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Difficulty: HardTrauma and Burns

A 19-year-old male is brought to the emergency department after colliding with a tree while snowboarding. On arrival, he complains of severe left upper quadrant abdominal pain and left shoulder pain. Initial vital signs include a blood pressure of 115/70 mm Hg, heart rate of 105/min, and respiratory rate of 18/min. A Focused Assessment with Sonography for Trauma (FAST) exam shows a moderate amount of free fluid in the splenorenal recess. Because the patient is hemodynamically stable, a computed tomography (CT) scan of the abdomen and pelvis with intravenous contrast is performed, which reveals a deep splenic laceration with active contrast extravasation. Shortly after returning to the trauma bay, the patient becomes confused and diaphoretic. Repeat vital signs show a blood pressure of 82/45 mm Hg and a heart rate of 138/min. The patient is rapidly transfused with 1 unit of uncrossmatched packed red blood cells, but his blood pressure remains 84/48 mm Hg. Which of the following is the most appropriate next step in management?

  1. A
    Splenic artery embolization
  2. B
    Repeat computed tomography of the abdomen
  3. C
    Diagnostic peritoneal lavage
  4. Exploratory laparotomyAnswer
  5. E
    Administration of intravenous norepinephrine

Answer

Exploratory laparotomy
This patient initially presented in a hemodynamically stable condition, allowing for a CT scan that appropriately identified a splenic laceration with active extravasation. However, his subsequent clinical deterioration (hypotension, tachycardia, confusion, diaphoresis) and failure to respond to blood transfusion indicate active, uncontrolled intra-abdominal hemorrhage. In any patient with blunt abdominal trauma and a positive FAST, hemodynamic instability that is unresponsive to resuscitation mandates immediate exploratory laparotomy. The patient's dynamic change in status overrides the imaging findings that might otherwise prompt a non-operative pathway.

Step-by-Step Solution

1
Assess the patient's current hemodynamic status.
The patient has become hemodynamically unstable (BP 82/45 mm Hg, HR 138/min) and is unresponsive to initial blood transfusion.
Hemodynamic status dictates the algorithmic pathway in trauma.
2
Re-evaluate the management plan based on the change in clinical status.
The initial plan for potential nonoperative management or angioembolization is no longer safe.
Active hemorrhage causing uncompensated shock requires immediate source control.
3
Determine the definitive intervention.
The patient must be taken immediately to the operating room for an exploratory laparotomy.
Laparotomy allows for rapid control of the splenic hemorrhage and evaluation of any other intra-abdominal injuries.

Key Concept

Patients with solid organ injuries who become hemodynamically unstable or fail to respond to initial resuscitation must undergo immediate exploratory laparotomy, regardless of previous imaging findings.
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Topics

Trauma and Burns

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