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Difficulty: HardTrauma and Burns

An emergency medical crew transports a 35-year-old female equestrian to the trauma bay after she was violently thrown from her horse and trampled. She arrives fully immobilized on a backboard with a cervical collar. Her airway is patent and self-maintained. Initial vital signs demonstrate a heart rate of 142/min, blood pressure of 72/38 mm Hg, and a respiratory rate of 26/min. Both lungs are clear to auscultation bilaterally, and heart sounds are crisp and normal. There is extensive ecchymosis across her anterior chest wall and lower abdomen. Pelvic compression elicits no crepitus or mechanical instability. A portable supine anteroposterior chest radiograph reveals a widened mediastinal silhouette and deviation of the trachea to the right, with no evidence of hemothorax or pneumothorax. A bedside focused assessment with sonography for trauma (FAST) demonstrates a large volume of anechoic fluid in the hepatorenal space (Morison pouch) and the rectouterine pouch. Which of the following is the most appropriate next step in the management of this patient?

  1. A
    Computed tomography angiography of the chest and abdomen
  2. Exploratory laparotomyAnswer
  3. C
    Diagnostic peritoneal lavage
  4. D
    Placement of a pelvic binder
  5. E
    Resuscitative left anterolateral thoracotomy

Answer

Exploratory laparotomy
Exploratory laparotomy is the correct next step because the patient is in profound hemorrhagic shock with clear evidence of intraperitoneal bleeding on the FAST exam. While the widened mediastinum on the chest radiograph is highly suspicious for a blunt thoracic aortic injury (BTAI), most patients who survive to reach the hospital with a BTAI have a temporarily contained hematoma. In contrast, the active intra-abdominal hemorrhage is the immediate driver of her shock and will be rapidly fatal if not addressed. ATLS guidelines mandate that the active, uncontained source of bleeding be controlled first in the operating room. Advanced imaging for the aorta can be pursued once the patient is hemodynamically stabilized post-laparotomy.

Step-by-Step Solution

1
Assess the patient's hemodynamic status.
The patient is in Class III/IV hemorrhagic shock (heart rate 142/min, blood pressure 72/38 mm Hg).
Hemodynamic instability dictates the urgency and location of the next intervention (operating room vs. imaging suite).
2
Analyze the primary survey and diagnostic adjuncts.
FAST is strongly positive for intraperitoneal hemorrhage. The chest x-ray suggests a blunt thoracic aortic injury (BTAI) due to the widened mediastinum.
Identifying all potential sources of life-threatening hemorrhage is necessary to prioritize surgical interventions.
3
Determine the priority of intervention based on ATLS protocols.
Active intra-abdominal bleeding takes precedence. The BTAI is likely contained by the adventitia as a pseudoaneurysm.
In polytrauma, the immediate cause of decompensation (free intra-abdominal hemorrhage) must be surgically controlled before evaluating or treating temporarily contained injuries.
4
Select the definitive management step.
The patient must be taken immediately for an exploratory laparotomy.
Laparotomy is the definitive treatment for uncontrolled intra-abdominal hemorrhage in an unstable patient.

Key Concept

In patients with multiple traumatic injuries, hemodynamic instability driven by active intra-abdominal hemorrhage (positive FAST) requires immediate exploratory laparotomy. Evaluation of suspected blunt thoracic aortic injury must be deferred until after the primary source of bleeding is surgically controlled.
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Trauma and Burns

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