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Difficulty: MediumTrauma and Burns

A 52-year-old man is transported to the trauma center by helicopter after a high-speed head-on motor vehicle collision. On arrival, he is confused and diaphoretic. His blood pressure is 82/54 mm Hg, heart rate is 128/min, and respiratory rate is 22/min. Oxygen saturation is 97% on a nonrebreather mask. The airway is secure, and breath sounds are present and equal bilaterally. The abdomen is grossly distended and rigid to palpation. Pelvic compression does not elicit instability. Intravenous access is established, and rapid fluid resuscitation with warmed crystalloid is initiated. A focused assessment with sonography for trauma (FAST) examination reveals an anechoic stripe in the hepatorenal recess. Which of the following is the most appropriate next step in management?

  1. A
    Computed tomography scan of the abdomen and pelvis
  2. B
    Diagnostic peritoneal lavage
  3. Exploratory laparotomyAnswer
  4. D
    Angiography with selective embolization
  5. E
    Continuation of fluid resuscitation and serial FAST examinations

Answer

Exploratory laparotomy
This patient presents with hypovolemic shock (hypotension, tachycardia, diaphoresis) following blunt abdominal trauma. The focused assessment with sonography for trauma (FAST) reveals an anechoic stripe in the hepatorenal recess (Morison's pouch), which confirms the presence of intraperitoneal fluid (blood). In the setting of hemodynamic instability and a positive FAST, the immediate standard of care is exploratory laparotomy to identify and control the source of intra-abdominal hemorrhage.

Step-by-Step Solution

1
Assess the patient's hemodynamic status.
The patient is hemodynamically unstable, evidenced by a blood pressure of 82/54 mm Hg, heart rate of 128/min, confusion, and diaphoresis.
Hemodynamic stability is the primary decision branch point in the ATLS algorithm for evaluating blunt abdominal trauma.
2
Evaluate the primary survey findings to localize the source of bleeding.
The patient has a grossly distended and rigid abdomen with a positive FAST exam indicating intraperitoneal fluid (blood).
A positive FAST exam confirms that the peritoneal cavity is the source of the hemorrhagic shock.
3
Determine the definitive next step in management.
The patient must undergo an immediate exploratory laparotomy.
A hemodynamically unstable patient with evidence of ongoing intra-abdominal hemorrhage requires prompt surgical exploration to achieve definitive hemostasis.

Key Concept

Hemodynamically unstable patients with blunt abdominal trauma and evidence of intraperitoneal hemorrhage on a FAST exam require immediate exploratory laparotomy.
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Topics

Trauma and Burns

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