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Difficulty: HardTrauma and Burns

A 19-year-old male collegiate rugby player collapses on the field after being tackled forcefully around the midsection by an opposing player. He is rushed to the emergency department. En route, emergency medical services administer 2 L of intravenous crystalloid solution. On arrival, he is restless and complaining of severe abdominal pain. His temperature is 36.1°C (97.0°F), pulse is 142/min, blood pressure is 76/40 mm Hg, and respiratory rate is 26/min. Oxygen saturation is 98% on high-flow oxygen. Physical examination reveals an exquisitely tender, board-like abdomen with severe rebound tenderness across all four quadrants. There is early ecchymosis developing over the periumbilical area. The pelvis is mechanically stable to anteroposterior and lateral compression. Cardiopulmonary auscultation reveals clear breath sounds bilaterally. Which of the following interventions should be prioritized next for this patient?

  1. Transfer directly to the operating room for exploratory laparotomyAnswer
  2. B
    Perform a bedside focused assessment with sonography for trauma
  3. C
    Obtain a contrast-enhanced computed tomography scan of the abdomen
  4. D
    Execute a diagnostic peritoneal lavage in the emergency department
  5. E
    Admit to the surgical intensive care unit for serial abdominal examinations

Answer

Immediate transfer to the operating room for an exploratory laparotomy is required due to the combination of severe hemodynamic instability and acute peritonitis.
This patient presents with hemorrhagic shock and an acute surgical abdomen (peritonitis) following blunt abdominal trauma. According to ATLS protocols, hemodynamically unstable patients who exhibit unequivocal signs of peritonitis (e.g., rigid, board-like abdomen, rebound tenderness) require immediate surgical exploration. Proceeding directly to an exploratory laparotomy is the only appropriate step to rapidly achieve hemostasis and control hollow viscus contamination. No further diagnostic workup is needed before surgery.

Step-by-Step Solution

1
Assess the patient's hemodynamic status.
The patient is in class III/IV hemorrhagic shock with a blood pressure of 76/40 mm Hg and a heart rate of 142/min despite 2 L of crystalloid resuscitation.
Hemodynamic instability dictates whether the patient can safely undergo time-consuming diagnostic imaging or requires immediate intervention.
2
Evaluate the abdominal physical examination findings.
The patient exhibits a board-like abdomen with severe rebound tenderness.
These are unequivocal signs of peritonitis, indicating massive intra-abdominal hemorrhage or hollow viscus perforation.
3
Apply the Advanced Trauma Life Support (ATLS) algorithm for blunt abdominal trauma.
The combination of shock and clear peritonitis mandates emergent laparotomy.
This specific clinical presentation bypasses the need for a FAST exam to achieve immediate surgical source control.

Key Concept

In patients with blunt abdominal trauma, the presence of hemodynamic instability combined with unequivocal peritonitis mandates immediate exploratory laparotomy, bypassing FAST or CT imaging.
Estimated Time:1m 15s
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Topics

Trauma and Burns

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