Emergency medical services bring a -year-old male to the trauma bay following a high-speed motorcycle collision. He was found unresponsive at the scene. Currently, the patient is obtunded but his airway remains patent with equal bilateral breath sounds. Initial vital signs include a blood pressure of and a heart rate of . Abdominal examination shows severe distension and a rigid contour with prominent ecchymosis over the lower quadrants. A bedside focused assessment with sonography for trauma (FAST) reveals a large volume of anechoic fluid in the hepatorenal recess and pelvis. Peripheral intravenous access is secured and crystalloid fluid administration is started. Which of the following is the most appropriate next step in management?
- AComputed tomography scan of the abdomen and pelvis
- BDiagnostic peritoneal lavage
- Exploratory laparotomyAnswer
- DIntravenous administration of broad-spectrum antibiotics
- EAdmission to the intensive care unit for serial abdominal examinations
Answer
The correct answer is exploratory laparotomy.
The most appropriate next step for a hemodynamically unstable patient with blunt abdominal trauma and a positive FAST examination is an immediate exploratory laparotomy. This patient is in class IV hemorrhagic shock, evidenced by profound hypotension and marked tachycardia. The rigid, distended abdomen and positive FAST indicate massive intra-abdominal hemorrhage. Emergent surgical exploration is required to identify and control the source of bleeding.
Step-by-Step Solution
Key Concept
In hemodynamically unstable patients with blunt abdominal trauma, a positive FAST exam is an absolute indication for immediate exploratory laparotomy.