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Difficulty: MediumTrauma and Burns

Following a severe pedestrian-vehicle collision, a young adult female is delivered to the trauma bay by paramedics. She was struck directly by a commercial truck that lost control on an icy road. On arrival, the patient is agitated, pale, and sweating profusely. The airway is clear, and bilateral breath sounds are symmetric and unlabored. Vital signs show a heart rate of 135/min and a blood pressure of 78/42 mm Hg, which remain unchanged after the rapid intravenous infusion of one liter of crystalloid solution. The abdomen is diffusely tender and mildly distended with a large ecchymosis across the periumbilical region. The pelvis is mechanically stable to anteroposterior and lateral compression. Which of the following is the most appropriate next step in management?

  1. Perform bedside abdominal ultrasonographyAnswer
  2. B
    Obtain a computed tomography scan of the abdomen and pelvis
  3. C
    Transfer the patient immediately for an exploratory laparotomy
  4. D
    Apply a circumferential pelvic compression device
  5. E
    Perform a diagnostic peritoneal lavage

Answer

Perform bedside abdominal ultrasonography
This patient has sustained blunt torso trauma and is presenting with hemorrhagic shock (tachycardia, hypotension) that is unresponsive to initial fluid resuscitation. According to Advanced Trauma Life Support (ATLS) protocols, the primary survey focuses on Airway, Breathing, and Circulation (ABC). Once the airway and breathing are secured, the source of hemodynamic instability must be rapidly identified. The Focused Assessment with Sonography for Trauma (FAST) exam is the diagnostic modality of choice for unstable blunt trauma patients. It is a rapid, non-invasive bedside test that detects free fluid (blood) in the pericardial sac and peritoneal cavity (hepatorenal, splenorenal, and retrovesical spaces). If the FAST exam is positive in this hemodynamically unstable patient, the next step would be an immediate exploratory laparotomy.

Step-by-Step Solution

1
Identify the patient's hemodynamic status and mechanism of injury.
The patient has experienced blunt trauma and is hemodynamically unstable (hypotensive and tachycardic) despite initial fluid resuscitation.
Hemodynamic stability dictates the diagnostic pathway in trauma; unstable patients cannot undergo prolonged or remote imaging studies.
2
Evaluate the clinical signs to localize potential sources of hemorrhage.
Breath sounds are normal (making massive hemothorax less likely), the pelvis is stable, but the abdomen is distended with ecchymosis, pointing to a likely intra-abdominal injury.
Identifying the most probable source of bleeding directs the immediate diagnostic focus.
3
Determine the most appropriate initial diagnostic test to confirm the source of bleeding.
A FAST (Focused Assessment with Sonography for Trauma) exam should be performed.
In unstable blunt trauma, FAST is the standard of care to quickly and non-invasively confirm intraperitoneal bleeding before proceeding to laparotomy.

Key Concept

In hemodynamically unstable patients with blunt abdominal trauma, a bedside FAST exam is the most appropriate next step to rapidly identify intraperitoneal hemorrhage before proceeding to definitive surgical intervention.
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Topics

Trauma and Burns

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