Examkin

Question

Difficulty: EasyTrauma and Burns

A 24-year-old man is brought to the emergency department after sustaining a stab wound to the right upper quadrant of his abdomen during a physical altercation. On arrival, he appears confused, pale, and profusely diaphoretic. Vital signs are temperature 36.8°C (98.2°F), heart rate 138/min, blood pressure 75/40 mm Hg, and respiratory rate 22/min. Physical examination reveals a 3-cm linear laceration just below the right costal margin. The abdomen is notably distended with diffuse guarding and marked rebound tenderness in all four quadrants. Peripheral pulses are weak and thready. Which of the following is the most appropriate next step in the management of this patient?

  1. Immediate surgical exploration of the peritoneal cavityAnswer
  2. B
    Intravenous contrast-enhanced CT scan of the abdomen
  3. C
    Bedside ultrasonography to evaluate for intraperitoneal fluid
  4. D
    Local bedside probing and exploration of the wound tract
  5. E
    Empirical administration of broad-spectrum antibiotics and observation

Answer

Immediate surgical exploration of the peritoneal cavity
The correct approach for a patient with penetrating abdominal trauma who exhibits hemodynamic instability (shock) or clear signs of peritonitis (rigidity, rebound tenderness) is immediate transport to the operating room for surgical exploration. This patient is actively bleeding (indicated by confusion, diaphoresis, tachycardia, and hypotension) and has peritoneal irritation. In this scenario, any delay for diagnostic imaging is potentially fatal.

Step-by-Step Solution

1
Assess the patient's hemodynamic status and mechanism of injury.
The patient has sustained penetrating abdominal trauma and is in hemorrhagic shock (HR 138/min, BP 75/40 mm Hg, confused).
Identifying hemodynamic instability is the critical first branch point in trauma management algorithms.
2
Evaluate for signs of acute intra-abdominal injury.
The physical exam demonstrates peritonitis (diffuse guarding and rebound tenderness) and abdominal distension.
Peritonitis indicates an acute surgical abdomen, likely due to hollow viscus injury or massive hemoperitoneum.
3
Determine the definitive next step in management.
The patient requires immediate surgical exploration of the peritoneal cavity.
Any patient with a penetrating abdominal injury accompanied by hemodynamic instability, evisceration, or peritonitis must go directly to the operating room.

Key Concept

Patients with penetrating abdominal trauma who present with hemodynamic instability or signs of peritonitis require immediate exploratory laparotomy without delay for further imaging.
Rate this question

Topics

Trauma and Burns

More questions from this topic