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Difficulty: MediumTrauma and Burns

A 19-year-old male is brought to the emergency department after a collision during a rugby match. While running, he was struck forcefully in the left upper quadrant of the abdomen by an opposing player's knee. He initially tried to continue playing but collapsed on the sideline due to lightheadedness and severe abdominal pain.

On presentation, his temperature is 36.6°C (97.9°F), blood pressure is 82/48 mm Hg, heart rate is 134/min, and respiratory rate is 22/min. He appears pale and diaphoretic. The airway is intact, and breath sounds are equal bilaterally. Cardiac examination reveals sinus tachycardia. His abdomen is rigid and diffusely tender with guarding and rebound tenderness, most pronounced in the left upper quadrant. The pelvis is stable to compression.

A focused assessment with sonography for trauma (FAST) examination demonstrates anechoic free fluid in the splenorenal recess and the rectovesical pouch. Two large-bore peripheral intravenous lines are established. Despite a 1-liter bolus of warmed isotonic crystalloid and initiation of an uncrossmatched blood transfusion, his blood pressure remains 84/50 mm Hg.

Which of the following is the most appropriate next step in management?

  1. Immediate exploratory laparotomyAnswer
  2. B
    Computed tomography of the abdomen and pelvis with intravenous contrast
  3. C
    Angiography with selective splenic artery embolization
  4. D
    Diagnostic peritoneal lavage
  5. E
    Continued resuscitation with packed red blood cells and serial abdominal examinations

Answer

Immediate exploratory laparotomy
This patient presents with hemodynamic instability following blunt abdominal trauma. The positive FAST exam confirms the presence of intra-abdominal hemorrhage. According to Advanced Trauma Life Support (ATLS) guidelines, a hemodynamically unstable patient with a positive FAST exam requires immediate surgical exploration (exploratory laparotomy) to identify and control the source of active bleeding. Delaying surgery for further imaging or observation in this setting is contraindicated.

Step-by-Step Solution

1
Assess the patient's hemodynamic status.
The patient is hypotensive, tachycardic, pale, and diaphoretic despite initial fluid and blood resuscitation, indicating uncompensated hemorrhagic shock.
Hemodynamic stability dictates the diagnostic and therapeutic algorithm in trauma.
2
Evaluate the mechanism of injury and physical exam findings.
Blunt abdominal trauma to the left upper quadrant with a rigid, peritonitic abdomen.
These findings raise high suspicion for a ruptured spleen or other major intra-abdominal solid organ injury.
3
Interpret the adjunct imaging.
The FAST exam is positive for free fluid in multiple spaces, confirming hemoperitoneum.
A positive FAST in the setting of trauma confirms the abdomen as the source of bleeding.
4
Determine the next best step based on ATLS protocols.
The patient must be taken directly to the operating room for an exploratory laparotomy.
A hemodynamically unstable patient with blunt abdominal trauma and a positive FAST exam requires immediate surgical exploration to achieve hemostasis.

Key Concept

Management of hemodynamically unstable blunt abdominal trauma
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Topics

Trauma and Burns

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