tommyk
04-09-2006, 04:38 AM
Hy 2114 (Sorry the last two posts are numbered wrong, I don't know what happened) :cry:
While driving home from the library, you see a rollover car accident, a 25 year old named Elle Macpherson is thrown from the car. The car subsequently lands on her and crushes her very long legs.
On physical examination in the emergency department, it is determined that she has a pelvic fracture, which is confirmed by portable x-rays done as she is being resuscitated. :shock:
Her initial blood pressure is 50/30 mm Hg, and her pulse is 160/min and barely perceptible.
Thirty minutes later, after 2 L Ringer's lactate and 2 U packed cells have been infused, her pressure is only 70/50 mm Hg, and her pulse is 130/min.
A sonogram done in the emergency department shows no intra-abdominal bleeding, and a diagnostic peritoneal lavage confirms that there is no blood in the abdomen (the recovered fluid is pink, but not grossly bloody). Rectal and vaginal exams show no injuries to those organs. There is no blood in her urine. Do you…
1-Give IV fentanyl first
2-Angiogram of torn vein vessels
3-Consult Orthopedics for “external fixation”
4- Consult Orthopedics for “internal fixation and open reduction”
5-Surgerical laparotomy
6-Tylenol 3 by mouth
7-Advise bed rest due to her young age for 4 weeks
(Think before Peek)
a) This is actually a terrible situation, with no easy way out. This is the rare USMLE question that points to a “consult”. Ans is #4, external! First, fentanyl is SHORT acting. Pelvic fractures can bleed massively, and often the source is torn veins that are not easily controlled. Minimizing the motion of the bone fragments by external fixation can be helpful, and it will not make the situation worse. Angiography can be very helpful when arteries are torn. It cannot do the same for veins. And as for the surgeons coming to the rescue, this is one place in which the high and mighty are routinely humbled. Opening the pelvic hematoma loses the tamponade effect, and once into the thick of things, pelvic veins bleed massively and are not easily controlled. This is why I did not go into surgery….
While driving home from the library, you see a rollover car accident, a 25 year old named Elle Macpherson is thrown from the car. The car subsequently lands on her and crushes her very long legs.
On physical examination in the emergency department, it is determined that she has a pelvic fracture, which is confirmed by portable x-rays done as she is being resuscitated. :shock:
Her initial blood pressure is 50/30 mm Hg, and her pulse is 160/min and barely perceptible.
Thirty minutes later, after 2 L Ringer's lactate and 2 U packed cells have been infused, her pressure is only 70/50 mm Hg, and her pulse is 130/min.
A sonogram done in the emergency department shows no intra-abdominal bleeding, and a diagnostic peritoneal lavage confirms that there is no blood in the abdomen (the recovered fluid is pink, but not grossly bloody). Rectal and vaginal exams show no injuries to those organs. There is no blood in her urine. Do you…
1-Give IV fentanyl first
2-Angiogram of torn vein vessels
3-Consult Orthopedics for “external fixation”
4- Consult Orthopedics for “internal fixation and open reduction”
5-Surgerical laparotomy
6-Tylenol 3 by mouth
7-Advise bed rest due to her young age for 4 weeks
(Think before Peek)
a) This is actually a terrible situation, with no easy way out. This is the rare USMLE question that points to a “consult”. Ans is #4, external! First, fentanyl is SHORT acting. Pelvic fractures can bleed massively, and often the source is torn veins that are not easily controlled. Minimizing the motion of the bone fragments by external fixation can be helpful, and it will not make the situation worse. Angiography can be very helpful when arteries are torn. It cannot do the same for veins. And as for the surgeons coming to the rescue, this is one place in which the high and mighty are routinely humbled. Opening the pelvic hematoma loses the tamponade effect, and once into the thick of things, pelvic veins bleed massively and are not easily controlled. This is why I did not go into surgery….