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Take to the angiography suite
69%
568/824
Take to the operating room for exploratory laparotomy
1%
6/824
Take to the operating room for pelvic external fixator
7%
54/824
Take to the operating room for exploratory laparotomy and pelvic external fixator
5%
40/824
Take to the operating room for pelvic external fixation and then take to the angiography suite
18%
151/824
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In a hemodynamically stable patient with an arterial bleed in the setting of an unstable open book pelvis fracture, the most appropriate course of action would be to take to the angiography suite. While a pelvic binder may eventually be converted to a pelvic external fixator to alleviate pressure on the skin, it is not necessary for the acute setting as studies have shown equivalent stability.Unstable pelvic ring fractures typically occur as a result of blunt trauma. They may be associated with solid organ, urogenital, or vascular injury. The management of unstable pelvic ring injuries often depends on the hemodynamic status of the patient. Adequate resuscitation with fluids and blood products in conjunction with a pelvic binder or sheet is the most common initial management. If the patient is stable, they may proceed to the CT scanner with possible interventional radiology intervention. If the patient is unstable, they are taken for exploratory laparotomy. Institutions may have varying protocols based on their availability of resources.Prasarn et al performed a cadaveric study investigating the stability conferred by a pelvic ex-fix compared to a pelvic binder. Five unstable pelvis fractures were created in 5 whole body cadavers and their stability was tested with electromagnetic sensors with both treatments. They found no difference in stability between the two.Marmor et al reviewed the management of the hemodynamically unstable patient with pelvic ring injury. They state that major bleeding on FAST or failure to respond to resuscitation is an indication for immediate intervention in the operating room. Major bleeding seen on CT in the hemodynamically stabilized patient is an indication for angiography.Figure A is an AP radiograph of the pelvis demonstrating an unstable open book pelvis fracture.Illustration A demonstrates the Young-Burgess classification of pelvic ring fractures.Incorrect Answers:Answers 2 and 4: In the setting of hemodynamic stability and with an available interventional radiologist, an initial trial of angiography and embolization is most appropriate.Answers 3 and 5: Studies have shown that a pelvic binder confers the same stability as a pelvic external fixator.
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