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Difficulty: HardTrauma and Burns

Following a kick to the left flank by a horse, a 45-year-old man arrives at the trauma center. He complains of severe left-sided abdominal pain that radiates to his left shoulder. Upon arrival, he appears in significant distress. Vital signs are temperature 36.8°C (98.2°F), blood pressure 105/65 mm Hg, pulse 112/min, and respirations 18/min. Oxygen saturation is 98% on room air. Two large-bore intravenous lines are established, and he is rapidly infused with 1 L of lactated Ringer solution. Following the fluid resuscitation, his blood pressure improves to 128/76 mm Hg and his pulse decreases to 88/min. Physical examination reveals ecchymosis over the left lower ribs and significant tenderness in the left upper quadrant with voluntary guarding. Breath sounds are clear and equal bilaterally. A bedside focused assessment with sonography for trauma (FAST) reveals a moderate amount of anechoic fluid in the splenorenal recess. Which of the following is the most appropriate next step in management?

  1. Computed tomography of the abdomen and pelvisAnswer
  2. B
    Exploratory laparotomy
  3. C
    Diagnostic peritoneal lavage
  4. D
    Angiography with empiric embolization
  5. E
    Diagnostic laparoscopy

Answer

Computed tomography of the abdomen and pelvis is the correct next step for a hemodynamically stable patient with a positive FAST exam.
The correct next step in management is a computed tomography (CT) scan of the abdomen and pelvis. This patient sustained blunt abdominal trauma and initially presented with mild hemodynamic compromise that completely resolved following a 1 L bolus of crystalloid fluids. Because his blood pressure and heart rate normalized, he is classified as a hemodynamic 'responder' and is currently considered hemodynamically stable. According to standard trauma protocols, hemodynamically stable patients with a positive FAST exam should undergo a CT scan of the abdomen and pelvis. The CT scan is crucial for delineating the exact source of the bleeding, grading the severity of solid organ injuries (in this case, likely a splenic laceration given the left-sided impact and Kehr sign), and evaluating for any active arterial extravasation. This information allows the trauma team to determine if the patient can be safely managed non-operatively or if specific interventions, such as angioembolization or surgery, are required.

Step-by-Step Solution

1
Assess the patient's hemodynamic status before and after initial interventions.
The patient initially presented with borderline hemodynamics (tachycardia, low-normal blood pressure) but normalized entirely after receiving a 1 L crystalloid bolus, classifying him as a hemodynamic responder.
Hemodynamic stability is the primary decision point in the ATLS blunt abdominal trauma algorithm, dictating whether the patient can safely undergo imaging or requires immediate surgical control.
2
Evaluate the primary survey and bedside imaging findings.
The primary survey shows an intact airway and clear lungs. The FAST exam is positive for intraperitoneal free fluid in the splenorenal recess, and the patient has Kehr sign (left shoulder pain), highly suspicious for a splenic injury.
A positive FAST indicates intra-abdominal hemorrhage, confirming the abdomen as the source of the patient's initial hypovolemia.
3
Apply the blunt abdominal trauma management algorithm.
Because the patient is hemodynamically stable, the algorithm directs the provider to obtain cross-sectional imaging (CT scan of the abdomen and pelvis).
CT imaging characterizes the exact source of bleeding, grades the solid organ injury, identifies any active arterial extravasation (blush), and determines if non-operative management is safe or if embolization/surgery is definitively required.

Key Concept

Hemodynamically stable patients with blunt abdominal trauma and a positive FAST exam must undergo a CT scan of the abdomen and pelvis to delineate the injury and evaluate the feasibility of non-operative management.
Estimated Time:1m 15s
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Topics

Trauma and Burns

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