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Difficulty: MediumTrauma and Burns

A 19-year-old male collegiate rugby player is evaluated in the emergency department immediately after a severe on-field collision. During the match, he was struck forcefully in the left flank by an opponent's shoulder. En route to the hospital, he received 1 L of intravenous lactated Ringer solution. Upon arrival, he appears pale, diaphoretic, and lethargic. His temperature is 36.5°C (97.7°F), blood pressure is 78/40 mm Hg, and pulse is 138/min. Oxygen saturation is 99% on room air. The trachea is midline, and breath sounds are clear and symmetric bilaterally. Heart sounds are rapid but normal in intensity, with no jugular venous distention. The abdomen is distended, rigid, and diffusely tender, with significant guarding in the left upper quadrant. The patient also reports worsening pain in his left shoulder while lying supine. A focused assessment with sonography for trauma (FAST) examination reveals an anechoic stripe in the splenorenal recess. What is the most appropriate next step in the management of this patient?

  1. A
    Computed tomography of the abdomen and pelvis with intravenous contrast
  2. B
    Diagnostic peritoneal lavage
  3. C
    Angiography with splenic artery embolization
  4. Immediate exploratory laparotomyAnswer
  5. E
    Left-sided tube thoracostomy

Answer

Immediate exploratory laparotomy is the correct next step in management.
The correct answer is immediate exploratory laparotomy. This patient presents with blunt abdominal trauma resulting in hemorrhagic shock that is unresponsive to an initial fluid bolus. The presence of left upper quadrant pain, rigidity, and referred left shoulder pain (Kehr sign) strongly points to a splenic rupture. The focused assessment with sonography for trauma (FAST) confirms the presence of free intraperitoneal fluid (blood). According to Advanced Trauma Life Support (ATLS) protocols, any hemodynamically unstable patient with blunt abdominal trauma and a positive FAST examination must be taken immediately to the operating room for an exploratory laparotomy to identify and stop the bleeding.

Step-by-Step Solution

1
Identify the patient's hemodynamic status.
The patient is in hemorrhagic shock (blood pressure 78/40 mm Hg, pulse 138/min) despite a 1 L crystalloid fluid bolus.
Hemodynamic status dictates the algorithmic pathway for blunt trauma (stable vs. unstable).
2
Analyze the physical exam and imaging findings.
The patient has a rigid abdomen, left upper quadrant guarding, Kehr sign (referred left shoulder pain), and an anechoic stripe in the splenorenal recess on FAST.
These findings confirm the abdomen (specifically a splenic injury) as the source of the hemorrhage.
3
Determine the definitive management based on the algorithm for unstable blunt abdominal trauma.
Proceed directly to the operating room for immediate exploratory laparotomy.
Hemodynamically unstable patients with a positive FAST examination require emergent surgical control of the bleeding.

Key Concept

Hemodynamically unstable patients with blunt abdominal trauma and a positive FAST examination require emergent exploratory laparotomy.
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Topics

Trauma and Burns

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