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Question

Difficulty: MediumTrauma and Burns

A 25-year-old man is brought to the emergency department via ambulance 20 minutes after being shot during an altercation. He sustained a single gunshot wound to the right anterior chest, located in the fifth intercostal space at the midclavicular line. There is no visible exit wound. The patient is pale, diaphoretic, and lethargic. Vital signs include a blood pressure of 76/40 mm Hg, heart rate of 132/min, and respiratory rate of 22/min. Oxygen saturation is 97% on high-flow oxygen. The trachea is midline, and neck veins are flat. Auscultation of the chest reveals clear and equal breath sounds bilaterally. The abdomen is visibly distended and demonstrates diffuse rigidity and guarding. Two large-bore intravenous lines are placed, and fluid resuscitation is initiated. Which of the following is the most appropriate next step in the management of this patient?

  1. Exploratory laparotomyAnswer
  2. B
    Computed tomography of the abdomen and pelvis
  3. C
    Focused Assessment with Sonography for Trauma (FAST)
  4. D
    Right-sided tube thoracostomy
  5. E
    Diagnostic peritoneal lavage

Answer

Exploratory laparotomy
This patient has sustained a penetrating injury below the level of the nipple (4th intercostal space). Because the diaphragm can elevate to this level during expiration, any penetrating trauma to this "thoracoabdominal area" carries a high risk of intra-abdominal injury. The patient is in profound hemorrhagic shock and exhibits overt signs of peritonitis (diffuse rigidity and guarding), making the abdomen the clear source of his instability. In the setting of penetrating trauma with hemodynamic instability or peritonitis, immediate exploratory laparotomy is the definitive, lifesaving intervention.

Step-by-Step Solution

1
Identify the trajectory risk based on the anatomical location of the wound.
The entrance wound is at the 5th intercostal space, which is below the nipple line (4th intercostal space).
The diaphragm can rise as high as the 4th intercostal space during exhalation, meaning any penetrating wound below this level must be assumed to involve the abdominal cavity.
2
Assess the patient's hemodynamic status and physical exam findings.
The patient is in hemorrhagic shock (BP 76/40 mm Hg, HR 132/min) and has a rigid, distended abdomen indicating peritonitis.
These findings localize the primary site of life-threatening hemorrhage and visceral injury to the abdomen, rather than the chest.
3
Determine the next best step in management according to ATLS protocols.
Proceed directly to exploratory laparotomy.
Hemodynamically unstable patients with penetrating abdominal trauma require immediate surgical exploration. Diagnostic imaging is contraindicated as it delays definitive care.

Key Concept

Any penetrating injury below the 4th intercostal space (nipple line) is considered a thoracoabdominal wound that can involve intra-abdominal organs. If accompanied by hemodynamic instability or peritonitis, immediate exploratory laparotomy is required.
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Topics

Trauma and Burns

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