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Difficulty: MediumTrauma and Burns

A 42-year-old woman is brought to the emergency department by ambulance following an all-terrain vehicle (ATV) rollover. She was thrown from the vehicle and struck her abdomen against a large rock. She reports severe diffuse abdominal pain. On presentation, her temperature is 36.6°C (97.9°F), blood pressure is 82/50 mmHg, pulse is 132/min, and respirations are 24/min. Intravenous fluid resuscitation with lactated Ringer's is initiated. Primary survey demonstrates an intact airway and clear, equal breath sounds bilaterally. The abdomen is visibly distended with diffuse involuntary guarding and rebound tenderness. Compression of the iliac crests reveals a stable pelvis. A bedside focused assessment with sonography for trauma (FAST) is performed and demonstrates an anechoic fluid collection in the hepatorenal recess (Morison pouch). Which of the following is the most appropriate next step in management?

  1. Exploratory laparotomyAnswer
  2. B
    Computed tomography of the abdomen and pelvis
  3. C
    Diagnostic peritoneal lavage
  4. D
    Diagnostic laparoscopy
  5. E
    Angiography with selective arterial embolization

Answer

Exploratory laparotomy
The correct answer is exploratory laparotomy. According to the Advanced Trauma Life Support (ATLS) algorithm for blunt abdominal trauma, initial management involves assessing hemodynamic stability. In patients who are hemodynamically unstable (e.g., hypotension, tachycardia), a primary survey must be followed immediately by a bedside FAST exam to identify the source of bleeding. A positive FAST indicates massive intra-abdominal hemorrhage. The standard of care for these patients is emergent exploratory laparotomy to identify the injured organs, repair them, and stop the hemorrhage.

Step-by-Step Solution

1
Assess the patient's hemodynamic status.
The patient is hemodynamically unstable, evidenced by hypotension (82/50 mmHg) and tachycardia (132/min).
Hemodynamic instability following blunt trauma indicates active, potentially life-threatening hemorrhage.
2
Identify the source of the hemorrhage.
The FAST exam is positive for anechoic fluid in the hepatorenal recess.
A positive FAST in the setting of trauma confirms the presence of intraperitoneal bleeding, likely from a solid organ injury.
3
Determine the definitive intervention based on ATLS guidelines.
Immediate exploratory laparotomy is required.
An unstable patient with confirmed intra-abdominal hemorrhage must be taken directly to the operating room to surgically control the bleeding.

Key Concept

Hemodynamically unstable patients with blunt abdominal trauma and a positive FAST exam require emergent exploratory laparotomy.
Estimated Time:1m 0s
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Topics

Trauma and Burns

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