Emergency medical services bring a 31-year-old female equestrian to the trauma center after her horse tripped and rolled over her torso during a jumping event. The patient is pale, diaphoretic, and lethargic. Vital signs are temperature 36.8°C (98.2°F), blood pressure 82/45 mm Hg, pulse 128/min, and respirations 22/min. Pulse oximetry shows 96% on high-flow oxygen. Primary survey reveals a patent airway and equal bilateral breath sounds. The abdomen is markedly distended with diffuse guarding and rebound tenderness. Bedside ultrasound evaluation of the abdomen demonstrates a significant amount of anechoic fluid in Morison pouch. Which of the following is the most appropriate next step in the management of this patient?
- Immediate transfer to the operating room for surgical explorationAnswer
- BContrast-enhanced multidetector CT scan
- CPerformance of diagnostic peritoneal lavage
- DGastric decompression and serial abdominal examinations
- EEmpiric initiation of broad-spectrum antimicrobial therapy
Answer
Immediate transfer to the operating room for surgical exploration
This patient presents with signs of profound hemorrhagic shock (hypotension, tachycardia, diaphoresis, lethargy) following blunt torso trauma. The rigid abdomen and positive focused assessment with sonography for trauma (FAST) examination, specifically showing fluid in Morison pouch, confirm the presence of significant intraperitoneal hemorrhage. The standard of care for a hemodynamically unstable patient with blunt abdominal trauma and a positive FAST is immediate surgical exploration to control the source of bleeding. Any delay for further diagnostic testing can be fatal.
Step-by-Step Solution
Key Concept
In a hemodynamically unstable patient with blunt abdominal trauma, a positive FAST examination mandates immediate surgical exploration to achieve hemorrhage control.