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Difficulty: MediumTrauma and Burns

A 34-year-old man is brought to the emergency department 30 minutes after being involved in a high-speed motor vehicle collision. He was the unrestrained driver of a vehicle that struck a concrete barrier. On arrival, he is groaning and withdrawing from painful stimuli.

Vital signs are temperature 36.5°C (97.7°F), blood pressure 78/45 mmHg, pulse 135/min, and respirations 22/min.

Primary survey reveals a patent airway and a midline trachea. Breath sounds are clear and equal bilaterally. Jugular venous distention is absent.

The abdomen is distended, with significant guarding and rebound tenderness. The pelvis is stable to anterior-posterior and lateral compression.

Two large-bore intravenous lines are placed, and warmed isotonic crystalloid fluid resuscitation is initiated. A bedside ultrasound examination demonstrates an anechoic stripe between the liver and right kidney.

Which of the following is the most appropriate next step in the management of this patient?

  1. A
    Cross-sectional imaging of the abdomen and pelvis
  2. Urgent operative abdominal explorationAnswer
  3. C
    Pelvic angiography with potential embolization
  4. D
    Serial abdominal examinations with observation
  5. E
    Performance of a diagnostic peritoneal aspirate

Answer

The most appropriate next step is urgent operative abdominal exploration.
The correct answer is urgent operative abdominal exploration. This patient is in hemorrhagic shock following a high-speed motor vehicle collision. The bedside ultrasound (FAST exam) reveals an anechoic stripe between the liver and right kidney, representing blood in Morison's pouch. According to Advanced Trauma Life Support (ATLS) guidelines, a hemodynamically unstable patient with a positive FAST exam requires immediate surgical intervention to identify and control the source of hemorrhage.

Step-by-Step Solution

1
Assess the patient's hemodynamic status.
The patient is hemodynamically unstable, exhibiting profound hypotension (BP 78/45 mmHg) and tachycardia (HR 135/min).
Identifying hemorrhagic shock dictates the urgency and pathway of the trauma management algorithm.
2
Interpret the bedside ultrasound (FAST) findings.
The ultrasound demonstrates an anechoic stripe between the liver and right kidney (Morison's pouch).
This finding confirms the presence of intraperitoneal free fluid, which in the context of trauma is presumed to be blood.
3
Determine the definitive management based on ATLS protocols.
The patient must be taken immediately to the operating room for an urgent operative abdominal exploration.
A hemodynamically unstable patient with confirmed intraperitoneal bleeding requires immediate surgical hemostasis.

Key Concept

Management of hemodynamically unstable blunt abdominal trauma
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Topics

Trauma and Burns

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