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Difficulty: EasyTrauma and Burns

A 42-year-old woman is brought to the emergency department 30 minutes after a high-speed motor vehicle collision in which she was the unrestrained driver. Upon arrival, her temperature is 36.5°C (97.7°F), blood pressure is 78/52 mmHg, pulse is 135/min, and respirations are 22/min. Her airway is patent and breath sounds are clear and equal bilaterally. Oxygen saturation is 97% on room air. The abdomen is severely distended with diffuse tenderness, guarding, and rebound tenderness. Two large-bore intravenous lines are established, and fluid resuscitation is initiated. A bedside focused assessment with sonography for trauma (FAST) reveals a significant amount of anechoic free fluid in the splenorenal and hepatorenal recesses. Which of the following is the most appropriate next step in management?

  1. Immediate exploratory laparotomyAnswer
  2. B
    Computed tomography (CT) scan of the abdomen and pelvis
  3. C
    Diagnostic peritoneal lavage
  4. D
    Observation with serial abdominal examinations
  5. E
    Angiography with selective embolization

Answer

Immediate exploratory laparotomy
The correct answer is immediate exploratory laparotomy. The algorithm for blunt abdominal trauma prioritizes assessing hemodynamic stability. This patient is clearly unstable (hypotensive and tachycardic). In unstable patients, a bedside FAST exam is performed to quickly evaluate for intraperitoneal hemorrhage. Since the FAST exam is positive (free fluid in hepatorenal and splenorenal recesses), the diagnosis of intra-abdominal hemorrhage causing shock is confirmed. The only appropriate next step to prevent exsanguination is an immediate exploratory laparotomy for hemorrhage control. Furthermore, the patient exhibits signs of peritonitis (guarding, rebound tenderness), which is an independent absolute indication for laparotomy.

Step-by-Step Solution

1
Assess the patient's hemodynamic status based on vital signs.
Blood pressure of 78/52 mmHg and pulse of 135/min indicate profound hemodynamic instability (Class III/IV hemorrhagic shock).
Hemodynamic stability is the primary branch point in the blunt abdominal trauma algorithm.
2
Identify the source of bleeding based on the primary survey and imaging.
The FAST exam is positive for free fluid in multiple dependent recesses.
A positive FAST in the setting of trauma confirms intraperitoneal hemorrhage.
3
Determine the definitive treatment for an unstable patient with confirmed intraperitoneal bleeding.
The patient must be taken directly to the operating room for an exploratory laparotomy.
Any delay for further imaging (like CT) in a patient with active, uncontrolled intra-abdominal hemorrhage can be fatal.

Key Concept

Hemodynamically unstable patients with blunt abdominal trauma and a positive FAST exam require immediate exploratory laparotomy.
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Topics

Trauma and Burns

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