A 29-year-old man arrives at the trauma center via ambulance following an altercation wher… — USMLE Step 2 CK

A 29-year-old man arrives at the trauma center via ambulance following an altercation where he sustained a stab wound to the periumbilical region. En route, he received $1$ L of intravenous crystalloid. Upon arrival, he appears pale and confused. Vital signs show a temperature of $36.6^\circ\text{C}$ ( $97.9^\circ\text{F}$ ), blood pressure of $78/45\text{ mm Hg}$ , heart rate of $138\text{/min}$ , and respiratory rate of $28\text{/min}$ . The airway is clear, and bilateral breath sounds are normal. Examination of the abdomen reveals a $4$ -cm transverse laceration $2\text{ cm}$ to the left of the umbilicus. The abdomen is rigid with severe diffuse tenderness and rebound. Intravenous access is secured with two large-bore peripheral catheters, and uncrossmatched blood transfusions are initiated. Which of the following is the most appropriate next step in management?

Emergent celiotomyAnswer
B
Point-of-care ultrasound of the abdomen
C
Multidetector CT scan of the abdomen and pelvis
D
Local wound exploration at the bedside
E
Diagnostic peritoneal lavage

Answer

Emergent celiotomy

The correct approach for this patient is immediate surgical exploration. In the setting of penetrating abdominal trauma, absolute indications for emergent celiotomy (laparotomy) include hemodynamic instability (e.g., systolic blood pressure <

90\text{ mm Hg}

), generalized peritonitis (e.g., rigidity, rebound tenderness), evisceration, and blood from a nasogastric tube or on rectal examination. This patient presents in hemorrhagic shock and has classic signs of peritonitis, mandating prompt transfer to the operating room to control bleeding and hollow viscus injury.

Step-by-Step Solution

Identify the mechanism of injury and the patient's hemodynamic status.

The patient has penetrating abdominal trauma (stab wound) and is hemodynamically unstable (hypotensive, tachycardic, confused).

Hemodynamic status determines whether a patient can safely undergo imaging or requires immediate operative intervention.

Evaluate the physical examination findings.

The patient exhibits a rigid abdomen with diffuse tenderness and rebound, indicating peritonitis.

Peritonitis following penetrating trauma strongly suggests bowel perforation or significant intra-abdominal bleeding.

Determine the appropriate management pathway according to ATLS guidelines.

The combination of penetrating trauma, hemodynamic instability, and peritonitis dictates immediate surgical exploration.

Any delay for diagnostic imaging in this clinical scenario increases mortality risk.

Key Concept

Indications for immediate laparotomy (celiotomy) in penetrating abdominal trauma include hemodynamic instability, peritonitis, or evisceration.

Question

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Topics

More questions from this topic