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Difficulty: EasyTrauma and Burns

A 22-year-old male is brought to the emergency department via ambulance after being kicked directly in the abdomen by a horse. On arrival, he is groggy but follows simple commands. His temperature is 36.5°C (97.7°F), blood pressure is 78/40 mm Hg, and pulse is 132/min. Oxygen saturation is 99% on room air. Large-bore intravenous access is established, and 1 liter of crystalloid fluid is rapidly administered. Following the fluid bolus, his blood pressure remains low at 82/45 mm Hg. Physical examination reveals a large contusion over the epigastrium. The abdomen is markedly distended with diffuse rebound tenderness and involuntary guarding. A focused assessment with sonography for trauma (FAST) exam demonstrates a large amount of free fluid in the hepatorenal recess and the splenorenal recess. Which of the following is the most appropriate next step in management?

  1. A
    Computed tomography (CT) of the abdomen and pelvis with intravenous contrast
  2. B
    Admission to the intensive care unit for serial abdominal examinations
  3. C
    Pelvic and abdominal angiography with planned arterial embolization
  4. Immediate exploratory laparotomyAnswer
  5. E
    Diagnostic peritoneal lavage (DPL)

Answer

Immediate exploratory laparotomy is the correct next step for this hemodynamically unstable trauma patient with a positive FAST exam.
The correct answer is immediate exploratory laparotomy. This patient has sustained high-energy blunt abdominal trauma and presents in hemorrhagic shock (hypotension, tachycardia) that is unresponsive to an initial fluid bolus. The positive FAST exam confirms the presence of significant intraperitoneal fluid, which must be presumed to be blood in this clinical context. According to standard trauma protocols, any patient who is hemodynamically unstable following blunt abdominal trauma and has a positive FAST exam must be taken directly to the operating room. An emergent laparotomy is necessary to identify and surgically control the source of the life-threatening bleeding.

Step-by-Step Solution

1
Assess the patient's hemodynamic status following initial interventions.
The patient remains hypotensive (82/45 mm Hg) and tachycardic despite receiving a 1-liter crystalloid fluid bolus, indicating ongoing hemorrhagic shock.
Hemodynamic stability is the primary decision point in the Advanced Trauma Life Support (ATLS) algorithm for abdominal trauma.
2
Evaluate the mechanism of injury and physical examination findings.
The patient sustained blunt abdominal trauma (horse kick) and exhibits signs of acute peritonitis (distension, rebound tenderness, guarding).
Physical signs of peritonitis strongly suggest visceral injury and intraperitoneal bleeding.
3
Interpret the results of the primary imaging modality.
The FAST exam is positive for free fluid in multiple dependent recesses of the abdomen.
In the context of trauma and shock, free intraperitoneal fluid is assumed to be blood.
4
Determine the definitive management plan based on the combination of shock and a positive FAST.
The patient must be transported immediately to the operating room.
Surgical exploration is required to locate and arrest the life-threatening intra-abdominal hemorrhage.

Key Concept

Management of Hemodynamically Unstable Blunt Abdominal Trauma
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Topics

Trauma and Burns

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