ABDOMINAL AND PELVIC TRAUMA242 Surgical Emergencies
4 Rectal examination is mandatory to identify rectal or urethral injury.
5 Insert two large-bore i.v. cannulae and send blood for FBC, U&Es, lipase/
amylase, coagulation profile, blood sugar and cross-match at least 6 units of
blood.
6 Request a pelvic X-ray in all multi-trauma patients, especially if there is
unexplained hypotension.
7 Pelv ic fractures associated wit h t he greatest risk of haemorrhage include:
(i) Quadripartite ‘butterfly’ fracture of all four pubic rami.
(ii) Open-book fracture with diastasis of the symphysis pubis over
2.5 cm.
(iii) Vertical shear fracture with hemipelvic disruption, such as the
Malgaigne fracture.
8 Arrange a CT scan with i.v. contrast providing the patient is not haemo-
dynamically unstable.MANAGEMENT1 Give high-f low oxygen. Commence i.v. f luid resuscitation, and change to
blood as indicated.
2 Do not attempt to catheterize the bladder if urethral rupture is suspected,
but await assistance from an experienced ED doctor, or the surgical team.
3 Fashion a pelvic sling from a sheet secured tightly around the front of the
pelvis, or preferably use one of the radiolucent, commercially available pelvic
slings.
4 Exclude intraperitoneal bleeding with an early bedside ultrasound (FAST) or
fai ling t his a supra-umbi lica l, open diagnostic peritonea l lavage (DPL), if t he
patient is too unstable for a CT scan.
5 Call the surgical, orthopaedic and interventional radiology team imme -
diately.
(i) Control of haemorrhage secondary to pelvic trauma may require
external fixation, arterial embolization and/or laparotomy.Blunt renal injury
DIAGNOSIS
1 These may be associated with injury to the vertebral column, lower ribs,
ureters, aorta, inferior vena cava and the abdominal contents.
2 Blunt renal trauma causes haematuria, loin pain and tenderness, and rarely a
f lank mass may be felt.
3 Hypotension is due to retroperitoneal bleeding or sometimes an associated
paralytic ileus.