Retroperitoneal bleed from the pelvic fracture should be uppermost. These can be quite difficult to control, but there are several interventions to stabilize the bleeding. In the first place, do no harm. Do not worsen the fracture and potentially the bleeding by rocking the pelvis to determine stability. Instead, if retroperitoneal hemorrhage from pelvic fracture is suspected, the pelvic bone should be stabilized with a commercial purpose-built device or by cinching a sheet around the patient's hips. Management can be expectant or can involve interventional radiology for embolization versus intraoperative management. The latter can lead to worse blood loss since the bleeding source can be difficult to identify and control in the OR. In such cases, packing and stabilization of the bony structures, then embolization, can be done.20 Retroperitoneal hemorrhage can occur with both blunt and penetrating abdominal injuries, with or without bony involvement. Other concerns in the differential are pulmonary embolus (fat, air, or thrombotic), pericardial tamponade, pneumothorax, or great vesselinjury. Neurogenic shock from a high spinal injury is less likely, given the tachycardia. Ongoing assessment of vital signs, imaging, or surgical exploration is indicated.
! Critical Considerations
ATLS guidelines provide an excellent basis for initial and ongoing management of abdominal trauma.
Understanding the mechanism and probable resulting patterns of injury are important for effective treatment.
Repeated surveys of the patient by examination and studies must be performed, and a high index of suspicion for occult injury maintained.
Investigation of related injuries outside of the abdomen, particularly in the chest, must be considered.
Early transfer to a definitive facility is a cornerstone of trauma management. Preparation and teamwork are paramount.
Understanding the relative strengths and weaknesses of the FAST, DPL, and CT scan improve care.
ICU management of the abdominal trauma patient should be viewed in continuum with the prehospital, trauma bay, and OR phases.
Injuries not apparent during initial stages of treatment may manifest in the ICU or floor setting, particularly as patient time in the initial stages decreases.