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Difficulty: MediumTrauma and Burns

Following a high-velocity collision during a collegiate rugby match, an athlete is transported to the trauma center complaining of progressive lightheadedness and severe left-sided abdominal pain. On arrival, the patient appears pale and diaphoretic. Vital signs show a heart rate of 128/min and a blood pressure of 82/50 mmHg. Primary survey reveals a patent airway, clear breath sounds bilaterally, and a rigid, distended abdomen with significant guarding. After rapid intravenous infusion of 1 liter of warmed lactated Ringer's solution, the blood pressure transiently improves to 105/65 mmHg but subsequently drops to 85/45 mmHg within 10 minutes. A bedside focused assessment with sonography for trauma (FAST) reveals a large amount of anechoic fluid in the splenorenal recess. Which of the following is the most appropriate next step in the management of this patient?

  1. Immediate exploratory laparotomyAnswer
  2. B
    Computed tomography of the abdomen and pelvis with intravenous contrast
  3. C
    Insertion of a nasogastric tube and continuous clinical observation
  4. D
    Administration of intravenous sodium bicarbonate
  5. E
    Postponement of intervention pending a complete blood count and coagulation panel

Answer

Immediate exploratory laparotomy.
The most appropriate next step is immediate exploratory laparotomy. This patient has sustained blunt abdominal trauma and presents with hemorrhagic shock. Although there was a brief response to initial fluid resuscitation, the subsequent rapid drop in blood pressure identifies the patient as a 'transient responder,' which signifies ongoing internal hemorrhage. The unequivocally positive FAST exam localizes the bleeding to the peritoneal cavity. According to Advanced Trauma Life Support (ATLS) protocols, any hemodynamically unstable patient with a positive FAST exam must bypass the CT scanner and proceed immediately to the operating room for an exploratory laparotomy to achieve surgical hemostasis.

Step-by-Step Solution

1
Assess the patient's hemodynamic status and response to initial resuscitation.
The patient is in hemorrhagic shock and is classified as a 'transient responder' because the blood pressure improved briefly but fell again after the initial fluid bolus.
Identifying the patient as hemodynamically unstable dictates the diagnostic pathway (FAST over CT).
2
Interpret the diagnostic imaging findings in the clinical context.
The FAST exam is positive for free fluid in the splenorenal recess, indicating active intra-abdominal hemorrhage (likely splenic rupture).
A positive FAST in the setting of trauma confirms the peritoneal cavity as the source of life-threatening bleeding.
3
Determine the definitive next step in management based on ATLS guidelines.
The patient must be taken directly to the operating room for an exploratory laparotomy.
Hemodynamically unstable patients with confirmed intra-abdominal bleeding require immediate surgical hemostasis; delays for advanced imaging or labs are contraindicated.

Key Concept

Management of hemodynamically unstable blunt abdominal trauma
Estimated Time:1m 0s
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Topics

Trauma and Burns

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