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Difficulty: HardTrauma and Burns

A 28-year-old woman is brought to the emergency department after falling from a fourth-story balcony. She was intubated at the scene due to a depressed level of consciousness. Upon arrival, her temperature is 36.1°C (97.0°F), blood pressure is 72/40 mm Hg, and pulse is 138/min. Physical examination reveals a 7-mm, nonreactive right pupil and a 3-mm, briskly reactive left pupil. The trachea is midline, and breath sounds are present and equal bilaterally. The pelvis is stable to anteroposterior and lateral compression. The left thigh is visibly swollen and deformed. Focused assessment with sonography for trauma (FAST) demonstrates an anechoic stripe in the hepatorenal recess. A peripheral intravenous line is established, and 1 L of warmed lactated Ringer solution is rapidly infused; her blood pressure remains 70/40 mm Hg. Which of the following is the most appropriate next step in the management of this patient?

  1. A
    Transport to the radiology department for unenhanced cranial imaging
  2. B
    Intravenous administration of a hyperosmolar agent and transport for neuroimaging
  3. C
    Transport to the radiology department for contrast-enhanced torso imaging
  4. Urgent transfer to the operating suite for abdominal explorationAnswer
  5. E
    Performance of a diagnostic peritoneal lavage

Answer

Urgent transfer to the operating suite for abdominal exploration
This patient has sustained polytrauma resulting in severe hemorrhagic shock and a traumatic brain injury. The presence of a fixed and dilated pupil in the setting of a depressed Glasgow Coma Scale score strongly suggests an expanding intracranial hematoma causing uncal herniation. However, the patient is also in profound shock that is unresponsive to initial fluid resuscitation, and the FAST examination is positive for intra-abdominal fluid (blood). According to ATLS protocols, management of the airway and breathing is followed immediately by management of circulation (hemorrhage control). The patient will die of exsanguination before any neurologic injury can be addressed if the intra-abdominal bleeding is not stopped. Therefore, the absolute most appropriate next step is urgent transfer to the operating room for an exploratory laparotomy. Once hemorrhage is controlled and hemodynamics are stabilized, the patient can safely be transported for cranial imaging.

Step-by-Step Solution

1
Assess the patient's hemodynamic status.
The patient is in class IV hemorrhagic shock, evidenced by a blood pressure of 72/40 mm Hg and a heart rate of 138/min, which is unresponsive to an initial fluid bolus.
Hemodynamic stability dictates the entire diagnostic and therapeutic algorithm in blunt trauma.
2
Identify the primary source of life-threatening hemorrhage.
The FAST exam reveals free fluid in the hepatorenal recess (Morison's pouch), indicating massive intra-abdominal hemorrhage.
Localizing the bleeding site determines which surgical team and intervention are required immediately.
3
Prioritize interventions based on Advanced Trauma Life Support (ATLS) principles.
Although the patient has signs of uncal herniation (blown right pupil) indicating a severe traumatic brain injury (TBI), Circulation (C) takes precedence over Disability (D). She must undergo abdominal exploration first.
A patient cannot survive a neurosurgical intervention or a trip to the CT scanner without adequate circulating blood volume. Hemorrhage control is the absolute highest priority.

Key Concept

In blunt trauma, hemodynamically unstable patients with a positive FAST exam require immediate exploratory laparotomy, even in the presence of severe traumatic brain injury.
Estimated Time:1m 30s
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Topics

Trauma and Burns

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