A 21-year-old male university student is rushed to the emergency department after a severe… — USMLE Step 2 CK

A 21-year-old male university student is rushed to the emergency department after a severe collision during a rugby game, where he was forcefully struck in the left flank by an opponent's shoulder. He reports intense left-sided abdominal pain with radiation to the top of his left shoulder. His temperature is $36.9^\circ\text{C}$ ( $98.4^\circ\text{F}$ ), pulse is $132 \text{ beats/min}$ , respirations are $24 \text{ breaths/min}$ , and blood pressure is $80/46 \text{ mmHg}$ . He is conscious but profusely diaphoretic and pale. Examination shows prominent guarding and rigidity over the left hemi-abdomen. The pelvis is mechanically stable, and chest auscultation is clear bilaterally. A bedside point-of-care ultrasound demonstrates significant free anechoic fluid in the splenorenal and hepatorenal spaces. Resuscitation with uncrossmatched blood products is initiated via two large-bore peripheral catheters. Which of the following is the most appropriate next step in this patient's management?

Transfer to the operating room for celiotomyAnswer
B
Multidetector computed tomography of the abdomen with intravenous contrast
C
Diagnostic peritoneal lavage
D
Splenic angiography with transcatheter embolization
E
Serial abdominal examinations and critical care admission

Answer

The correct answer is to transfer the patient to the operating room for immediate surgical exploration (celiotomy).

The correct answer is surgical exploration. This patient has sustained blunt abdominal trauma and is hemodynamically unstable due to hemorrhagic shock. The positive point-of-care ultrasound confirms free intraperitoneal fluid, which in this clinical context represents active bleeding from a solid organ injury (likely a ruptured spleen, given the left flank impact and referred left shoulder pain known as Kehr's sign). Standard trauma guidelines dictate that a hemodynamically unstable patient with a positive ultrasound for hemoperitoneum must be taken directly to the operating room for emergency celiotomy to achieve hemostasis.

Step-by-Step Solution

Evaluate the patient's hemodynamic stability and clinical signs.

The patient is in hemorrhagic shock, evidenced by significant hypotension (

80/46 \text{ mmHg}

) and tachycardia (

132 \text{ beats/min}

), along with signs of peritonitis (guarding, rigidity).

Hemodynamic status determines whether a trauma patient can undergo cross-sectional imaging or requires immediate intervention.

Interpret the results of the initial diagnostic adjuncts.

The point-of-care ultrasound is positive for free anechoic fluid in multiple spaces, indicating hemoperitoneum.

Identifying the source of bleeding in an unstable patient directs the appropriate surgical or interventional response.

Select the most appropriate definitive management.

The patient must be taken to the operating room for a celiotomy (laparotomy).

According to advanced trauma life support protocols, the combination of hemodynamic instability and confirmed intra-abdominal bleeding is an absolute indication for emergency surgical hemostasis.

Key Concept

Management of hemodynamically unstable blunt abdominal trauma requires immediate surgical exploration when intra-abdominal bleeding is confirmed.

Estimated Time:1m 0s

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