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Difficulty: MediumTrauma and Burns

Match each clinical presentation of a trauma patient to the most appropriate next step in management or diagnostic imaging.

  • Hemodynamically unstable patient with blunt abdominal trauma and a positive FAST scan showing free intraperitoneal fluid.Immediate exploratory laparotomy
  • Hemodynamically stable patient with blunt abdominal trauma, a seatbelt sign across the lower abdomen, and localized tenderness.Computed tomography (CT) scan of the abdomen and pelvis with intravenous contrast
  • Hemodynamically unstable patient with an 'open book' pelvic fracture, applied pelvic binder, and a negative FAST scan.Pelvic angiography with possible embolization
  • Hemodynamically stable patient with a penetrating stab wound to the left lower chest, normal breath sounds, and a benign abdominal exam.Diagnostic laparoscopy
  • Hemodynamically stable patient with a pubic ramus fracture and gross hematuria following a motor vehicle collision.Retrograde cystography or CT cystogram

Answer

1 matches with Immediate exploratory laparotomy; 2 matches with CT scan; 3 matches with Pelvic angiography; 4 matches with Diagnostic laparoscopy; 5 matches with Retrograde cystography.
The correct pairings follow Advanced Trauma Life Support (ATLS) algorithms. Hemodynamic instability with intraperitoneal fluid necessitates exploratory laparotomy. Stable blunt trauma patients require CT imaging. Retroperitoneal pelvic bleeding is managed angiographically. Occult diaphragmatic injuries require laparoscopy, and gross hematuria with a pelvic fracture mandates cystography.

Step-by-Step Solution

1
Assess hemodynamic stability.
Patients are divided into stable and unstable categories.
Hemodynamic instability dictates immediate life-saving interventions over delayed, higher-resolution imaging like CT.
2
Evaluate unstable patients based on FAST results.
Unstable presentation with a positive FAST leads to exploratory laparotomy. Unstable presentation with a negative FAST and pelvic fracture leads to pelvic angiography.
A positive FAST in an unstable patient confirms intra-abdominal hemorrhage. A negative FAST shifts suspicion to retroperitoneal bleeding, which is managed with angiography or extraperitoneal packing.
3
Evaluate stable patients based on mechanism and specific physical findings.
Stable blunt trauma goes to CT. Left thoracoabdominal penetrating trauma goes to laparoscopy. Gross hematuria goes to cystography.
Stable patients can tolerate specific diagnostic workups to uncover occult injuries, such as diaphragmatic tears, hollow viscus injuries, or bladder ruptures.

Key Concept

Algorithmic management of torso trauma based on hemodynamic stability, mechanism of injury, and FAST results.
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Topics

Trauma and Burns

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