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Difficulty: MediumTrauma and Burns

A 48-year-old male ski instructor is airlifted to the trauma bay after colliding with a tree at high speed. During transport, he received 11 L of lactated Ringer solution. Upon arrival, the patient appears pale, diaphoretic, and confused. His temperature is 36.1∘C36.1^\circ\text{C} (97.0∘F97.0^\circ\text{F}), pulse is 135135/min, respirations are 2424/min, and blood pressure is 78/4278/42 mm Hg. Pulse oximetry shows 95%95\% on room air. The trachea is midline, and breath sounds are present and equal bilaterally. Heart sounds are rapid but normal in intensity, with no jugular venous distention. The abdomen is tense with significant left upper quadrant tenderness and involuntary guarding. The pelvis is mechanically stable to gentle compression. Bedside focused assessment with sonography for trauma (FAST) demonstrates a well-defined anechoic stripe in the splenorenal recess. Which of the following is the most appropriate next step in the management of this patient?

  1. A
    Contrast-enhanced computed tomography of the abdomen
  2. B
    Diagnostic peritoneal lavage
  3. Urgent exploratory celiotomyAnswer
  4. D
    Percutaneous transcatheter arterial embolization
  5. E
    Continued volume resuscitation and serial abdominal examinations

Answer

The most appropriate next step in management is urgent exploratory celiotomy.
The correct answer is urgent exploratory celiotomy (laparotomy). This patient has sustained blunt abdominal trauma and is in hemorrhagic shock, evidenced by hypotension (78/4278/42 mm Hg), tachycardia (135135/min), and altered mental status. According to the ATLS algorithm, any patient who remains hemodynamically unstable with a positive FAST scan (demonstrating intraperitoneal fluid, likely a ruptured spleen given the left upper quadrant findings) must undergo immediate surgical exploration to achieve definitive hemorrhage control.

Step-by-Step Solution

1
Assess the patient's hemodynamic status.
The patient is in class III/IV hemorrhagic shock (blood pressure 78/4278/42 mm Hg, pulse 135135/min, confusion) despite receiving 11 L of crystalloid.
Hemodynamic instability dictates whether the patient is managed operatively or non-operatively.
2
Identify the source of shock based on the primary survey and adjuncts.
The chest is clear, pelvis is stable, but the abdomen is tense with a positive FAST showing fluid in the splenorenal recess.
Shock in trauma is assumed to be hemorrhagic until proven otherwise. A positive FAST localized the bleeding to the intraperitoneal cavity.
3
Determine the definitive intervention based on Advanced Trauma Life Support (ATLS) algorithms.
The combination of hemodynamic instability and a positive FAST requires immediate operative intervention (exploratory celiotomy).
Delays for further diagnostic testing (e.g., CT scan) in an unstable patient with a known source of hemorrhage can be fatal.

Key Concept

Hemodynamically unstable patients with blunt abdominal trauma and a positive FAST scan require immediate exploratory celiotomy.
Estimated Time:1m 0s
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Topics

Trauma and Burns

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