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Difficulty: EasyTrauma and Burns

A 42-year-old woman is brought to the trauma bay by helicopter emergency medical services after crashing her snowmobile into a fence at high speed. She complains of severe abdominal pain. Her temperature is 36.5°C (97.7°F), blood pressure is 76/45 mm Hg, and pulse is 128/min. She is lethargic but appropriately answers questions. The airway is clear, and the trachea is midline. Breath sounds are clear and equal bilaterally. Jugular venous pressure is not elevated. The abdomen is distended, rigid, and exhibits diffuse guarding. A bedside focused assessment with sonography for trauma (FAST) demonstrates a significant anechoic stripe in the hepatorenal recess. Two large-bore intravenous lines are established, and crystalloid fluid resuscitation is initiated. Which of the following is the most appropriate next step in management?

  1. Urgent exploratory laparotomyAnswer
  2. B
    Computed tomography of the abdomen and pelvis
  3. C
    Diagnostic peritoneal lavage
  4. D
    Observation with serial abdominal examinations
  5. E
    Administration of broad-spectrum intravenous antibiotics

Answer

Urgent exploratory laparotomy
The correct answer is urgent exploratory laparotomy. This patient has sustained blunt abdominal trauma and is in hemorrhagic shock (hypotension, tachycardia, altered mental status). In the Advanced Trauma Life Support (ATLS) algorithm, the primary survey focuses on Airway, Breathing, and Circulation. This patient has a patent airway and clear lungs, ruling out tension pneumothorax or massive hemothorax as the primary cause of shock. The distended, rigid abdomen and positive FAST exam (fluid in the hepatorenal recess, or Morison's pouch) confirm intra-abdominal hemorrhage. The combination of hemodynamic instability and a positive FAST mandates immediate exploratory laparotomy to surgically control the bleeding.

Step-by-Step Solution

1
Evaluate the patient's hemodynamic status.
The patient is hemodynamically unstable, evidenced by a blood pressure of 76/45 mm Hg and a heart rate of 128/min.
Hemodynamic stability dictates the algorithm for evaluating blunt abdominal trauma.
2
Interpret the bedside imaging findings.
The FAST exam is positive, showing free fluid (blood) in the hepatorenal recess.
A positive FAST in a hypotensive patient localizes the source of hemorrhagic shock to the intra-abdominal cavity.
3
Determine the definitive intervention.
The patient requires immediate transport to the operating room for an exploratory laparotomy.
Intra-abdominal hemorrhage in an unstable patient cannot be managed expectantly or delayed for advanced imaging; it requires rapid surgical hemostasis.

Key Concept

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

Trauma and Burns

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