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Difficulty: HardTrauma and Burns

Evaluate the following clinical scenarios of trauma patients and pair each presentation with the single most appropriate next step in management.

  • A 29-year-old man involved in a high-speed collision. Blood pressure is 82/50 mm Hg. Focused assessment with sonography for trauma (FAST) shows free fluid in the hepatorenal recess.Immediate exploratory laparotomy
  • A 38-year-old woman evaluated after a bicycle crash. Blood pressure is 118/76 mm Hg. FAST examination reveals a small amount of fluid in the splenorenal recess.Computed tomography scan of the abdomen and pelvis with intravenous contrast
  • A 22-year-old man with a stab wound to the left anterior neck. He presents with an expanding, pulsatile hematoma and audible stridor.Immediate operative neck exploration
  • A 55-year-old man who fell from a roof. Blood pressure is 86/52 mm Hg. FAST is negative, pelvis is stable, and ECG reveals a new-onset right bundle branch block.Transthoracic echocardiography

Answer

The hemodynamically unstable patient with a positive FAST requires exploratory laparotomy. The stable patient with a positive FAST requires a CT scan. The patient with penetrating neck trauma and hard signs requires operative neck exploration. The unstable patient with negative FAST and new ECG changes requires transthoracic echocardiography.
Trauma management protocols strictly delineate interventions based on hemodynamic stability and the presence of 'hard signs' of injury. Unstable patients with intra-abdominal fluid or patients with expanding neck hematomas require immediate surgery. Stable patients can undergo CT imaging, while unexplained shock with ECG changes warrants echocardiography.

Step-by-Step Solution

1
Assess the hemodynamic status of the patient in each scenario.
Two patients are hemodynamically unstable (hypotensive), one is stable, and one has hard signs of vascular/airway injury.
Hemodynamic stability is the primary decision point in trauma algorithms, determining whether the patient can safely undergo imaging or must go directly to the operating room.
2
Determine the significance of the FAST exam results based on stability.
The unstable patient with a positive FAST goes to laparotomy. The stable patient with a positive FAST can safely undergo CT scanning.
A positive FAST in an unstable patient indicates active intra-abdominal hemorrhage that is the likely cause of shock. In a stable patient, it merely indicates the presence of fluid, which could be from a minor solid organ laceration that can be managed nonoperatively.
3
Identify hard signs of penetrating neck trauma.
The patient with a neck stab wound has an expanding hematoma and stridor (hard signs), dictating immediate operative exploration.
Hard signs of aerodigestive or vascular injury require immediate surgical intervention to secure the airway and control bleeding, bypassing further diagnostic workup.
4
Evaluate the cause of shock in the patient with a negative FAST and stable pelvis.
The presence of a new right bundle branch block suggests blunt cardiac injury, which is evaluated with an echocardiogram.
When hemorrhage has been ruled out in an unstable blunt trauma patient, cardiogenic shock (due to myocardial contusion) must be considered and investigated with echocardiography.

Key Concept

Advanced Trauma Life Support (ATLS) algorithms dictate that hemodynamically unstable patients with identified bleeding or hard signs of injury require immediate surgical intervention, while stable patients should undergo detailed imaging to guide management.
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Topics

Trauma and Burns

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