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  #1  
Old 01-22-2013
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Default pelvic fracture

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 examination 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
confi rms a pelvic fracture. What is the best
next step in management?

(A) Application of an external fi xation device
(B) Exploratory laparotomy with packing of
the pelvis
(C) Open reduction and internal fi xation of
the fracture
(D) Pelvic CT with contrast
(E) Surgical exploration of pelvic hematoma
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  #2  
Old 01-22-2013
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Quote:
Originally Posted by aknz View Post
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 examination 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
confi rms a pelvic fracture. What is the best
next step in management?

(A) Application of an external fi xation device
(B) Exploratory laparotomy with packing of
the pelvis
(C) Open reduction and internal fi xation of
the fracture
(D) Pelvic CT with contrast
(E) Surgical exploration of pelvic hematoma
I think the answer is C, because it is an unstable fracture so A) won't work for sure.
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  #3  
Old 01-22-2013
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I ll goo with A
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  #4  
Old 01-22-2013
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(A) Application of an external fixation device
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Old 01-22-2013
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(A) Application of an external fixation device= external fixation + pelvic hematoma will compress the injured vessels preventing further bleeding
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  #6  
Old 01-23-2013
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External Fixative Device is the correct answer.

2L of lactated ringers' in most cases is enough to raise the systolic BP to at least 100mmHg, failure to do so in a trauma patient, should arouse the possibility of active bleeding and the need to identify the source of this bleeding.

Diagnostic peritoneal lavage (DPL) is Negative, ruling out intra-abdominal hemorrhage.

The question gives away the answer by telling us a pelvic fracture is seen on an AP X-ray.

It is not clinically feasible to perform open surgery to stop bleeding considering:

a)the pelvis is not nearly as surgically accessible as the abdomen, so the best bet is an attempt at external fixation with the hope of achieving apposition of cut bone surfaces. This encourages the formation of a hematoma that would eventually arrest the bleed. Once bleeding is arrested, the patient would respond better to IV fluids.

b) Combining the above (surgical difficulty of the region) with the fact that the patient is currently not hemodynamically stable increases the chance that the patient will die on the OR table should he/she be operated on at that point.

...my 2 cents !
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  #7  
Old 01-23-2013
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Quote:
Originally Posted by kb_1 View Post
External Fixative Device is the correct answer.

2L of lactated ringers' in most cases is enough to raise the systolic BP to at least 100mmHg, failure to do so in a trauma patient, should arouse the possibility of active bleeding and the need to identify the source of this bleeding.

Diagnostic peritoneal lavage (DPL) is Negative, ruling out intra-abdominal hemorrhage.

The question gives away the answer by telling us a pelvic fracture is seen on an AP X-ray.

It is not clinically feasible to perform open surgery to stop bleeding considering:

a)the pelvis is not nearly as surgically accessible as the abdomen, so the best bet is an attempt at external fixation with the hope of achieving apposition of cut bone surfaces. This encourages the formation of a hematoma that would eventually arrest the bleed. Once bleeding is arrested, the patient would respond better to IV fluids.

b) Combining the above (surgical difficulty of the region) with the fact that the patient is currently not hemodynamically stable increases the chance that the patient will die on the OR table should he/she be operated on at that point.

...my 2 cents !
Nice explanation.
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Old 01-23-2013
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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.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 tamponadeof the bleeding sources in the pelvis.

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