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Difficulty: MediumTrauma and Burns

A 19-year-old female university student is rushed to the trauma center by helicopter after a high-speed collision while riding an electric scooter. She was not wearing a helmet and struck a concrete barrier. Upon arrival, her airway is clear, and breath sounds are present bilaterally. Vital signs show a blood pressure of 72/40 mm Hg, a heart rate of 144/min, and a respiratory rate of 22/min. Her abdomen is bruised across the lower quadrants, distended, and rigid to palpation. Bedside ultrasonography (FAST) demonstrates a significant accumulation of anechoic fluid in the hepatorenal recess and the rectouterine pouch. A pelvic binder is placed by emergency medical services, and a portable chest radiograph is unremarkable. Which of the following is the most appropriate next step in the management of this patient?

  1. A
    Transport to the radiology suite for multiphase cross-sectional imaging
  2. B
    Transfer to the interventional radiology suite for pelvic angiography
  3. Immediate transfer to the operating room for therapeutic celiotomyAnswer
  4. D
    Bedside diagnostic peritoneal lavage
  5. E
    Continuous resuscitation with blood products and serial clinical assessments

Answer

Immediate transfer to the operating room for therapeutic celiotomy
The correct answer is immediate transfer to the operating room for therapeutic celiotomy. In the Advanced Trauma Life Support (ATLS) algorithm for blunt abdominal trauma, hemodynamic stability determines the appropriate diagnostic and therapeutic pathway. This patient is exhibiting signs of severe hemorrhagic shock (hypotension and tachycardia) and has a positive FAST exam showing intraperitoneal fluid. The combination of hemodynamic instability and confirmed intraperitoneal bleeding is an absolute indication for emergent abdominal exploration (celiotomy) to achieve mechanical hemostasis.

Step-by-Step Solution

1
Assess the patient's hemodynamic status.
The patient is in hemorrhagic shock, evidenced by severe hypotension (72/40 mm Hg) and marked tachycardia (144/min).
Hemodynamic stability dictates the initial algorithm for evaluating and managing blunt abdominal trauma.
2
Identify the primary source of hemorrhage using adjuncts to the primary survey.
The FAST exam reveals free fluid in the hepatorenal recess and rectouterine pouch, confirming hemoperitoneum.
In unstable trauma patients, bedside imaging is necessary to quickly locate life-threatening bleeding without leaving the resuscitation area.
3
Determine the definitive management based on clinical and ultrasound findings.
Immediate therapeutic celiotomy (laparotomy) is selected.
The combination of hemodynamic instability and confirmed intraperitoneal bleeding mandates immediate surgical exploration to control the hemorrhage.

Key Concept

Hemodynamically unstable patients with blunt abdominal trauma and a positive FAST exam require immediate surgical exploration (celiotomy/laparotomy).
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Topics

Trauma and Burns

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