A 32-year-old man is brought to the emergency department 20\text{ minutes} after sustainin… — USMLE Step 2 CK

A $32$ -year-old man is brought to the emergency department $20\text{ minutes}$ after sustaining a gunshot wound to the right groin. On arrival, he is confused and diaphoretic. His temperature is $36.5^\circ\text{C}$ ( $97.7^\circ\text{F}$ ), blood pressure is $76/40\text{ mmHg}$ , heart rate is $138/\text{min}$ , and respiratory rate is $22/\text{min}$ . Physical examination reveals a single penetrating wound just below the right inguinal ligament. There is a rapidly expanding, pulsatile hematoma measuring approximately $12\text{ cm}$ in diameter in the right groin. Active, bright red blood is oozing from the wound. The right foot is pale and cold to the touch, and the right dorsalis pedis and posterior tibial pulses are not palpable by Doppler ultrasound. Two large-bore intravenous lines are established, and a massive transfusion protocol is initiated. Which of the following is the most appropriate immediate next step in management?

Transfer to the operating room for emergent surgical explorationAnswer
B
Computed tomography angiography of the right lower extremity
C
Application of a pressure dressing and serial neurovascular examinations
D
Duplex ultrasonography of the right lower extremity
E
Local wound exploration in the emergency department

Answer

Transfer to the operating room for emergent surgical exploration

The correct answer addresses the immediate life-threatening hemorrhage and limb-threatening ischemia. 'Hard signs' of vascular injury include active pulsatile hemorrhage, expanding or pulsatile hematoma, absent distal pulses, palpable thrill or audible bruit, and signs of distal ischemia (pain, pallor, pulselessness, paralysis, paresthesias). The presence of any hard sign, particularly in a hemodynamically unstable patient, mandates immediate operative exploration. Bypassing imaging saves critical time needed to obtain proximal and distal vascular control and repair the injury.

Step-by-Step Solution

Assess the patient's hemodynamic status.

The patient is in Class III/IV hemorrhagic shock, evidenced by confusion, hypotension (

76/40\text{ mmHg}

), and marked tachycardia (

138/\text{min}

Hemodynamic instability dictates that diagnostic testing should be bypassed in favor of immediate life-saving interventions.

Evaluate the extremity for signs of vascular injury.

The patient has multiple 'hard signs' of vascular trauma: a rapidly expanding and pulsatile hematoma, active hemorrhage, absent distal pulses, and signs of distal ischemia (pale, cold foot).

Differentiating between hard signs and soft signs determines the need for immediate surgery versus further imaging.

Determine the definitive management plan based on findings.

The combination of hemodynamic instability and hard signs of vascular injury requires immediate transport to the operating room.

Emergent surgical exploration is required to achieve proximal and distal vascular control and repair the arterial injury before irreversible ischemic damage or death occurs.

Key Concept

Patients with penetrating extremity trauma who exhibit hard signs of vascular injury (e.g., pulsatile bleeding, expanding hematoma, absent pulses, palpable thrill) or hemodynamic instability require immediate surgical exploration without prior imaging.

Alternative Method

A useful mnemonic for hard signs of vascular injury is 'PEAP': Pulsatile bleeding/hematoma, Expanding hematoma, Absent pulses, and Palpable thrill/bruit.

Estimated Time:1m 0s

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Step-by-Step Solution

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