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Difficulty: MediumTrauma and Burns

A 52-year-old man is brought to the emergency department by ambulance after a high-speed motor vehicle collision. He was the unrestrained driver and was ejected from the vehicle. On arrival, the patient is lethargic and confused. His blood pressure is 78/48 mm Hg, and his pulse is 132/min and thready. His respiratory rate is 24/min, and oxygen saturation is 96% on a non-rebreather face mask. Physical examination reveals equal breath sounds bilaterally and normal heart sounds with no murmurs. The abdomen is distended, tympanitic, and diffusely tender with involuntary guarding. The pelvis is stable to anterior-posterior and lateral compression. Extremities show multiple abrasions but no obvious deformities. An arterial blood gas analysis shows a pH of 7.22, pCO2 of 32 mm Hg, and HCO3- of 12 mEq/L. Which of the following is the most appropriate next step in the management of this patient?

  1. A
    Computed tomography of the abdomen and pelvis
  2. Focused assessment with sonography for traumaAnswer
  3. C
    Nasogastric tube placement and serial abdominal examinations
  4. D
    Intravenous administration of sodium bicarbonate
  5. E
    Intravenous administration of broad-spectrum antibiotics

Answer

Focused assessment with sonography for trauma
The correct answer is Focused assessment with sonography for trauma (FAST). This patient presents with hemorrhagic shock following severe blunt trauma. His physical examination strongly points to an intra-abdominal source of bleeding (distended, rigid abdomen). According to the Advanced Trauma Life Support (ATLS) algorithm, a hemodynamically unstable patient with blunt abdominal trauma must undergo immediate bedside evaluation to confirm the presence of intraperitoneal fluid (blood). FAST is the preferred modality because it can rapidly detect hemoperitoneum at the bedside without delaying transport to the operating room for an exploratory laparotomy.

Step-by-Step Solution

1
Evaluate the patient's vital signs and hemodynamic status.
The patient is in severe shock (blood pressure 78/48 mm Hg, heart rate 132/min).
Hemodynamic status dictates whether a trauma patient can undergo advanced imaging or requires immediate bedside intervention.
2
Analyze the physical examination findings in the context of the injury mechanism.
Breath sounds are equal and the pelvis is stable, making tension pneumothorax and massive pelvic bleeding less likely. The abdomen is distended, tender, and guarded.
This localizes the likely source of hemorrhagic shock to the intra-abdominal cavity.
3
Determine the appropriate diagnostic test for a hemodynamically unstable patient with suspected intra-abdominal injury.
Focused assessment with sonography for trauma (FAST) is selected.
FAST is rapid, non-invasive, and can be performed at the bedside in the resuscitation bay without moving the unstable patient.

Key Concept

In hemodynamically unstable patients with blunt abdominal trauma, bedside Focused Assessment with Sonography for Trauma (FAST) is the initial diagnostic test of choice to evaluate for intraperitoneal hemorrhage.
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Topics

Trauma and Burns

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