During a severe thunderstorm, a 52-year-old male is struck by a heavy falling tree branch and sustains significant blunt force trauma to his torso. On presentation to the trauma bay, his blood pressure is 78/52 mm Hg and pulse is 132/min. He is tachypneic with a respiratory rate of 26/min and oxygen saturation of 94% on room air. The primary survey reveals equal breath sounds bilaterally and no tracheal deviation. His abdomen is rigid with severe, diffuse tenderness to palpation. A bedside ultrasound demonstrates an anechoic stripe between the right kidney and the liver. Which of the following is the most appropriate next step in the management of this patient?
- Urgent exploratory laparotomyAnswer
- BComputed tomography scan of the abdomen and pelvis
- CDiagnostic peritoneal lavage
- DRight-sided tube thoracostomy placement
- EContinued intravenous crystalloid resuscitation and observation
Answer
Urgent exploratory laparotomy
The correct answer is urgent exploratory laparotomy. The initial evaluation of blunt abdominal trauma focuses on determining hemodynamic stability and identifying the presence of intra-abdominal hemorrhage. This patient is in severe hypovolemic shock following significant blunt torso trauma. The bedside ultrasound (Focused Assessment with Sonography for Trauma, or FAST exam) reveals an anechoic stripe in the hepatorenal recess (Morison's pouch), which indicates the presence of intraperitoneal free fluid (blood). The combination of hemodynamic instability and a positive FAST exam strongly suggests massive, ongoing intra-abdominal hemorrhage. This triad—blunt abdominal trauma, hemodynamic instability, and a positive FAST—is an absolute indication for immediate exploratory laparotomy to rapidly identify and control the source of bleeding.
Step-by-Step Solution
Key Concept
Hemodynamically unstable patients with blunt abdominal trauma and a positive FAST exam require immediate exploratory laparotomy.