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Difficulty: EasyTrauma and Burns

A 28-year-old man arrives at the emergency department following a violent collision during a rugby match. Paramedics report he was struck aggressively in the mid-abdomen by another player's helmet. Upon arrival, he appears pale and lethargic. His temperature is 36.6°C (97.9°F), pulse is 135/min, respirations are 24/min, and blood pressure is 78/45 mm Hg. Pulse oximetry is 95% on room air. The airway is clear, and breath sounds are symmetric bilaterally. Abdominal examination reveals severe distension, diffuse rigidity, and rebound tenderness. A bedside focused assessment with sonography for trauma (FAST) demonstrates a large volume of anechoic fluid in the hepatorenal recess. 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
  3. C
    Diagnostic peritoneal lavage
  4. D
    Continued fluid resuscitation and serial abdominal examinations
  5. E
    Transport to the radiology suite for a comprehensive ultrasound

Answer

Immediate exploratory laparotomy
The most appropriate next step for a hemodynamically unstable patient with blunt abdominal trauma and a positive FAST exam is an immediate exploratory laparotomy. This patient is experiencing hemorrhagic shock and has clear evidence of intra-abdominal bleeding (fluid in Morison's pouch). In the setting of instability, a positive FAST dictates immediate surgical intervention to find and control the bleeding source.

Step-by-Step Solution

1
Assess the patient's hemodynamic status.
The patient is in hemorrhagic shock, evidenced by tachycardia (135/min), hypotension (78/45 mm Hg), and lethargy.
Identifying hemodynamic instability is the critical first step in the trauma algorithm, as it determines whether the patient can safely undergo imaging or requires immediate surgical intervention.
2
Evaluate the primary survey and bedside imaging results.
The airway and breathing are intact, but the FAST exam is positive for free fluid in the hepatorenal recess.
A positive FAST in a hemodynamically unstable patient rapidly localizes the source of the shock to the abdomen, confirming intra-peritoneal hemorrhage.
3
Determine the definitive management step based on the Advanced Trauma Life Support (ATLS) algorithm.
The patient must be taken directly to the operating room for surgery.
The standard of care for blunt abdominal trauma with hemodynamic instability and a positive FAST is an emergency exploratory laparotomy to achieve hemorrhage control.

Key Concept

In the management of blunt abdominal trauma, a patient who is hemodynamically unstable with a positive FAST examination requires an immediate exploratory laparotomy. Imaging modalities that delay surgery are contraindicated.
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Trauma and Burns

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