Examkin

Question

Difficulty: MediumTrauma and Burns

A 28-year-old woman, G1P0, at 32 weeks gestation is brought to the emergency department via ambulance after a high-speed motor vehicle collision. She was the unrestrained driver. Upon arrival, she is lethargic and pale. Her blood pressure is 78/45 mm Hg, pulse is 132/min, and respiratory rate is 26/min. Physical examination reveals a gravid, distended abdomen with diffuse tenderness and rebound guarding. The uterus is palpated, but no vaginal bleeding is noted. Fetal heart rate is 145/min. A bedside Focused Assessment with Sonography for Trauma (FAST) reveals a large volume of free intraperitoneal fluid in the hepatorenal recess. Arterial blood gas analysis on room air shows a pH of 7.25, pCO2 of 30 mm Hg, and HCO3- of 14 mEq/L. Two large-bore intravenous lines are established, and a massive transfusion protocol is initiated. Which of the following is the most appropriate next step in the management of this patient?

  1. A
    Computed tomography of the abdomen and pelvis
  2. B
    Placement of a nasogastric tube and serial abdominal examinations
  3. Immediate exploratory laparotomyAnswer
  4. D
    Intravenous administration of sodium bicarbonate
  5. E
    Left lateral decubitus positioning and continued conservative observation

Answer

Immediate exploratory laparotomy
The correct answer is immediate exploratory laparotomy because this patient is hemodynamically unstable with clear evidence of intra-abdominal hemorrhage (a positive FAST exam and a rigid, distended abdomen) following blunt trauma. In any unstable trauma patient, especially those who are pregnant, maternal resuscitation and immediate surgical control of bleeding are the highest priorities. Stabilizing the mother is the most effective way to stabilize the fetus.

Step-by-Step Solution

1
Evaluate the patient's hemodynamic stability.
The patient is in profound shock, as evidenced by a blood pressure of 78/45 mm Hg and a heart rate of 132/min.
Hemodynamic status determines whether the patient can undergo further diagnostic imaging (like a CT scan) or requires immediate intervention.
2
Assess the primary survey adjuncts.
The bedside FAST exam is positive for free intraperitoneal fluid.
A positive FAST in the setting of blunt trauma confirms the abdomen as the source of major hemorrhage.
3
Determine the definitive management plan.
The patient must be transported immediately to the operating room.
Hemodynamically unstable patients with confirmed intra-abdominal hemorrhage require emergent exploratory laparotomy to achieve mechanical bleeding control and save both the mother and fetus.

Key Concept

Management of hemodynamically unstable blunt abdominal trauma
Rate this question

Topics

Trauma and Burns

More questions from this topic