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Difficulty: MediumTrauma and Burns

A 52-year-old man is brought to the emergency department after falling 20 feet from a roof. On arrival, he is confused and diaphoretic. His blood pressure is 82/50 mmHg and his pulse is 130/min. His airway is patent, and breath sounds are clear and equal bilaterally. A rigid cervical collar is in place. Physical examination reveals significant ecchymosis and guarding over the left upper quadrant of the abdomen. The pelvis is mechanically stable to anteroposterior and lateral compression. Intravenous fluid resuscitation with warmed crystalloid is initiated. A bedside focused assessment with sonography for trauma (FAST) demonstrates a large amount of anechoic fluid 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 with intravenous contrast
  3. C
    Diagnostic peritoneal lavage
  4. D
    Pelvic angiography with selective embolization
  5. E
    Administration of broad-spectrum intravenous antibiotics and intensive care admission

Answer

Exploratory laparotomy
The correct answer is exploratory laparotomy. This patient presents with hemorrhagic shock following blunt abdominal trauma. The Advanced Trauma Life Support (ATLS) algorithm dictates that patients with blunt trauma and hemodynamic instability must be rapidly assessed for the source of bleeding. The FAST exam is the ideal initial diagnostic tool in this setting. A positive FAST exam (showing anechoic free fluid, which represents blood) in a hemodynamically unstable patient confirms life-threatening intraperitoneal hemorrhage. The immediate next step is exploratory laparotomy to rapidly identify and control the source of bleeding. Transferring this patient for further imaging would cause a dangerous delay in definitive care.

Step-by-Step Solution

1
Evaluate the patient's hemodynamic status.
The patient is hypotensive (BP 82/50 mmHg) and tachycardic (HR 130/min), indicating severe hemorrhagic shock.
Hemodynamic stability determines whether a trauma patient can safely undergo advanced imaging or requires immediate surgical intervention.
2
Identify the mechanism and anatomical location of injury.
The patient sustained blunt trauma (fall from 20 feet) with localized signs in the left upper quadrant and a positive FAST exam showing fluid in the splenorenal recess.
A positive FAST in the setting of blunt trauma indicates intraperitoneal hemorrhage, likely from a splenic injury given the left upper quadrant findings.
3
Determine the definitive management.
The combination of hemodynamic instability and a positive FAST dictates immediate surgical exploration.
Delaying surgery for CT scans or other diagnostic modalities in an unstable patient with known intraperitoneal bleeding significantly increases mortality.

Key Concept

In patients with blunt abdominal trauma, the combination of hemodynamic instability and a positive FAST examination is an absolute indication for immediate exploratory laparotomy.
Estimated Time:1m 15s
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Topics

Trauma and Burns

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