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Old 04-25-2012
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ER Pelvic fracture Question

A 26-year-old woman was hit by a car and brought to the trauma bay with a blood pressure of 62/40 mm Hg. On xamination she is unresponsive, her pupils are equally round and reactive, her distal pulses are weak, and her extremities
are cold. X-ray of the chest is normal.
Peritoneal lavage shows no blood in the abdomen. After receiving 2 L of lactated Ringer’s solution, her blood pressure increases to 71/46 mm Hg. The pelvis is unstable with compression, and an anteroposterior x-ray of the pelvis confirms a pelvic fracture. What is the best next step in management?

(A) Application of an external fixation device
(B) Exploratory laparotomy with packing of the pelvis
(C) Open reduction and internal fixation of the fracture
(D) Pelvic CT with contrast
(E) Surgical exploration of pelvic hematoma
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Old 04-26-2012
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(E) Surgical exploration of pelvic hematoma
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Old 04-26-2012
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E) Surgical exploration, eventho her BP went up, she is still losing blood and seeing the peritoneal lavage didnt yield anything, we have to look for the source of bleeding and then correct the fracture
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Old 04-26-2012
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Best next step in management..............A
This will decrease/stop the bleeding and buy time to resuscitate her.

However, the best step in management would be to an angiogram (once she is hemodynamically stable) with embolization of the bleeding vessel.

"her distal pulses are weak" because her BP is so low.

Last edited by Novobiocin; 04-26-2012 at 06:59 AM.
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Quote:
Originally Posted by pakigal View Post
(E) Surgical exploration of pelvic hematoma
You NEVER do surgical exploration for a pelvic hematoma. It always ends in a disaster. It's like trying to find a needle (source of bleed) in a sea (abdomen/pelvis filling up with blood).
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Quote:
Originally Posted by XpaezX View Post
E) Surgical exploration, eventho her BP went up, she is still losing blood and seeing the peritoneal lavage didnt yield anything, we have to look for the source of bleeding and then correct the fracture

As Conrad Fisher would say--Surgical exploration for a pelvic hematoma is always the wrong answer.
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Old 04-26-2012
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I think answer is (B) Exploratory laparotomy with packing of
the pelvis...not sure about packing of pelvis

After MVA if patient is stable next step should be DPL
if unstable then exploratory laprotomy....

what is the answer ??
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Old 04-26-2012
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Quote:
Originally Posted by Novobiocin View Post
As Conrad Fisher would say--Surgical exploration for a pelvic hematoma is always the wrong answer.
in which video?
btw, you are correct. pelvic fracture ->fixature. and angiography and embolization. hematoma are not removed surgically.
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Old 04-26-2012
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Answer is A
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The correct answer is A. An exsanguinating
hemorrhage is likely when hypotension and
shock are present in the setting of a pelvic fracture.
Patients with evidence of unstable fractures
of the pelvis associated with hypotension
should be considered for some form of external
pelvic stabilization, which has been shown to
decrease mortality in these patients. The exact
mechanism by which early pelvic stabilization
is effective in promoting hemodynamic stability
in patients with unstable pelvic fractures is
not completely understood. However, some believe
that reducing the pelvis back to its normal
configuration reduces pelvic volume, and
therefore limits the amount of blood loss to the
retroperitoneal pelvic hematoma. Thus, keeping
the pelvic volume small may promote tamponade
of the bleeding sources in the pelvis.

Answer B is incorrect. Laparotomy is not warranted
without evidence of gross blood in the
abdomen or evidence of intestinal perforation.
The diagnostic peritoneal lavage is a reliable
diagnostic test for this purpose. In addition,
patients with evidence of unstable pelvic fractures
who warrant laparotomy should receive
external pelvic stabilization prior to any incisions.

Answer C is incorrect. Internal fixation should
be considered only if the patient is hemodynamically
stable.

Answer D is incorrect. Patients who are hemodynamically
unstable should not be sent to
the CT scanner. Once stable, a patient may be
taken to the scanner. Patients with evidence of
arterial extravasation of intravenous contrast in
the pelvis via CT should be considered for pelvic
angiography and possible embolization.

Answer E is incorrect. A pelvic hematoma
should never be explored due to the risk of uncontrollable
bleeding.
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Old 04-27-2012
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Quote:
Originally Posted by Novobiocin View Post
Best next step in management..............A
This will decrease/stop the bleeding and buy time to resuscitate her.

However, the best step in management would be to an angiogram (once she is hemodynamically stable) with embolization of the bleeding vessel.

"her distal pulses are weak" because her BP is so low.
yes we dont do surgical exploration in pelvic fracture ..we have to see if hemodynamically stable with pelvic fracture then leave them alone with foley cath...if unstable next step DPL to rule out any bleeding from abdominal organ if pelvic is the source then external fixation device with arteriographic embolization.
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Old 04-27-2012
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Also be careful when inserting a folleye catheter in a patient of pelvic fracture.These patients may also have associated urethral injury.
If you see blood at urethral meatus an papable bladder, don't attempt folleye's catheter, do supra pubic catheterization.



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