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Difficulty: MediumTrauma and Burns

A 30-year-old woman, gravida 2, para 1, at 32 weeks gestation is brought to the emergency department after falling approximately 8 feet (2.4 meters) from a ladder. She complains of severe, generalized abdominal pain. On presentation, she is pale, diaphoretic, and lethargic. Her temperature is 36.6°C (97.9°F), blood pressure is 78/45 mm Hg, and pulse is 132/min. Her respiratory rate is 24/min and oxygen saturation is 97% on face mask oxygen. Cardiopulmonary auscultation is unremarkable. Abdominal examination reveals a gravid, distended abdomen that is diffusely tender with involuntary guarding. A focused assessment with sonography for trauma (FAST) scan shows a significant volume of anechoic fluid in the hepatorenal recess (Morison's pouch). Fetal heart tones are present at 145/min. Which of the following is the most appropriate next step in management?

  1. A
    Computed tomography of the abdomen and pelvis
  2. B
    Continuous electronic fetal monitoring and maternal left lateral positioning
  3. C
    Placement of a nasogastric tube and serial abdominal examinations
  4. D
    Emergent Cesarean delivery
  5. Exploratory laparotomyAnswer

Answer

Exploratory laparotomy
This patient has sustained blunt abdominal trauma and presents with hemorrhagic shock (hypotension, tachycardia) and peritonitis. The positive FAST scan confirms the presence of intra-abdominal hemorrhage. According to Advanced Trauma Life Support (ATLS) protocols, any hemodynamically unstable patient with a positive FAST scan requires immediate exploratory laparotomy to control the bleeding. The presence of a 32-week gestation does not alter this initial step; the cardinal rule of trauma in pregnancy is that maternal resuscitation and stabilization take absolute precedence, as fetal survival depends completely on maternal hemodynamics.

Step-by-Step Solution

1
Assess the patient's hemodynamic status.
The patient is in hypovolemic shock (blood pressure 78/45 mm Hg, pulse 132/min, pale and diaphoretic).
Hemodynamic stability dictates the algorithmic pathway for blunt abdominal trauma.
2
Evaluate the mechanism of injury and primary physical findings.
The patient sustained blunt trauma from a fall and has a rigid, tender abdomen, raising high suspicion for intra-abdominal injury.
Physical examination guides the choice of immediate diagnostic adjuncts.
3
Interpret the diagnostic adjuncts.
The FAST scan is positive, showing free fluid in Morison's pouch.
In the setting of trauma, free fluid on a FAST scan represents hemorrhage until proven otherwise.
4
Apply the principles of trauma resuscitation in pregnancy.
Maternal stabilization takes absolute priority. The treatment for an unstable patient with a positive FAST is immediate surgery.
Fetal survival is entirely dependent on maternal survival; treating the mother's life-threatening injuries is the best way to protect the fetus.

Key Concept

Management of hemodynamically unstable blunt abdominal trauma in pregnancy
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Topics

Trauma and Burns

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