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Difficulty: EasyTrauma and Burns

Paramedics rush a 41-year-old female to the emergency department after she was thrown from a horse. The patient is confused and diaphoretic. Vital signs show a heart rate of 135/min, respiratory rate of 24/min, and blood pressure of 78/50 mm Hg. Large-bore intravenous access is established, and a 1-liter bolus of crystalloid is rapidly infused, but her blood pressure only improves to 82/55 mm Hg. Physical examination reveals extensive ecchymosis and guarding over the left upper quadrant of the abdomen. A bedside focused assessment with sonography for trauma (FAST) demonstrates a large anechoic stripe in the splenorenal recess. 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
    Angiography with splenic artery embolization
  4. D
    Diagnostic peritoneal lavage
  5. E
    Initiation of a norepinephrine infusion

Answer

Exploratory laparotomy
The correct response reflects the fundamental Advanced Trauma Life Support (ATLS) algorithm. In a patient with blunt abdominal trauma, signs of shock (tachycardia, hypotension), failure to respond to an initial crystalloid bolus, and a positive FAST exam all point to massive, ongoing intraperitoneal hemorrhage. The standard of care is emergent transport to the operating room for an exploratory laparotomy to obtain surgical hemostasis. Any delay for further diagnostic workup increases mortality.

Step-by-Step Solution

1
Assess the patient's hemodynamic status following initial interventions.
The patient remains tachycardic and hypotensive despite receiving a fluid bolus, indicating ongoing, uncompensated hemorrhagic shock.
Hemodynamic stability is the primary decision node in the ATLS algorithm for blunt abdominal trauma.
2
Interpret the bedside imaging adjuncts.
The FAST exam shows an anechoic stripe in the splenorenal recess, confirming the presence of free intraperitoneal fluid (blood).
Identifies the anatomic cavity responsible for the blood loss.
3
Determine the definitive management pathway.
The combination of hemodynamic instability and a positive FAST exam dictates immediate surgical intervention.
Unstable patients with a known source of abdominal bleeding require exploratory laparotomy to surgically ligate or pack the bleeding vessels/organs.

Key Concept

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

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