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Difficulty: MediumTrauma and Burns

A 30-year-old woman, gravida 2, para 1, at 33 weeks gestation, is brought to the emergency department via ambulance after her vehicle struck a concrete barrier at highway speeds. Upon arrival, she is lethargic, pale, and diaphoretic. She localizes to painful stimuli and moans incomprehensibly. Her temperature is 36.4°C (97.5°F), blood pressure is 76/40 mmHg, heart rate is 135/min, and respiratory rate is 26/min. Physical examination reveals a seatbelt sign across her lower abdomen. The abdomen is distended and exhibits diffuse rebound tenderness. A focused assessment with sonography for trauma (FAST) demonstrates significant free fluid in the hepatorenal and splenorenal recesses. Continuous fetal monitoring shows a baseline heart rate of 100/min with minimal variability. Which of the following is the most appropriate next step in management?

  1. Immediate exploratory laparotomyAnswer
  2. B
    Cross-sectional imaging of the abdominopelvic region
  3. C
    Emergent cesarean delivery as the primary procedure
  4. D
    Aggressive intravenous crystalloid resuscitation and serial abdominal examinations
  5. E
    Withhold operative intervention until next-of-kin arrives to provide informed consent

Answer

Immediate exploratory laparotomy
The correct answer is immediate exploratory laparotomy. This patient is presenting with severe hemorrhagic shock following blunt abdominal trauma, evidenced by profound hypotension, tachycardia, altered mental status, and a positive FAST examination. The anatomical source of bleeding is confirmed to be intra-abdominal. In any pregnant trauma patient, maternal stabilization is the absolute priority, as maternal survival is the most critical determinant of fetal survival. A positive FAST in a hemodynamically unstable patient is an absolute indication for an emergent exploratory laparotomy to identify and surgically control the source of hemorrhage.

Step-by-Step Solution

1
Assess the patient's hemodynamic status.
The patient is hemodynamically unstable (blood pressure 76/40 mmHg, heart rate 135/min) and exhibits signs of hemorrhagic shock (lethargy, pallor, diaphoresis).
Hemodynamic stability dictates the entire algorithm for blunt abdominal trauma.
2
Evaluate the mechanism of injury and primary diagnostic findings.
The patient suffered high-speed blunt trauma, has signs of peritonitis, and the FAST examination is positive for intra-abdominal fluid (blood).
A positive FAST in an unstable patient pinpoints the abdomen as the source of life-threatening hemorrhage.
3
Integrate obstetric considerations into the trauma algorithm.
Despite being 33 weeks pregnant with a distressed fetus (bradycardia), maternal survival remains the absolute priority. Emergent laparotomy is indicated to control maternal hemorrhage.
Maternal resuscitation is the best and most effective method of fetal resuscitation. Addressing the mother's bleeding restores uteroplacental blood flow.

Key Concept

In pregnant trauma patients, maternal stabilization takes absolute priority. Hemodynamically unstable patients with a positive FAST exam require immediate exploratory laparotomy, regardless of gestational age.
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Topics

Trauma and Burns

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