Unstable Pelvis and Suspected Hemorrhagic Shock
You are dispatched to a two-vehicle collision on a county road. A 34-year-old unrestrained driver struck a tree head-on at approximately 50 mph. He is awake but confused and complains of abdominal and pelvic pain. He is lying on the ground next to the car after self-extrication. Vital signs: BP 78/44, HR 138, RR 28, SpO2 92% on room air, GCS 14 (E4 V4 M6). His abdomen is tender and guarded; his pelvis is unstable to compression and he has blood at the meatus. He has no obvious external hemorrhage. Breath sounds are equal. The Level I trauma center is 22 minutes away; a community hospital with a small ED is 7 minutes away. Medical direction authorizes 1 unit of whole blood and tranexamic acid. You have a pelvic binder and spinal motion restriction equipment.
1. What is the priority physiologic problem, and what are the first three interventions?
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The priority is hemorrhagic shock from a mechanically unstable pelvis and possible intra-abdominal injury. Apply a pelvic binder at the level of the greater trochanters, not the iliac crests. Establish IV/IO access and give blood if available; limit crystalloid to avoid diluting clotting factors and raising BP before hemorrhage control. Give tranexamic acid within 3 hours of injury per protocol. Maintain spinal motion restriction, prevent hypothermia with blankets, and monitor for deterioration. Do not repeatedly palpate the pelvis. The GCS 14 is a warning but not the primary driver; hypotension is.
2. Transport to the 7-minute community ED or the 22-minute Level I trauma center? Explain your reasoning.
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Transport to the Level I trauma center, 22 minutes away. The community ED is closer but cannot provide definitive hemorrhage control; stopping there adds a second transfer and delays surgery. The patient is borderline but has a perfusing pressure and a short extra transport time. Notify the trauma center en route, continue blood and TXA, and reassess for airway or mental status decline. If he loses his airway or becomes pulseless, the closest ED becomes appropriate. Permissive hypotension (SBP about 80-90) is acceptable until hemorrhage control in this blunt trauma patient, but avoid profound hypotension and monitor mental status.
3. What should you avoid doing because of the blood at the meatus and the unstable pelvis?
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Do not insert a urinary catheter when there is blood at the meatus and an unstable pelvis; urethral injury is possible. Do not perform repeated pelvic exams or use the binder as a tourniquet. Avoid large-volume crystalloid and avoid delaying transport for nonessential procedures. If the pelvis is unstable, apply the binder once and leave it. Document the meatal blood, distal pulses, and neurologic status.