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Difficulty: EasyTrauma and Burns

A 34-year-old woman is brought to the emergency department after falling approximately 15 feet from a roof. Upon arrival, she is lethargic but responsive to painful stimuli. Her blood pressure is 78/45 mmHg, and her heart rate is 132/min. Oxygen saturation is 96% on room air. Her airway is clear, and breath sounds are present and equal bilaterally. The abdomen appears distended and is tense on palpation. A bedside focused assessment with sonography in trauma (FAST) reveals a significant amount of anechoic fluid surrounding the spleen and liver. Which of the following is the most appropriate next step in management?

  1. Immediate surgical exploration of the abdomenAnswer
  2. B
    Cross-sectional imaging of the torso
  3. C
    Placement of a catheter for peritoneal fluid analysis
  4. D
    Initiation of a continuous vasopressor infusion
  5. E
    Endovascular intervention with arterial occlusion

Answer

The most appropriate next step is immediate surgical exploration of the abdomen.
The correct answer is immediate surgical exploration because the patient presents with classic signs of hemorrhagic shock following blunt trauma, and the positive ultrasound localizes the bleeding to the peritoneal cavity. In this scenario, time is critical, and immediate operative hemorrhage control is the definitive treatment.

Step-by-Step Solution

1
Assess the patient's hemodynamic status.
The patient is hypotensive (78/45 mmHg) and tachycardic (132/min), indicating hemodynamic instability and shock.
Hemodynamic status determines whether a trauma patient can safely undergo advanced diagnostic imaging or requires immediate intervention.
2
Evaluate the mechanism of injury and primary survey findings.
The patient suffered blunt trauma from a fall. The airway is clear and breathing is equal, pointing toward the abdomen as the source of shock due to distension and tenseness.
Identifying the likely source of hemorrhage directs the focus of the secondary assessment and immediate treatment.
3
Interpret the bedside ultrasound (FAST) results.
The FAST exam is positive, showing anechoic fluid (blood) around the spleen and liver.
A positive FAST in a hemodynamically unstable patient confirms intra-abdominal hemorrhage.
4
Determine the definitive management.
The combination of blunt trauma, hemodynamic instability, and a positive FAST exam mandates emergency surgical intervention.
Immediate operative control of bleeding is life-saving and takes precedence over further diagnostic studies.

Key Concept

Hemodynamically unstable patients with blunt abdominal trauma and a positive FAST exam require immediate exploratory surgery.
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Topics

Trauma and Burns

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