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Difficulty: MediumTrauma and Burns

A 38-year-old male is brought to the emergency department after a high-speed head-on motor vehicle collision. He was an unrestrained driver and was ejected from the vehicle. Upon arrival, his blood pressure is 76/40 mmHg and his heart rate is 135/min. He is unresponsive with a Glasgow Coma Scale score of 3. The airway is secured with an endotracheal tube, and breath sounds are clear and equal bilaterally. The trachea is midline, and jugular veins are flat. Examination of the abdomen reveals mild distension and a transverse band of ecchymosis across the lower abdomen. The pelvis is mechanically stable to anteroposterior and lateral compression. Intravenous access is rapidly established, and a massive transfusion protocol is initiated. Which of the following is the most appropriate next step in management?

  1. A
    Computed tomography of the abdomen and pelvis
  2. Focused assessment with sonography for traumaAnswer
  3. C
    Immediate exploratory laparotomy
  4. D
    Diagnostic peritoneal lavage
  5. E
    Administration of intravenous norepinephrine

Answer

Focused assessment with sonography for trauma
In the management of blunt abdominal trauma, the patient's hemodynamic status determines the diagnostic pathway. After securing the airway and confirming adequate ventilation (which rules out immediate thoracic life threats like tension pneumothorax), a patient who remains in shock (BP 76/40 mmHg) must be rapidly evaluated for the source of bleeding. The Focused Assessment with Sonography for Trauma (FAST) is the standard next step. It is performed at the bedside and can quickly detect intraperitoneal free fluid (blood). If the FAST is positive, the patient is taken immediately for an exploratory laparotomy. If it is negative, a search for extra-abdominal sources of hemorrhage (e.g., retroperitoneal bleeding) continues.

Step-by-Step Solution

1
Assess the patient's hemodynamic status and mechanism of injury.
The patient is hemodynamically unstable (BP 76/40 mmHg, HR 135/min) following severe blunt trauma.
Hemodynamic instability dictates a specialized algorithm focused on rapid, bedside diagnostics and immediate life-saving interventions.
2
Evaluate the primary survey findings to localize potential sources of shock.
Airway is secure, and breathing is intact (clear lungs, midline trachea, flat neck veins), ruling out tension pneumothorax or massive hemothorax. Pelvis is stable. The abdomen is distended with a seatbelt sign.
By ruling out intrathoracic causes, the abdomen becomes the most likely source of massive hemorrhage.
3
Select the most appropriate initial diagnostic modality for suspected intra-abdominal hemorrhage in an unstable patient.
Perform a Focused Assessment with Sonography for Trauma (FAST).
FAST is a rapid, non-invasive bedside tool that can quickly confirm the presence of intraperitoneal free fluid, guiding the decision to proceed to exploratory laparotomy.

Key Concept

In hemodynamically unstable patients with blunt abdominal trauma, the immediate next diagnostic step is a bedside FAST exam to identify intraperitoneal hemorrhage before proceeding to surgical intervention.
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Topics

Trauma and Burns

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