A 41-year-old male warehouse worker is brought to the trauma center after being pinned bet… — USMLE Step 2 CK

A 41-year-old male warehouse worker is brought to the trauma center after being pinned between a forklift and a loading dock. He complains of severe abdominal pain. On arrival, he is awake and anxious.

Vital signs show a temperature of $36.8^\circ\text{C}$ ( $98.2^\circ\text{F}$ ), a blood pressure of $78/48\text{ mmHg}$ , a heart rate of $136\text{ /min}$ , and a respiratory rate of $26\text{ /min}$ . Oxygen saturation is $96\%$ on room air.

Primary survey reveals a patent airway and equal breath sounds bilaterally. There are extensive abrasions and ecchymoses across the anterior abdominal wall. Palpation of the abdomen elicits diffuse tenderness with involuntary guarding. The pelvis is mechanically stable to anteroposterior and lateral compression.

Two large-bore intravenous lines are established, and $1\text{ L}$ of warmed lactated Ringer solution is rapidly infused. Following the fluid bolus, his blood pressure is $82/50\text{ mmHg}$ and heart rate is $130\text{ /min}$ . A bedside focused assessment with sonography for trauma (FAST) demonstrates a significant anechoic collection in the hepatorenal recess (Morison pouch).

Which of the following is the most appropriate next step in the management of this patient?

Immediate exploratory laparotomyAnswer
B
Computed tomography scan of the abdomen and pelvis with intravenous contrast
C
Application of a pelvic circumferential compression device
D
Admission to the surgical intensive care unit for serial abdominal examinations
E
Administration of broad-spectrum intravenous antibiotics

Answer

Immediate exploratory laparotomy

The correct next step is an immediate exploratory laparotomy. This patient has sustained blunt abdominal trauma and presents with hemorrhagic shock. Despite initial fluid resuscitation with

1\text{ L}

of crystalloids, he remains hemodynamically unstable (blood pressure

82/50\text{ mmHg}

, heart rate

130\text{ /min}

). The positive FAST exam demonstrates intraperitoneal free fluid, which in this context represents active bleeding. The standard of care for a hemodynamically unstable patient with a positive FAST exam is immediate transport to the operating room for an exploratory laparotomy to achieve source control of the hemorrhage.

Step-by-Step Solution

Assess hemodynamic status and response to initial fluid resuscitation.

The patient remains hemodynamically unstable (hypotensive and tachycardic) after a

1\text{ L}

crystalloid bolus.

Determining hemodynamic stability is the critical branch point in the blunt abdominal trauma algorithm.

Identify the potential source of hemorrhage.

The FAST exam reveals free fluid in Morison's pouch, confirming intraperitoneal bleeding.

In unstable trauma patients, a FAST exam rapidly identifies whether the abdomen, thorax, or pericardium is the source of shock.

Determine the definitive management based on the findings.

The combination of hemodynamic instability and a positive FAST exam mandates immediate surgical source control.

An unstable patient with active intra-abdominal hemorrhage cannot tolerate the delay of further diagnostic imaging and requires emergent laparotomy.

Key Concept

Hemodynamically unstable patients with blunt abdominal trauma and a positive FAST exam require immediate exploratory laparotomy.

Estimated Time:1m 0s

Question

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Topics

More questions from this topic