Trauma reportA case-based approach to contemporary managementPelvic fracture
Section snippets
Case report
A 23-year-old man was brought in by ambulance after being “run over by a bus.” Witnesses described a moderate-speed, blunt force impact directly to the young man’s lower torso while he was crossing the street. En route, the patient was unresponsive except for moaning, with a systolic blood pressure of 90 mm Hg by palpation and a heart rate of 110–120 beats/min. On Emergency Department (ED) arrival, vitals signs revealed a blood pressure of 98 mm Hg systolic by palpation, a heart rate of 138
Discussion of initial evaluation and intervention
Pelvic fractures present many challenges for emergency physicians. Generally, these injuries are the result of high-energy blunt trauma and are often accompanied by severe intra-abdominal and vascular injuries (1). Hemodynamic instability can result from several sources of hemorrhage, between which the emergency physician must rapidly differentiate. These initial decisions are crucial: the majority of patients who die from pelvic fracture hemorrhage do so within the first 24 h (2, 3). The
Further ED management
After the equivocal bedside ultrasound results for hemoperitoneum, a diagnostic peritoneal lavage (DPL) was performed. Serosanguinous effluent, but no gross blood, was retrieved and interpreted as normal.
The initial plain radiographs were then read. The chest X-ray was negative for hemo- or pneumothorax, rib fractures, or pulmonary contusion. The pelvic film (Figure 1) showed a 2-cm pubic diastasis, a right ischial fracture involving the acetabulum, and widening of the left sacroiliac joint.
Ongoing treatment of severe injury
The next issue is how to control the bleeding. Three basic options exist: 1) externally closing the pelvic volume as previously discussed, 2) direct packing of the retroperitoneum in the operating room, or 3) angiography and embolization. Surgical packing is generally done only as a temporizing measure during the exploratory laporotomy; it rarely definitively controls the bleeding and can also release any tamponade that may exist within the retroperitoneum. Between the other two modalities,
Summary and prognosis
Given the equivocal FAST and DPL findings, the patient was transported to the operating room (OR) for exploratory laparotomy, which did not reveal any significant intrabdominal hemorrhage. The orthopedic team applied an external fixator during the surgery.
From the surgical suite, the patient was transported to angiography: the right superior gluteal artery and the left hypogastric artery demonstrated gross extravasation and were embolized. Finally, after aggressive fluid and blood
Authors’ recommendations
As in all aspects of Emergency Medicine, the physician must first determine if the patient is stable or unstable, as this delineation will guide all further management decisions. In stable patients with suspected pelvic fracture, pelvic X-ray should be performed only in 1) alert patients with a physical examination suggestive of pelvic injury and 2) altered patients in whom CT scan is not planned for other reasons. CT scan should be performed in all patients with either a positive PXR or
Conclusion
Our patient remained in the surgical intensive care unit for several months. Multiple grafts were placed to the sacral wound by the plastic surgery service. His hospital course was complicated by an enterocutaneous fistula, an abdominal wall abscess, and multiple episodes of septic shock requiring pressors. The patient was successfully extubated and, after 5 months in the hospital, discharged to a long-term care facility. His mental status has returned to baseline, but he is non-ambulatory and
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Cited by (0)
Trauma Reports are coordinated by Eric Legome, md, of the New York University School of Medicine and NYU/Bellevue Emergency Medicine Residency, New York, New York and Phillip Levy, md, of the Wayne State University School of Medicine and Detroit Receiving Hospital Emergency Medicine Residency, Detroit, Michigan