[size=20px]A seven year old unrestrained back seat passenger is involved in a high speed automobile crash. He is initially hemodynamically stable. There is lower abdominal and suprapubic tenderness on exam. Plain x-rays show unilateral pubic ramus and ischial fractures. An initial abdominopelvic computerized tomography (CT) scan shows normal parenchymal organs but a deep pelvic hematoma. After four hours of observation and resuscitation, his pulse rate remains unchanged at 110/min, his blood pressure is 110/70 mm Hg, and his hematocrit has fallen from 40% to 34%. The next step in management should be:

 

A. apply external fixation

 

B. immediate arteriography with embolization

 

C. continued volume resuscitation

 

D. repeat abdominal CT scan

 

E. urgent laparotomy[/size]

Edited November 30, 20205 yr by Admin

A

Think again my friend

Life-threatening hemorrhage related to pelvic fractures may originate from fractured bone, the pelvic venous plexus, major pelvic veins, and/or iliac arterial branches. Pelvic fracture hemorrhage caused by venous injury and the fracture site can be effectively treated with external fixation by reducing the pelvic volume and stabilizing the fracture (^,9). Arterial hemorrhage is the most serious problem associated with pelvic fractures (^,5), and it remains the leading cause of death. Several authors have suggested that the external fixation is not likely to be sufficient to stop arterial bleeding. Urgent angiography and subsequent transcatheter embolization are currently accepted as the most effective methods for controlling ongoing arterial bleeding in pelvic fractures (^,3,^,5,^,10).

A rough guide to the lower limit (5th percentile) of normal systolic blood pressure is 70 mm Hg+2x (Age in years). This child is demonstrating signs of blood loss from the pelvic fracture but is not hemodynamically unstable. Hemodynamic instability would be an indication for angiography and embolization. In unstable patients with ongoing bleeding from a pelvic fracture, embolization is highly successful in controlling hemorrhage if utilized in the first three hours. Repeat CT scan four hours after a study negative for intra abdominal visceral injury is not likely to provide useful information. There is no indication for laparotomy in this child - disturbing the pelvic hematoma may release the physiologic tamponade and result in bleeding which would be very difficult to control. External fixation is not required for the fracture described. Pneumatic anti-shock garments (PASG) have fallen out of favor due to complications such as lower extremity compartment syndrome, ventilatory limitation, and marked hypotension with decompression. Pelvic binders or other splint devices are preferentially used in the prehospital phase. PSAG's are not a definitive treatment of the pelvic fracture, and offer little benefit in this setting. Retroperitoneal hematomas can be classified as Zone 1 (Central hematomas), Zone 2 (Lateral hematomas), and Zone 3 (pelvic hematomas). A general guide to management is shown in the table below:

B; as long as he has ongoing bleeding and hemodynamically stable

The bleed will stopped

B

Correct answer is C