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Difficulty: MediumTrauma and Burns

A 1919-year-old male college student is brought to the emergency department 3030 minutes after a bicycle accident. He was riding down a steep trail when he lost control, flipped over the handlebars, and struck his left upper abdomen against a large rock. He complains of severe abdominal pain and pain radiating to his left shoulder. His temperature is 36.8∘C36.8^{\circ}\text{C} (98.2∘F98.2^{\circ}\text{F}), blood pressure is 82/5082/50 mm Hg, pulse is 130130/min, and respirations are 2424/min. Pulse oximetry shows 98%98\% on room air. He appears pale and diaphoretic. Physical examination reveals ecchymosis over the left upper quadrant. The abdomen is distended, rigid, and diffusely tender with involuntary guarding. A focused assessment with sonography for trauma (FAST) exam demonstrates a large anechoic stripe in the splenorenal recess and hepatorenal recess. Two large-bore intravenous lines are established, and fluid resuscitation with 11 L of warmed crystalloid is initiated. Repeat blood pressure is 84/5284/52 mm Hg. Which of the following is the most appropriate next step in management?

  1. A
    Computed tomography of the abdomen and pelvis with intravenous contrast
  2. Immediate exploratory laparotomyAnswer
  3. C
    Diagnostic peritoneal lavage
  4. D
    Angiography with selective splenic artery embolization
  5. E
    Admission to the surgical intensive care unit for serial abdominal examinations

Answer

Immediate exploratory laparotomy
This patient has suffered blunt abdominal trauma and presents with hemodynamic instability (hypotension, tachycardia) and signs of peritonitis. The positive FAST exam confirms the presence of intra-abdominal hemorrhage. The pain radiating to the left shoulder (Kehr sign) strongly suggests a splenic rupture. In a hemodynamically unstable patient with a positive FAST exam, the definitive management is immediate exploratory laparotomy to identify and control the source of bleeding. Fluid resuscitation is a temporizing measure, and the failure to normalize vital signs after initial fluid administration further mandates emergent surgical intervention.

Step-by-Step Solution

1
Identify the primary mechanism of injury and the patient's hemodynamic status.
The patient suffered blunt abdominal trauma and presents with hemodynamic instability (blood pressure 82/5082/50 mm Hg, pulse 130130/min) that does not significantly improve after an initial fluid bolus.
Determining hemodynamic stability is the critical branch point in the Advanced Trauma Life Support (ATLS) algorithm for managing blunt abdominal trauma.
2
Evaluate the physical examination findings and the results of the initial diagnostic adjuncts.
The patient has a rigid abdomen with peritonitis, Kehr sign (referred left shoulder pain suggesting splenic injury), and a positive FAST exam showing free intra-abdominal fluid.
A positive FAST exam in the setting of hypovolemic shock reliably indicates significant intraperitoneal hemorrhage as the cause of the instability.
3
Determine the appropriate definitive management based on the ATLS treatment algorithm.
Immediate exploratory laparotomy is required.
Hemodynamically unstable patients with confirmed intra-abdominal bleeding require emergent surgical intervention to identify and stop the hemorrhage. Diagnostic delays are contraindicated.

Key Concept

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

Trauma and Burns

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