable anteroposterior pelvic x-ray is shown in the image below: In addition to resuscitation with IV crystalloid and/or blood products, which of the following is the best next step in management of this patient?

Question

A 25-year-old man is brought to the emergency department following a high-speed motorcycle collision.  The patient is alert and in distress due to pain.  Blood pressure is 84/52 mm Hg and pulse is 130/min.  The airway is patent, the trachea is midline, and breath sounds are present bilaterally.  Heart sounds are normal.  There is bruising across the left chest wall, the lower abdomen, and the left flank.  The abdomen is soft and mildly tender to palpation diffusely, without rebound tenderness.  The bony pelvis is unstable to gentle downward pressure.  The left lower leg is visibly deformed but distal lower extremity capillary refill is symmetric.  There is blood present at the urethral meatus.  Chest x-ray reveals multiple rib fractures without pneumothorax.  Focused Assessment with Sonography for Trauma reveals no pericardial effusion or intraperitoneal free fluid.  Portable anteroposterior pelvic x-ray is shown in the image below:  In addition to resuscitation with IV crystalloid and/or blood products, which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d85e_2c26_bc81_e9e7f93a6a22_MD0003_00 This trauma patient has shock (eg, severe hypotension and tachycardia) in the setting of severe pelvic fracture (eg, unstable pelvis on palpation, pelvic ring disruption on x-ray) with accompanying signs of retroperitoneal hemorrhage (eg, flank ecchymosis). To prevent exsanguination during ongoing resuscitation efforts and evaluation, a pelvic binder should be immediately placed. Patients with severe pelvic fractures, such as this open-book pelvic fracture (ie, pelvic ring disruption with anterior widening), are at risk for life-threatening hemorrhage. Hemorrhage is typically caused by the tearing of the thin-walled venous plexus (presacral, lumbar) but rarely may involve the iliac vessels. Resultant bleeding can both fill the expanded pelvic volume (from widening of the pelvic ring) and extend into the retroperitoneum. Therefore, rapid, external stabilization with a pelvic binder should be performed as soon as possible in hemodynamically unstable (ie, systolic blood pressure <90 mm Hg) patients, such as this one; this decreases pelvic volume and promotes tamponade of venous bleeding. (Choices A and E) The eventual workup of this patient will likely include CT scan of the abdomen and pelvis to assess for intraabdominal injury and provide three-dimensional visualization of the pelvic fractures. Retrograde cystourethrogram will also be indicated to assess for urethral injury, especially given the finding of blood at the urethral meatus. However, because this patient is currently hemodynamically unstable, hemorrhage control (eg, pelvic binder) and resuscitation should be performed first to stabilize the patient prior to any diagnostic testing that requires transport away from the trauma bay. (Choices C and D) This patient with a left lower leg deformity will likely undergo plain radiographs of the left tibia and fibula and reduction of the lower leg deformity (eg, temporary splinting) following stabilization. However, hemorrhage control (eg, pelvic binder) and resuscitation should be performed first. Patients are more likely to lose large amounts of blood into the pelvis (eg, up to the entire blood volume) or thigh (eg, up to 1-2 L) compared to the lower leg. Educational objective: Pelvic fractures, especially those with pelvic ring disruption, can cause life-threatening hemorrhage from vascular (eg, venous plexus) injury. Pelvic binder application can decrease pelvic volume and promote tamponade of bleeding. References: Pelvic trauma: WSES classification and guidelines. (http://www.ncbi.nlm.nih.gov/pubmed/28115984) Western Trauma Association Critical Decisions in Trauma: management of pelvic fracture with hemodynamic instability - 2016 updates. (http://www.ncbi.nlm.nih.gov/pubmed/27537512) Trends and efficacy of external emergency stabilization of pelvic ring fractures: results from the German Pelvic Trauma Registry. (http://www.ncbi.nlm.nih.gov/pubmed/31119322)

A 25-Year-Old Man Is Brought to the Emergency Department Following