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Difficulty: MediumTrauma and Burns

A 19-year-old man is rushed to the trauma center by emergency medical services after being struck by a fast-moving motor vehicle while crossing the street. On arrival, his blood pressure is 72/44 mmHg, heart rate is 140/min, and respiratory rate is 26/min. Pulse oximetry shows 96% on a non-rebreather mask. The airway is patent, and breath sounds are present and equal bilaterally. Trachea is midline. Peripheral pulses are rapid and thready. He immediately receives 1 L of intravenous Ringer's lactate and 1 unit of uncrossmatched packed red blood cells. Reassessment vital signs show a blood pressure of 78/48 mmHg and a heart rate of 130/min. Physical examination reveals a distended abdomen with diffuse guarding and rebound tenderness. The pelvis is mechanically stable to gentle compression. A focused assessment with sonography for trauma (FAST) exam demonstrates a prominent anechoic stripe in the right upper quadrant between the liver and kidney. Which of the following is the most appropriate next step in management?

  1. A
    Contrast-enhanced CT scan of the abdomen and pelvis
  2. B
    Diagnostic peritoneal lavage
  3. C
    Angiography with transcatheter embolization
  4. Emergent surgical exploration of the abdomenAnswer
  5. E
    Admission to the surgical intensive care unit for serial abdominal examinations

Answer

The most appropriate next step is emergent surgical exploration of the abdomen.
The correct intervention is emergent surgical exploration of the abdomen. This patient presents with blunt trauma, evidence of hemorrhagic shock, and failure to appropriately respond to initial fluid and blood resuscitation. The positive FAST exam (showing an anechoic stripe, which represents free fluid/blood) in conjunction with diffuse peritonitis localizes the bleeding to the peritoneal cavity. According to advanced trauma life support (ATLS) algorithms, hemodynamically unstable patients with a positive FAST must bypass the CT scanner and proceed directly to the operating room for a laparotomy to rapidly control the bleeding.

Step-by-Step Solution

1
Assess the patient's hemodynamic status following initial resuscitation.
The patient remains hemodynamically unstable (hypotensive and tachycardic) despite receiving intravenous crystalloids and a unit of blood.
Hemodynamic status dictates the algorithmic approach to trauma; unstable patients cannot safely undergo advanced imaging like CT scans.
2
Interpret the physical exam and imaging findings.
The patient has a distended, peritonitic abdomen and a positive FAST exam showing fluid in Morison's pouch.
A positive FAST exam in the setting of blunt trauma and hemodynamic instability confirms ongoing intraperitoneal hemorrhage as the source of shock.
3
Determine the definitive intervention based on ATLS guidelines.
The patient must be transported immediately to the operating room for a laparotomy.
Surgical exploration is required to identify the source of bleeding, achieve hemostasis, and prevent exsanguination.

Key Concept

In patients with blunt abdominal trauma, persistent hemodynamic instability, and a positive FAST exam, the standard of care is immediate exploratory laparotomy.
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Topics

Trauma and Burns

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