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Difficulty: MediumTrauma and Burns

A 19-year-old female collegiate rugby player arrives at the trauma center via ambulance shortly after sustaining an injury during a match. Witnesses report she was forcefully tackled and struck in the left abdomen by an opponent's knee. Upon arrival, her temperature is 36.2∘C36.2^\circ\text{C} (97.2∘F97.2^\circ\text{F}), heart rate is 138/min138/\text{min}, blood pressure is 76/42 mmHg76/42\text{ mmHg}, and respiratory rate is 26/min26/\text{min}. Oxygen saturation is 95%95\% on room air. The patient is lethargic but localizes to painful stimuli. The airway is patent, and breath sounds are vesicular and equal bilaterally. The abdomen is grossly distended with severe diffuse tenderness to palpation, guarding, and rebound tenderness. A large ecchymosis is present over the left upper quadrant. The pelvis is stable to anterior-posterior and lateral compression. Bedside ultrasound of the abdomen demonstrates a significant anechoic collection in the splenorenal recess and the rectouterine pouch. Which of the following is the most appropriate next step in the management of this patient?

  1. Transfer to the operating room for exploratory laparotomyAnswer
  2. B
    Computed tomography scan of the abdomen and pelvis with intravenous contrast
  3. C
    Nasogastric intubation and serial abdominal examinations
  4. D
    Intravenous administration of broad-spectrum antibiotics and intensive care admission
  5. E
    Withhold intervention until informed consent is obtained from a surrogate decision-maker

Answer

The most appropriate next step is to transfer the patient to the operating room for an immediate exploratory laparotomy to control the intra-abdominal hemorrhage.
The correct answer is to proceed directly to the operating room. This patient presents with clear signs of hemorrhagic shock following blunt abdominal trauma. The positive bedside ultrasound indicates significant intra-abdominal bleeding, likely from a splenic laceration given the left upper quadrant ecchymosis and fluid in the splenorenal recess. According to Advanced Trauma Life Support (ATLS) guidelines, any patient with blunt abdominal trauma who remains hemodynamically unstable and has a positive ultrasound must undergo immediate exploratory laparotomy for definitive hemorrhage control.

Step-by-Step Solution

1
Assess the patient's hemodynamic status.
The patient is in Class III/IV hemorrhagic shock, evidenced by marked hypotension (76/42 mmHg76/42\text{ mmHg}), severe tachycardia (138/min138/\text{min}), and altered mental status (lethargy).
Hemodynamic status dictates the diagnostic and therapeutic algorithm in trauma patients.
2
Evaluate the mechanism of injury and primary survey findings.
The patient suffered blunt abdominal trauma. Bedside ultrasound confirms hemoperitoneum (anechoic fluid in the splenorenal and rectouterine spaces).
Identifying the source of bleeding is critical; a positive ultrasound in an unstable patient localizes the hemorrhage to the peritoneal cavity.
3
Determine the definitive management based on ATLS protocols.
The combination of hemodynamic instability and a positive bedside ultrasound mandates emergent surgical exploration.
Delaying surgery for further imaging or observation in this scenario significantly increases mortality.

Key Concept

Hemodynamically unstable patients with blunt abdominal trauma and evidence of intraperitoneal fluid on bedside ultrasound require immediate exploratory laparotomy.
Estimated Time:1m 15s
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Topics

Trauma and Burns

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