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Difficulty: EasyTrauma and Burns

A 34-year-old woman is evaluated in the trauma bay after being struck by a fast-moving electric bicycle while crossing the street. She was thrown several feet and struck her abdomen against the edge of a sidewalk. On arrival, she is lethargic but responds to voice. Her temperature is 36.8∘C36.8^\circ C (98.2∘F98.2^\circ F), blood pressure is 82/5082/50 mm Hg, pulse is 128128/min, and respirations are 2222/min. Primary survey reveals a patent airway and clear, equal breath sounds bilaterally. The abdomen is visibly distended, firm, and diffusely tender to palpation with guarding. A focused assessment with sonography for trauma (FAST) shows a large amount of anechoic fluid in the hepatorenal recess (Morison's pouch) and the splenorenal recess. Two large-bore intravenous lines are placed, and fluid resuscitation is initiated. Which of the following is the most appropriate next step in management?

  1. A
    Computed tomography of the abdomen and pelvis
  2. B
    Diagnostic peritoneal lavage
  3. C
    Observation and serial abdominal examinations
  4. Exploratory laparotomyAnswer
  5. E
    Administration of broad-spectrum antibiotics

Answer

Exploratory laparotomy
The correct answer is exploratory laparotomy because the patient presents with the classic triad requiring immediate surgical intervention in blunt abdominal trauma: mechanism of injury, hemodynamic instability (hypotension, tachycardia), and evidence of intra-abdominal hemorrhage (positive FAST exam). Hemorrhagic shock must be controlled rapidly in the operating room.

Step-by-Step Solution

1
Assess the patient's hemodynamic status.
The patient is in hemorrhagic shock with a blood pressure of 82/5082/50 mm Hg and a pulse of 128128/min.
Hemodynamic instability dictates whether the patient can safely undergo time-consuming diagnostic imaging or requires immediate intervention.
2
Evaluate the results of the primary survey and initial imaging.
The FAST exam is strongly positive for intra-abdominal fluid (blood) in the setting of blunt trauma.
A positive FAST in a hypotensive trauma patient confirms the abdomen as the source of major bleeding.
3
Determine the definitive management.
The patient requires immediate exploratory laparotomy.
The combination of hemodynamic instability and a positive FAST exam in blunt trauma requires emergent surgical intervention to achieve hemostasis.

Key Concept

Patients with blunt abdominal trauma who are hemodynamically unstable and have a positive FAST exam require immediate exploratory laparotomy.
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Topics

Trauma and Burns

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