Examkin

Question

Difficulty: HardTrauma and Burns

A 38-year-old female is brought to the emergency department after a snowmobile collision in which she struck a tree at high speed. On arrival, she is lethargic and pale. Her temperature is 36.1°C (97.0°F), blood pressure is 74/42 mmHg, heart rate is 136/min, and respiratory rate is 24/min. Oxygen saturation is 96% on a non-rebreather mask. Two large-bore intravenous lines are established, and she receives 1 L of warmed lactated Ringer solution and 1 unit of uncrossmatched type O-negative packed red blood cells. Reassessment reveals a blood pressure of 76/40 mmHg and a heart rate of 132/min. Primary survey shows a patent airway and equal breath sounds bilaterally. A portable chest radiograph demonstrates a widened mediastinum and blurring of the aortic knob but no pneumothorax or hemothorax. A focused assessment with sonography for trauma (FAST) examination reveals a large amount of anechoic fluid in the hepatorenal recess (Morison pouch). An anteroposterior pelvic radiograph shows an intact pelvic ring with no fractures. Which of the following is the most appropriate next step in management?

  1. Exploratory laparotomyAnswer
  2. B
    Computed tomography angiography of the chest
  3. C
    Computed tomography of the abdomen and pelvis
  4. D
    Transesophageal echocardiography
  5. E
    Diagnostic peritoneal lavage

Answer

Exploratory laparotomy
The correct answer is exploratory laparotomy. This patient is in hemorrhagic shock (hypotension, tachycardia) following blunt trauma and remains hemodynamically unstable despite initial resuscitation with crystalloid and uncrossmatched blood. The focused assessment with sonography for trauma (FAST) examination is positive for free intraperitoneal fluid, confirming that the abdomen is the source of active hemorrhage. In any hemodynamically unstable patient with a positive FAST, immediate exploratory laparotomy is indicated to identify and surgically control the bleeding.

Although the widened mediastinum on the chest radiograph is highly suspicious for a blunt thoracic aortic injury (BTAI), this finding does not change the immediate management priority. Patients with BTAI who survive the initial impact and reach the emergency department almost always have a contained hematoma (with the adventitial layer of the aorta still intact). An actively bleeding, uncontained aortic rupture would present with massive hemothorax on imaging or result in immediate death at the scene. Therefore, the active intra-abdominal hemorrhage is the definitive cause of the patient's ongoing shock and must be prioritized. Once the abdominal bleeding is controlled, the patient can be further evaluated (e.g., with transesophageal echocardiography in the operating room or CT angiography once stabilized) to address the thoracic injury.

Step-by-Step Solution

1
Evaluate the patient's hemodynamic status.
The patient remains in hemorrhagic shock (blood pressure 76/40 mmHg, heart rate 132/min) despite initial fluid and blood product resuscitation.
Hemodynamic stability dictates whether a trauma patient can safely undergo time-consuming diagnostic imaging or requires immediate surgical or resuscitative intervention.
2
Interpret the primary survey and adjunct imaging findings.
A positive FAST indicates intra-abdominal hemorrhage. The widened mediastinum on chest radiograph suggests a possible blunt thoracic aortic injury (BTAI).
Identifying all potential sources of life-threatening shock is necessary to formulate a prioritized treatment plan.
3
Prioritize management based on the most immediate threat to life.
Proceed directly to the operating room for an exploratory laparotomy.
The active intra-abdominal hemorrhage is the definitive cause of the patient's current exsanguinating shock. A BTAI that survives to hospital presentation is typically a contained hematoma and must be addressed after controlling the active intra-abdominal bleeding.

Key Concept

In a hemodynamically unstable patient with blunt trauma and multiple injuries, a positive FAST mandates immediate exploratory laparotomy to control intra-abdominal bleeding, taking precedence over diagnostic evaluation of a suspected blunt thoracic aortic injury.
Rate this question

Topics

Trauma and Burns

More questions from this topic