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Difficulty: MediumTrauma and Burns

A 6262-year-old man arrives at the emergency department via helicopter after falling approximately 2020 feet from a roof. The patient was intubated in the field due to a depressed level of consciousness. Upon arrival, his blood pressure is 74/4274/42 mm Hg and his heart rate is 144144/min. Breath sounds are symmetric and clear bilaterally. The pelvis is stable to anteroposterior compression. Physical examination reveals a large right-sided parietal scalp hematoma. The right pupil is 55 mm and reacts sluggishly to light, while the left pupil is 33 mm and briskly reactive. His abdomen is markedly distended and tense. Bedside focused assessment with sonography for trauma (FAST) demonstrates significant anechoic fluid in the hepatorenal and splenorenal recesses. What is the most appropriate next step in the management of this patient?

  1. Emergent celiotomyAnswer
  2. B
    Non-contrast computed tomography of the brain and abdomen
  3. C
    Bedside peritoneal aspiration and lavage
  4. D
    Intravenous administration of hypertonic saline
  5. E
    Pelvic angiography with embolization

Answer

Emergent celiotomy
The correct answer is emergent celiotomy. This patient presents with multiple severe injuries, including traumatic brain injury with signs of uncal herniation (anisocoria) and profound hemorrhagic shock. According to Advanced Trauma Life Support (ATLS) protocols, airway and breathing are secured first (he is intubated with clear breath sounds). The next priority is circulation. He has class IV shock, and the positive FAST scan localizes the hemorrhage to the peritoneal cavity. When a patient with blunt abdominal trauma is hemodynamically unstable and has a positive FAST, the absolute next step is immediate surgical exploration (celiotomy/laparotomy) to achieve source control. Taking this patient to the CT scanner to evaluate the head injury would result in death from exsanguination.

Step-by-Step Solution

1
Identify the patient's hemodynamic status.
The patient is in class IV hemorrhagic shock with a blood pressure of 74/4274/42 mm Hg and a heart rate of 144144/min.
Hemodynamic instability dictates the treatment algorithm in trauma, overriding diagnostic imaging that requires transporting the patient.
2
Locate the source of the shock using the primary survey and adjuncts.
The chest is clear, the pelvis is stable, but the abdomen is distended and the FAST scan is positive for fluid.
A positive FAST in a hypotensive patient confirms intra-abdominal hemorrhage as the cause of shock.
3
Determine the priority of interventions given the competing injuries.
Despite signs of severe traumatic brain injury (anisocoria, depressed consciousness), the immediate cause of death is exsanguination.
Advanced Trauma Life Support (ATLS) principles require that circulation (C) and severe hemorrhage be addressed immediately; thus, source control in the operating room takes precedence over CT imaging of the brain.

Key Concept

In patients with multiple traumatic injuries, life-threatening hemorrhagic shock from an intra-abdominal source (indicated by a positive FAST) requires immediate emergent celiotomy (exploratory laparotomy), which takes precedence over diagnostic imaging for traumatic brain injury.
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Topics

Trauma and Burns

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