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Difficulty: MediumTrauma and Burns

Emergency medical personnel deliver a 19-year-old male to the emergency department following a gunshot wound to the abdomen. The patient is confused and visibly pale. Initial vital signs include a blood pressure of 72/42 mm Hg, a heart rate of 145/min, and respirations of 26/min. Examination shows a single bullet entry hole in the periumbilical region with no corresponding exit wound. The abdominal wall is rigid, and generalized guarding is present. Bilateral breath sounds are clear. Large-bore intravenous access is obtained, and a massive transfusion protocol is initiated. Which of the following is the most appropriate next step in the management of this patient?

  1. Immediate exploratory laparotomyAnswer
  2. B
    Computed tomography of the abdomen and pelvis
  3. C
    Focused assessment with sonography for trauma
  4. D
    Diagnostic peritoneal lavage
  5. E
    Local wound exploration

Answer

Immediate exploratory laparotomy
The correct answer is immediate exploratory laparotomy. This patient has sustained a penetrating abdominal injury (gunshot wound) and presents with profound hemodynamic instability (hypotension, marked tachycardia) as well as clear clinical signs of peritonitis (rigid abdomen, generalized guarding). According to Advanced Trauma Life Support (ATLS) protocols, any patient with a penetrating abdominal injury who is hemodynamically unstable or demonstrates signs of peritonitis requires immediate surgical exploration. The goal is rapid hemostasis and control of gastrointestinal spillage. Diagnostic testing should not delay transfer to the operating room in this critical scenario.

Step-by-Step Solution

1
Identify the mechanism of injury and the patient's physiological state.
The patient has a penetrating abdominal injury (gunshot wound) and is in profound hemorrhagic shock (blood pressure 72/42 mm Hg, heart rate 145/min).
Determining the mechanism of injury and hemodynamic status dictates the algorithm for trauma management.
2
Evaluate the abdominal physical examination findings.
The patient exhibits a rigid abdomen with generalized guarding, indicating peritonitis from intra-abdominal organ injury.
The presence of peritonitis in the setting of trauma is a crucial decision node for operative intervention.
3
Determine the definitive next step in management.
The patient must be taken directly to the operating room for an immediate exploratory laparotomy.
Advanced Trauma Life Support (ATLS) protocols mandate that patients with penetrating abdominal trauma who are hemodynamically unstable or have peritonitis bypass further diagnostic imaging and proceed directly to surgery.

Key Concept

Management of hemodynamically unstable penetrating abdominal trauma
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Topics

Trauma and Burns

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