Examkin

Question

Difficulty: MediumCardiothoracic and Vascular Surgery

A 24-year-old man is brought to the emergency department by paramedics following a street altercation where he sustained a stab wound to his left anteromedial thigh. On presentation, he appears pale, diaphoretic, and confused. His temperature is 36.5°C (97.7°F), blood pressure is 82/46 mmHg, heart rate is 128/min, and respiratory rate is 24/min. Pulse oximetry shows 97% on room air. Two large-bore intravenous lines are placed, and fluid resuscitation is initiated. Physical examination reveals a 4-cm laceration over the left medial thigh. There is a rapidly expanding hematoma around the wound and active pulsatile bleeding. The left foot is cold to the touch. Capillary refill is delayed in the left toes, and both the left dorsalis pedis and posterior tibial pulses are absent to palpation and Doppler ultrasound. The right lower extremity has normal pulses. Which of the following is the most appropriate next step in the management of this patient?

  1. Immediate surgical explorationAnswer
  2. B
    Computed tomography angiography of the lower extremities
  3. C
    Measurement of the injured extremity index
  4. D
    Application of a pressure dressing and intensive care observation
  5. E
    Intravenous administration of broad-spectrum antibiotics and tetanus toxoid

Answer

Immediate surgical exploration
This patient presents with hemorrhagic shock and classic 'hard signs' of major vascular injury following penetrating extremity trauma. Hard signs include pulsatile bleeding, an expanding hematoma, absent distal pulses, distal ischemia (cold, pale limb), and a palpable thrill or audible bruit. The presence of any single hard sign, especially in the setting of hemodynamic instability, is an absolute indication for immediate surgical exploration in the operating room. Delaying surgery for imaging or prolonged observation places the patient at imminent risk of exsanguination and irreversible limb loss.

Step-by-Step Solution

1
Assess the patient's hemodynamic status based on vital signs.
The patient is hypotensive (82/46 mmHg) and tachycardic (128/min), indicating Class III/IV hemorrhagic shock.
Hemodynamic instability dictates the urgency of intervention and precludes time-consuming diagnostic imaging.
2
Evaluate the extremity for signs of vascular injury.
The patient exhibits pulsatile bleeding, a rapidly expanding hematoma, and absent distal pulses with a cold, pale foot.
These findings constitute 'hard signs' of major arterial injury.
3
Apply the trauma management algorithm for penetrating extremity injuries.
The combination of hard signs and hemodynamic instability requires bypassing the scanner and proceeding directly to the operating room.
Immediate surgical exploration is necessary to obtain vascular control, prevent exsanguination, and salvage the ischemic limb.

Key Concept

Management of penetrating extremity trauma with hard signs of vascular injury
Estimated Time:1m 0s
Rate this question

Topics

Cardiothoracic and Vascular Surgery

More questions from this topic