A 29-year-old woman, G2P1, at 32 weeks gestation is brought to the emergency department vi… — USMLE Step 2 CK

A $29$ -year-old woman, G2P1, at $32$ weeks gestation is brought to the emergency department via ambulance following a motor vehicle collision. She was the restrained driver of a sedan that was struck on the driver's side by a commercial truck. On arrival, she is immobilized on a backboard with a cervical collar. She appears confused and is diaphoretic. Temperature is $36.5^\circ\text{C}$ ( $97.7^\circ\text{F}$ ), blood pressure is $78/45\text{ mmHg}$ , heart rate is $132\text{/min}$ , and respiratory rate is $24\text{/min}$ . Pulse oximetry is $96\%$ on $15\text{ L/min}$ oxygen via a nonrebreather mask. The airway is patent, and breath sounds are equal bilaterally. The uterus is palpated above the umbilicus. The abdomen is diffusely tender to palpation with involuntary guarding. There is no external vaginal bleeding. A focused assessment with sonography for trauma (FAST) reveals a large amount of free fluid in the hepatorenal space (Morison's pouch). Fetal heart tones are $140\text{/min}$ . Two large-bore intravenous lines are established, and administration of warmed crystalloid fluids is initiated. Which of the following is the best next step in management?

Exploratory laparotomyAnswer
B
Computed tomography of the abdomen and pelvis
C
Repositioning the patient to the left lateral decubitus position
D
Emergent cesarean delivery
E
Diagnostic peritoneal lavage

Answer

Exploratory laparotomy

The correct answer is exploratory laparotomy. This patient has experienced blunt abdominal trauma and is exhibiting signs of severe hemorrhagic shock (hypotension, tachycardia, altered mental status). The positive FAST examination indicates a massive intraperitoneal hemorrhage, likely from a solid organ injury such as a splenic or hepatic laceration. According to Advanced Trauma Life Support (ATLS) protocols, the standard of care for a hemodynamically unstable patient with a positive FAST is immediate exploratory laparotomy to surgically control the bleeding. Although the patient is pregnant, the fundamental principles of trauma resuscitation do not change; maternal resuscitation and stabilization remain the absolute priority because saving the mother provides the best chance of saving the fetus.

Step-by-Step Solution

Identify the patient's hemodynamic status.

The patient has a blood pressure of

78/45\text{ mmHg}

and a heart rate of

132\text{/min}

, indicating hemodynamic instability (Class III/IV hemorrhagic shock).

Determining hemodynamic stability is the critical branch point in the blunt abdominal trauma algorithm.

Evaluate the results of the primary diagnostic adjuncts.

The FAST examination is positive for free fluid in Morison's pouch.

A positive FAST in a trauma setting confirms the presence of intraperitoneal hemorrhage.

Determine the appropriate intervention based on the trauma algorithm.

The combination of hemodynamic instability and a positive FAST exam mandates immediate exploratory laparotomy.

Definitive surgical control of hemorrhage is required. Maternal stabilization takes absolute precedence to optimize both maternal and fetal outcomes.

Key Concept

Hemodynamically unstable patients with blunt abdominal trauma and a positive FAST exam require immediate exploratory laparotomy, and maternal resuscitation is the priority in pregnant trauma patients.

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