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Difficulty: MediumTrauma and Burns

A 28-year-old pregnant woman at 34 weeks gestation is evaluated in the trauma center following a high-velocity motor vehicle collision. First responders noted substantial vehicular damage. On arrival, she is alert but anxious. Her airway is patent and breathing is unlabored. Vital signs show a temperature of 36.7∘C36.7^\circ\text{C} (98.1∘F98.1^\circ\text{F}), blood pressure of 78/48 mm Hg78/48\text{ mm Hg}, pulse of 134/min134/\text{min}, and respiratory rate of 24/min24/\text{min}. The trachea is midline, and breath sounds are symmetric. Her abdomen is distended, gravid, and diffusely tender with rebound. Manual compression of the iliac crests reveals a stable pelvis. Two large-bore peripheral intravenous catheters are placed, and warmed crystalloid infusion is started. A bedside ultrasonographic assessment demonstrates an anechoic fluid collection in the hepatorenal space. Which of the following is the most appropriate next step in the management of this patient?

  1. A
    Transport the patient for cross-sectional radiographic imaging of the torso
  2. B
    Delay any invasive intervention until her spouse arrives to provide informed consent
  3. Transfer the patient to the surgical suite for an operative explorationAnswer
  4. D
    Perform an emergent bedside cesarean delivery to salvage the fetus
  5. E
    Initiate continuous electronic fetal monitoring to assess for decelerations prior to any surgery

Answer

Transfer the patient to the surgical suite for an operative exploration
This patient presents with hemorrhagic shock following blunt trauma, evidenced by severe hypotension and tachycardia. The positive focused assessment with sonography for trauma (FAST) confirms the presence of intraperitoneal hemorrhage. In any hemodynamically unstable patient with a positive FAST, the immediate next step is urgent transfer to the operating room for an exploratory laparotomy to control the bleeding. Although this patient is pregnant, the core algorithms of trauma resuscitation remain identical to those for non-pregnant patients. Maternal stabilization and survival are the absolute highest priorities, as they are the most crucial determinants of fetal survival.

Step-by-Step Solution

1
Assess hemodynamic stability
The patient is hypotensive (78/48 mm Hg78/48\text{ mm Hg}) and tachycardic (134/min134/\text{min}), indicating hemorrhagic shock.
Determines the appropriate algorithmic pathway for blunt trauma management.
2
Interpret the FAST examination
The ultrasound shows free fluid in the hepatorenal space (Morison's pouch), confirming intraperitoneal hemorrhage.
Identifies the anatomic source of bleeding in an unstable patient.
3
Determine the definitive management
The patient requires immediate surgical exploration (laparotomy).
An unstable patient with confirmed intraperitoneal bleeding needs immediate operative hemorrhage control; other concerns (such as pregnancy or surrogate consent) must not delay life-saving maternal resuscitation.

Key Concept

Hemodynamically unstable patients with blunt abdominal trauma and a positive FAST examination require immediate exploratory laparotomy, regardless of pregnancy status. Maternal stabilization is the primary priority in pregnant trauma patients.
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Topics

Trauma and Burns

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