Examkin

Question

Difficulty: MediumTrauma and Burns

A 24-year-old woman arrives at the trauma center via helicopter after losing control while down-hill skiing and forcefully striking a stationary snow-making machine. She complains of severe left flank and abdominal pain. Her temperature is 36.2 °C (97.2 °F), pulse is 135/min, blood pressure is 78/48 mmHg, and respirations are 24/min. On physical examination, her airway is patent, and breath sounds are clear and equal bilaterally. The abdomen exhibits marked tenderness in the left upper quadrant with localized guarding. The pelvis is stable to anteroposterior and lateral compression. A bedside focused assessment with sonography for trauma (FAST) exam reveals an anechoic stripe between the spleen and the left kidney. She is rapidly administered 1 L of warmed lactated Ringer solution and 1 unit of uncrossmatched O-negative packed red blood cells. Reassessment vital signs show a pulse of 128/min and a blood pressure of 82/50 mmHg. Which of the following is the most appropriate next step in the management of this patient?

  1. Transfer to the operating room for celiotomyAnswer
  2. B
    Cross-sectional imaging of the abdomen with intravenous contrast
  3. C
    Endovascular embolization of the splenic artery
  4. D
    Diagnostic peritoneal lavage
  5. E
    Continued observation with serial abdominal examinations

Answer

Transfer to the operating room for celiotomy
The correct answer is transfer to the operating room for celiotomy. This patient has sustained blunt abdominal trauma and presents with hemorrhagic shock that is unresponsive to initial volume resuscitation. The positive FAST exam confirms the presence of intraperitoneal fluid (likely blood from a splenic laceration, given the left upper quadrant findings). According to Advanced Trauma Life Support (ATLS) algorithms, hemodynamically unstable patients with a positive FAST exam must undergo immediate surgical exploration to control the hemorrhage.

Step-by-Step Solution

1
Assess the patient's hemodynamic status and response to initial resuscitation.
The patient remains in hemorrhagic shock (BP 82/50 mmHg, pulse 128/min) despite administration of crystalloids and blood products.
Hemodynamic stability is the primary decision point in the blunt abdominal trauma algorithm.
2
Evaluate the results of the primary survey and bedside imaging.
The FAST exam is unequivocally positive for intraperitoneal fluid in the left upper quadrant.
A positive FAST in the setting of trauma identifies the abdomen as the source of life-threatening hemorrhage.
3
Determine the definitive management based on stability and FAST results.
The patient requires immediate surgical exploration.
Hemodynamically unstable patients with intra-abdominal bleeding require rapid operative hemostasis to survive.

Key Concept

Patients with blunt abdominal trauma who are hemodynamically unstable and have a positive FAST exam require immediate exploratory celiotomy (laparotomy) to identify and control the source of bleeding.
Rate this question

Topics

Trauma and Burns

More questions from this topic