An Open Book and still not Bored Review

EMS brings in a trauma notification: 40 year old man was so absorbed reading his book (51 Shades of Grey’s Anatomy) while crossing the street that he didn’t see the truck that struck him. He is moaning in pain and lethargic as he is rolled in.

VS: BP 86/64, HR 118, RR 20, T 98.6, 98% on RA. You cover your ABC’s and expose him. You do your E-FAST and see no free fluid and no pneumothorax. You feel pelvic instability.

What's the diagnosis, how do you confirm?

Pelvic fracture! Confirm with pelvis XR

What's the next step?

Apply a pelvic binder to control bleeding. The pelvis and retroperitoneum can hold up to 4 L of blood. If you don’t have a pelvic binder available use a bed sheet tied tight and low across the waist. Start massive transfusion. If the FAST is negative and there is no sign of intraperitoneal bleeding, then the next step for management is for external pelvic fixation and IR-guided arterial embolization.

However, if there is any sign of abdominal or thoracic bleeding, both an ex-lap and angiography are needed. There is debate regarding the order of these; traditionally ex-lap first then IR, however, ex-lap can increase pelvic bleeding so be aware of this controversy–in certain cases it may be prudent to first do IR-angiography.

Should you get a CT? There is some debate, but when a patient is hemodynamically unstable (like our patient above) this is contra-indicated.

What are some other complications you are worried about?

Urethral injury and bladder rupture. Check for blood at the meatus or a high-riding prostate. If these signs are present, do not place a foley, and get a retrograde urethrogram.

References

Tintinalli’s 7th Ed.

Simon’s Orthopedic Emergencies 7th Ed.

By Dr. Kylie Birnbaum

Special thanks to Dr. Willis

Photo cred: http://www.wikiradiography.net/page/Open+Book+Fracture