Snapshot A 23-year-old man presents to the emergency department after a motor vehicle accident. He was riding in the front seat of the car while wearing a seatbelt. After the accident, he developed severe pain in the pelvic region. The emergency medical technician arrived at the scene and immediately immobilized the patient and intravenous fluids are started. The patient’s blood pressure is 98/62 mmHg and pulse is 104/min. In the emergency department, there is disfigurement of the hip with ecchymosis in the affected area. There is no blood in the urethral meatus. A radiograph of the pelvis demonstrates a pelvic fracture. A pelvic binder is placed and orthopedic surgery is consulted. Introduction Clinical definition fracture of the pelvic bone Epidemiology incidence highest in patients 15-28 years of age < 35 years of age more common in men > 35 years of age more common in women Etiology low-energy trauma e.g., fall and athletic injury high-energy trauma e.g., motor vehicle accident Pathogenesis trauma to the pelvis may result in fracture hemorrhage may occur with the pelvic fracture due to bleeding from the exposed fracture injury to soft tissues venous bleeding Prognosis improved outcomes in patients managed with early pelvic stabilization Presentation Symptoms pain disability Physical exam physical exam findings depend on the severity of the trauma and involved structures pelvic deformity hematomas may be present the patient may have associated injuries involving the head chest abdomen Imaging Radiography indication initial imaging study in patients with suspected pelvic trauma view anteroposterior view of the pelvis Computerized tomography (CT) scan indication gold standard imaging modality for pelvic fracture Studies Labs in the emergency setting, the following labs are typically ordered complete blood count hemoglobin and hematocrit to monitor for ongoing blood loss blood type and screen in case a blood transfusion is needed creatinine and urine studies coagulation profile toxicology screen Making the diagnosis a clinical diagnosis supported by imaging studies Treatment Conservative pelvic binder indication to create a tamponade effect, stabilize the fracture, and improve patient comfort Operative vessel embolization indication can be indicated in cases of refractory bleeding Complications Neurological injury erectile dysfunction due to nerve damage Infection Hemorrhage References
QUESTIONS 1 of 3 1 2 3 Previous Next Lab Values Blood Hematologic Cerebrospinal Sweat, Urine, and BMI Blood, Plasma, Serum Reference Range ALT 8-20 U/L Amylase, serum 25-125 U/L AST 8-20 U/L Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL Calcium, serum (Ca2+) 8.4-10.2 mg/dL Cholesterol, serum Rec: < 200 mg/dL Cortisol, serum 0800 h: 5-23 μg/dL //1600 h: 3-15 μg/dL 2000 h: ≤ 50% of 0800 h Creatine kinase, serum Male: 25-90 U/LFemale: 10-70 U/L Creatinine, serum 0.6-1.2 mg/dL Electrolytes, serum Sodium (Na+) 136-145 mEq/L Chloride (Cl-) 95-105 mEq/L Potassium (K+) 3.5-5.0 mEq/L Bicarbonate (HCO3-) 22-28 mEq/L Magnesium (Mg2+) 1.5-2.0 mEq/L Estriol, total, serum (in pregnancy) 24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL 28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL Ferritin, serum Male: 15-200 ng/mLFemale: 12-150 ng/mL Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL Female: premenopause: 4-30 mIU/mL midcycle peak: 10-90 mIU/mL postmenopause: 40-250 pH 7.35-7.45 PCO2 33-45 mmHg PO2 75-105 mmHg Glucose, serum Fasting: 70-110 mg/dL2-h postprandial:<120 mg/dL Growth hormone - arginine stimulation Fasting: <5 ng/mLProvocative stimuli: > 7ng/mL Immunoglobulins, serum IgA 76-390 mg/dL IgE 0-380 IU/mL IgG 650-1500 mg/dL IgM 40-345 mg/dL Iron 50-170 μg/dL Lactate dehydrogenase, serum 45-90 U/L Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL Female: follicular phase: 5-30 mIU/mL midcycle: 75-150 mIU/mL postmenopause 30-200 mIU/mL Osmolality, serum 275-295 mOsmol/kd H2O Parathyroid hormone, serume, N-terminal 230-630 pg/mL Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L Phosphorus (inorganic), serum 3.0-4.5 mg/dL Prolactin, serum (hPRL) < 20 ng/mL Proteins, serum Total (recumbent) 6.0-7.8 g/dL Albumin 3.5-5.5 g/dL Globulin 2.3-3.5 g/dL Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h Thyroxine (T4), serum 5-12 μg/dL Triglycerides, serum 35-160 mg/dL Triiodothyronine (T3), serum (RIA) 115-190 ng/dL Triiodothyronine (T3) resin uptake 25%-35% Urea nitrogen, serum 7-18 mg/dL Uric acid, serum 3.0-8.2 mg/dL Hematologic Reference Range Bleeding time 2-7 minutes Erythrocyte count Male: 4.3-5.9 million/mm3Female: 3.5-5.5 million mm3 Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/hFemale: 0-20 mm/h Hematocrit Male: 41%-53%Female: 36%-46% Hemoglobin A1c ≤ 6 % Hemoglobin, blood Male: 13.5-17.5 g/dLFemale: 12.0-16.0 g/dL Hemoglobin, plasma 1-4 mg/dL Leukocyte count and differential Leukocyte count 4,500-11,000/mm3 Segmented neutrophils 54%-62% Bands 3%-5% Eosinophils 1%-3% Basophils 0%-0.75% Lymphocytes 25%-33% Monocytes 3%-7% Mean corpuscular hemoglobin 25.4-34.6 pg/cell Mean corpuscular hemoglobin concentration 31%-36% Hb/cell Mean corpuscular volume 80-100 μm3 Partial thromboplastin time (activated) 25-40 seconds Platelet count 150,000-400,000/mm3 Prothrombin time 11-15 seconds Reticulocyte count 0.5%-1.5% of red cells Thrombin time < 2 seconds deviation from control Volume Plasma Male: 25-43 mL/kgFemale: 28-45 mL/kg Red cell Male: 20-36 mL/kgFemale: 19-31 mL/kg Cerebrospinal Fluid Reference Range Cell count 0-5/mm3 Chloride 118-132 mEq/L Gamma globulin 3%-12% total proteins Glucose 40-70 mg/dL Pressure 70-180 mm H2O Proteins, total < 40 mg/dL Sweat Reference Range Chloride 0-35 mmol/L Urine Calcium 100-300 mg/24 h Chloride Varies with intake Creatinine clearance Male: 97-137 mL/minFemale: 88-128 mL/min Estriol, total (in pregnancy) 30 wks 6-18 mg/24 h 35 wks 9-28 mg/24 h 40 wks 13-42 mg/24 h 17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 hFemale: 2.0-8.0 mg/24 h 17-Ketosteroids, total Male: 8-20 mg/24 hFemale: 6-15 mg/24 h Osmolality 50-1400 mOsmol/kg H2O Oxalate 8-40 μg/mL Potassium Varies with diet Proteins, total < 150 mg/24 h Sodium Varies with diet Uric acid Varies with diet Body Mass Index (BMI) Adult: 19-25 kg/m2 Calculator ( ) xy AC 7 8 9 ÷ 4 5 6 × 1 2 3 - 0 . = + Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (M2.OR.17.4756) A 29-year-old male presents to the emergency department after a motor vehicle accident. The patient was an unrestrained passenger who was involved in a head-on collision. The patient has a Glasgow Coma Scale of 7 on arrival. On physical exam, you note a young man covered in bruises and scrapes. There is notable erythema and edema of his pelvis, and profound bruising of his dorsal upper back. His temperature is 99.5°F (37.5°C), pulse is 112/min, blood pressure is 100/70 mmHg, respirations are 18/min, and oxygen saturation is 97% on room air. The patient is started on IV fluids and radiography is obtained as seen in Figure A and B. The patient’s blood pressure 15 minutes later is 98/69 mmHg. IV fluids are continued, and a FAST exam is performed which is negative for signs of intrathoracic or intraabdominal trauma. Which of the following is the best next step in management? Review Topic | Tested Concept QID: 109011 FIGURES: A B Type & Select Correct Answer 1 CT scan of the abdomen and pelvis 10% (4/42) 2 Placement of a pelvic binder 79% (33/42) 3 Embolization of the pelvic vessels 10% (4/42) 4 Large needle decompression of the 4th intercostal space 2% (1/42) 5 Immediate blood transfusion 0% (0/42) L 3 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review tested concept (M2.OR.17.4757) A 69-year-old male presents to the emergency department after a car crash. The patient is unconscious and his shirt is covered in blood. The patient has severe JVD and seems to be struggling to breathe. His temperature is 99.5°F (37.5°C), pulse is 160/min, blood pressure is 90/50 mmHg, respirations are 18/min, and oxygen saturation is 93% on room air. Large needle decompression is performed, and IV fluids are started. A pelvic binder is placed and a full trauma assessment is started. The patient's physical exam is notable for multiple bruises and erythema over the ventral chest, arms, and pelvis. The patient has a type and screen sent off and a radiograph of the pelvis is ordered and is in Figure A. A radiograph of the chest is performed and is notable for multiple broken ribs. A FAST exam is ordered and returns negative for any signs of abdominal bleeding or cardiac tamponade. During this time, IV fluids are continued and a chest tube is placed. There is no drainage of blood from the chest tube. His temperature is 99.5°F (37.5°C), pulse is 170/min, blood pressure is 85/55 mmHg, respirations are 10/min, and oxygen saturation is 96% on room air. IV fluids are continued, however, the patient’s vitals do not improve. Which of the following is the best next step in management? Review Topic | Tested Concept QID: 109012 FIGURES: A Type & Select Correct Answer 1 Vessel embolization 37% (11/30) 2 Repeat FAST exam 3% (1/30) 3 Exploratory laparotomy 47% (14/30) 4 Exploratory laparoscopy 3% (1/30) 5 Norepinephrine 10% (3/30) L 3 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review tested concept