A 31-year-old man is brought to the emergency department by ambulance after sustaining a s… — USMLE Step 2 CK

A 31-year-old man is brought to the emergency department by ambulance after sustaining a stab wound to the abdomen during a physical altercation. On arrival, he is lethargic and pale. Vital signs are temperature $36.8^\circ\text{C}$ ( $98.2^\circ\text{F}$ ), blood pressure $78/42\text{ mmHg}$ , pulse $142/\text{min}$ , and respirations $24/\text{min}$ . Pulse oximetry is $97\%$ on high-flow oxygen. Primary survey reveals a patent airway and equal bilateral breath sounds. There is a single $4\text{ cm}$ laceration in the left upper quadrant, just below the costal margin. The patient's abdomen is markedly distended, rigid, and exhibits diffuse rebound tenderness. Peripheral pulses are thready. Two large-bore intravenous lines are established, and isotonic fluid resuscitation is initiated. Which of the following is the most appropriate next step in the management of this patient?

Immediate exploratory laparotomyAnswer
B
Computed tomography of the abdomen and pelvis
C
Focused assessment with sonography for trauma
D
Local wound exploration
E
Intravenous piperacillin-tazobactam and close observation

Answer

Immediate exploratory laparotomy

The correct action is immediate exploratory laparotomy. This patient presents with penetrating abdominal trauma, profound hemodynamic instability (blood pressure

78/42\text{ mmHg}

, pulse

142/\text{min}

), and clear signs of peritonitis (abdominal rigidity, rebound tenderness). According to Advanced Trauma Life Support (ATLS) principles, the presence of hemodynamic instability, peritonitis, or evisceration following penetrating abdominal trauma are absolute indications for immediate surgical exploration. The primary goal is emergent hemorrhage control and repair of intra-abdominal injuries. Any further diagnostic testing would dangerously delay definitive, life-saving treatment.

Step-by-Step Solution

Assess the patient's hemodynamic status.

The patient is in profound hypovolemic shock (blood pressure

78/42\text{ mmHg}

, pulse

142/\text{min}

, lethargy).

Hemodynamic stability dictates whether a trauma patient can safely undergo imaging or requires immediate surgical intervention.

Evaluate the mechanism of injury and abdominal exam findings.

The patient has penetrating abdominal trauma (stab wound) with clear signs of peritonitis (rigidity, diffuse rebound tenderness).

Peritonitis indicates hollow viscus perforation or severe intra-abdominal hemorrhage, both of which are absolute surgical indications.

Determine the next appropriate clinical step based on established trauma protocols.

The patient must be taken directly to the operating room for an exploratory laparotomy.

In penetrating abdominal trauma, hemodynamic instability or peritonitis mandates immediate laparotomy. Any delay for imaging is strictly contraindicated.

Key Concept

Hemodynamically unstable patients with penetrating abdominal trauma and signs of peritonitis have an absolute indication for immediate exploratory laparotomy.

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