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Difficulty: MediumTrauma and Burns

A 35-year-old male is transported to the emergency department after his motorcycle struck a concrete barrier at high speed. Upon arrival, he is lethargic and visibly pale. Vital signs show a heart rate of 142/min, a blood pressure of 76/40 mm Hg, and a respiratory rate of 24/min. Oxygen saturation is 96% on a non-rebreather mask. The airway is patent, and breath sounds are crisp and equal bilaterally. The abdomen is tense, distended, and dull to percussion. The pelvis is stable to manual compression. Focused assessment with sonography for trauma demonstrates significant free anechoic fluid in the splenorenal and hepatorenal recesses. Two large-bore intravenous lines are established, and resuscitation with balanced crystalloids and uncrossmatched blood is initiated. Which of the following is the most appropriate next step in management?

  1. Immediate transport to the operating room for abdominal explorationAnswer
  2. B
    Computed tomography of the abdomen and pelvis with intravenous contrast
  3. C
    Diagnostic peritoneal lavage to confirm the source of hemorrhage
  4. D
    Angiography with prophylactic embolization of the splenic artery
  5. E
    Insertion of a decompressive nasogastric tube and close clinical observation

Answer

Immediate transport to the operating room for abdominal exploration is the correct next step.
The correct intervention for a patient with blunt abdominal trauma who presents with hemodynamic instability and a positive FAST exam is immediate surgical exploration. The FAST exam reliably identifies intraperitoneal hemorrhage, and when paired with shock, indicates active, life-threatening bleeding that must be operatively controlled.

Step-by-Step Solution

1
Assess the patient's hemodynamic status.
The patient is in class III/IV hemorrhagic shock, indicated by a heart rate of 142/min and a blood pressure of 76/40 mm Hg.
Hemodynamic stability dictates the diagnostic and therapeutic algorithm in trauma.
2
Identify the source of bleeding based on primary survey findings.
Breath sounds are equal (ruling out massive hemothorax) and pelvis is stable. The abdomen is tense with a positive FAST exam, localizing the hemorrhage to the peritoneal cavity.
Identifying the compartment of hemorrhage directs the specific intervention.
3
Determine the definitive intervention.
The combination of hemodynamic instability and confirmed intraperitoneal bleeding mandates immediate surgical exploration.
Further diagnostic delays, such as CT imaging, increase mortality in unstable patients.

Key Concept

Hemodynamically unstable patients with blunt abdominal trauma and a positive FAST exam require immediate surgical exploration.
Estimated Time:1m 15s
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Topics

Trauma and Burns

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