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Difficulty: MediumTrauma and Burns

A 26-year-old man is evaluated in the emergency department after a mountain biking accident. He lost control on a steep downhill trail and was thrown over the handlebars, striking his left flank against a large tree stump. He complains of severe left-sided abdominal pain that radiates to his left shoulder.

His temperature is 37.1°C (98.8°F), blood pressure is 132/84 mmHg, heart rate is 86/min, and respiratory rate is 16/min. On physical examination, the patient is alert and oriented. There is an abrasion and extensive ecchymosis over the left lower rib cage. Abdominal examination reveals tenderness to palpation in the left upper quadrant, but no guarding, rigidity, or rebound tenderness is present. The pelvis is stable to anteroposterior and lateral compression.

A bedside focused assessment with sonography for trauma (FAST) demonstrates a small accumulation of anechoic fluid in the splenorenal recess.

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

  1. CT of the abdomen and pelvis with intravenous contrastAnswer
  2. B
    Urgent exploratory laparotomy
  3. C
    Percutaneous diagnostic peritoneal lavage
  4. D
    Endovascular angiography with selective embolization
  5. E
    Observation with serial hemoglobin measurements alone

Answer

CT of the abdomen and pelvis with intravenous contrast
This patient presents with blunt abdominal trauma, left upper quadrant pain, and referred left shoulder pain (Kehr sign), which are highly suspicious for a splenic injury. This clinical suspicion is confirmed by a positive FAST exam demonstrating fluid in the splenorenal recess. The critical decision point in this scenario is the patient's hemodynamic status. He is currently normotensive and has a normal heart rate (blood pressure 132/84 mmHg, heart rate 86/min), classifying him as hemodynamically stable. The standard of care for a hemodynamically stable patient with a positive FAST is to proceed to a CT scan of the abdomen and pelvis with intravenous contrast. The CT scan provides essential diagnostic information, including the specific grade of the splenic laceration and the presence or absence of active contrast extravasation (a 'blush'). This imaging ultimately determines whether the patient is a candidate for nonoperative management, angioembolization, or requires definitive surgery.

Step-by-Step Solution

1
Assess the patient's hemodynamic status upon arrival.
The patient is normotensive (blood pressure 132/84 mmHg) and has a normal heart rate (86/min), indicating he is hemodynamically stable.
Hemodynamic status is the primary branch point in the blunt abdominal trauma algorithm.
2
Evaluate the results of the primary adjunct imaging.
The FAST exam is positive for intraperitoneal fluid (blood) in the splenorenal recess, consistent with a splenic injury.
A positive FAST indicates intra-abdominal hemorrhage, explaining the patient's left upper quadrant pain and Kehr sign (referred shoulder pain).
3
Determine the definitive diagnostic modality based on stability and FAST results.
A CT scan of the abdomen and pelvis with intravenous contrast is chosen.
For a stable patient with a positive FAST, cross-sectional imaging is required to grade the solid organ injury, detect active contrast extravasation, and evaluate for concurrent injuries.

Key Concept

In hemodynamically stable patients with blunt abdominal trauma and a positive FAST examination, the most appropriate next step is a CT scan of the abdomen and pelvis with intravenous contrast to delineate the injury and guide further management.
Estimated Time:1m 30s
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Topics

Trauma and Burns

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