Unstable Pelvic Fracture With Intraperitoneal Fluid
A 31-year-old man is brought in after a high-speed motorcycle crash. He is confused, with a systolic blood pressure of 76 mmHg, heart rate 142/min, and a pelvic binder in place. FAST shows fluid in the left upper quadrant and pelvis. A pelvic radiograph shows an open-book fracture with widening of the symphysis. He has received 2 units of packed red cells through a rapid infuser and remains hypotensive. The trauma bay has immediate access to operating rooms and interventional radiology, but CT would require leaving the resuscitation area. He has no prior history, and family is not present.
1. What is the immediate management sequence, and how do you decide between laparotomy and angiography?
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Operate first. He is hemodynamically unstable with a positive FAST in the left upper quadrant, which suggests intraperitoneal hemorrhage, and he has an open-book pelvic fracture that can also bleed. He needs activation of the massive transfusion protocol, continued pelvic binding, warming, and immediate laparotomy-not CT. The left upper quadrant fluid may be spleen or bowel/mesentery; either way, laparotomy addresses it. Pelvic bleeding is often venous or from branches of the internal iliac and is best controlled by angioembolization after packing. If laparotomy is negative and he remains unstable, proceed to angiography. REBOA may be a bridge in refractory shock but should not delay hemorrhage control. The decision is driven by physiology and FAST, not by the fracture pattern alone.
2. At laparotomy, a mesenteric tear is controlled, but a large nonpulsatile pelvic retroperitoneal hematoma is expanding. What do you do and why?
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Do not open the pelvic retroperitoneum. The expanding nonpulsatile hematoma is likely pelvic venous bleeding, and opening it releases tamponade and can cause fatal exsanguination. Pack the pelvis, place a temporary abdominal closure, and transfer urgently to interventional radiology for embolization while continuing resuscitation. If the hematoma is pulsatile or the patient has signs of major arterial injury, proximal control-not direct opening-is needed. Re-explore at a planned second look after correction of coagulopathy and acidosis. Opening zone III blindly is one of the classic lethal maneuvers in trauma.
3. On ICU day 2, peak airway pressures rise, urine output falls, and bladder pressure is 26 mmHg. How do you manage this?
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Bladder pressure 26 mmHg with rising airway pressures and falling urine output indicates abdominal compartment syndrome. The patient needs decompression: ensure the temporary closure is not constricting, deepen sedation, consider paralysis, and remove excess fluid with diuresis or renal replacement if needed. If pressures and organ dysfunction persist, open the abdomen and use a negative-pressure temporary closure. Avoid large-volume crystalloid, which worsens edema. Monitor lactate, urine output, and ventilation. After decompression, plan delayed fascial closure and watch for reperfusion and bleeding.