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Difficulty: MediumTrauma and Burns

A 38-year-old female is evaluated in the emergency department after a low-speed collision in which her bicycle was struck by a turning vehicle. She was wearing a helmet and reports no loss of consciousness. She complains primarily of left-sided abdominal pain and left shoulder pain. Upon arrival, her blood pressure is 122/78 mm Hg, heart rate is 88/min, and respiratory rate is 16/min. Oxygen saturation is 99% on room air. The primary survey is unremarkable. Physical examination reveals bruising over the left lower ribs. Abdominal examination demonstrates mild left upper quadrant tenderness but no rebound or guarding. A bedside focused assessment with sonography for trauma (FAST) demonstrates a distinct rim of anechoic fluid surrounding the spleen. Which of the following is the most appropriate next step in management?

  1. A
    Immediate exploratory laparotomy
  2. B
    Diagnostic peritoneal lavage
  3. Computed tomography of the abdomen and pelvis with intravenous contrastAnswer
  4. D
    Splenic artery angiography with endovascular embolization
  5. E
    Admission to the surgical ward for serial hemoglobin checks and observation

Answer

Computed tomography of the abdomen and pelvis with intravenous contrast is the correct next step because the patient is hemodynamically stable, allowing for safe anatomic localization and grading of the intra-abdominal injury.
The correct action is to obtain a computed tomography (CT) scan of the abdomen and pelvis with intravenous contrast. The management of blunt abdominal trauma hinges primarily on the patient's hemodynamic status. This patient has evidence of intra-abdominal hemorrhage (a positive FAST exam) but maintains normal blood pressure and heart rate. According to trauma algorithms, hemodynamically stable patients with a positive FAST should proceed to a CT scan. This imaging modality precisely localizes the injury, grades solid organ damage, detects active extravasation, and evaluates for hollow viscus injury, allowing the surgical team to determine if nonoperative management is safe or if angioembolization/surgery is required.

Step-by-Step Solution

1
Evaluate the patient's hemodynamic status.
The patient's vital signs (BP 122/78 mm Hg, HR 88/min) demonstrate clear hemodynamic stability.
Stability determines whether the patient can safely be transported to the radiology suite for advanced imaging or requires immediate operative intervention.
2
Interpret the adjuncts to the primary survey.
The FAST examination reveals free intraperitoneal fluid (hemoperitoneum), likely from a splenic injury given the left upper quadrant tenderness and left shoulder pain (Kehr's sign).
Identifying fluid confirms intra-abdominal injury, shifting the management algorithm toward defining the extent of that injury.
3
Select the appropriate diagnostic pathway based on the ATLS algorithm.
A hemodynamically stable patient with a positive FAST must undergo a CT scan of the abdomen and pelvis with IV contrast.
CT imaging safely defines the exact organ injured, grades the severity, identifies active arterial extravasation, and rules out associated injuries, which guides whether management should be surgical, angiographic, or observational.

Key Concept

In blunt abdominal trauma, hemodynamically stable patients with a positive FAST exam should undergo CT scanning of the abdomen and pelvis with intravenous contrast to define the anatomy and severity of the injury.
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Topics

Trauma and Burns

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