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Difficulty: MediumTrauma and Burns

Match each clinical presentation of a trauma patient to the most appropriate next step in management based on standard trauma evaluation principles.

  • A patient with a blood pressure of 78/42 mmHg following a motor vehicle collision; bedside ultrasound shows free fluid in the hepatorenal recess.Immediate exploratory laparotomy
  • A patient with a blood pressure of 122/80 mmHg following a high-speed collision; bedside ultrasound shows free fluid around the spleen.Computed tomography (CT) of the abdomen and pelvis
  • A patient with a blood pressure of 80/40 mmHg after a crush injury; bedside ultrasound is negative for free fluid, but a pelvic radiograph reveals significant diastasis of the pubic symphysis.Application of a pelvic binder
  • A patient with a blood pressure of 70/30 mmHg after a fall; bedside ultrasound is negative for free fluid, and physical exam reveals absent breath sounds on the right with distended neck veins.Needle decompression or tube thoracostomy

Answer

1. Unstable with positive FAST requires exploratory laparotomy. 2. Stable with positive FAST requires CT of the abdomen and pelvis. 3. Unstable with negative FAST and an open-book pelvic fracture requires application of a pelvic binder. 4. Unstable with negative FAST and signs of tension pneumothorax requires needle decompression or tube thoracostomy.
The correct matches align precisely with the established trauma protocol for blunt injuries. Hemodynamic instability paired with a positive FAST exam dictates immediate exploratory laparotomy, whereas hemodynamic stability permits further evaluation with a CT scan. When the FAST is negative in an unstable patient, alternative sources of shock must be addressed immediately, such as massive pelvic venous bleeding (managed acutely with a pelvic binder) or a tension pneumothorax (managed with immediate pleural decompression).

Step-by-Step Solution

1
Assess the hemodynamic status of each trauma patient.
Three patients are hemodynamically unstable (hypotensive), while one patient is hemodynamically stable.
Hemodynamic stability is the critical branch point that dictates whether a patient can safely be transported for advanced imaging (like a CT scan) or if they require immediate bedside/operative intervention.
2
Evaluate the primary survey and FAST exam findings for the unstable patients.
One unstable patient has a positive FAST (needs laparotomy), one has a severe pelvic fracture without intraperitoneal fluid (needs a binder), and one has clinical signs of a tension pneumothorax (needs chest decompression).
In unstable patients, the specific source of shock (hemorrhagic versus obstructive) must be rapidly identified using adjuncts like FAST and treated with targeted, life-saving procedures before any further diagnostic workup.
3
Determine the diagnostic pathway for the stable patient with a positive FAST.
The stable patient should proceed to a CT scan.
Because the patient's vital signs are stable, there is time to obtain precise anatomical delineation of the injury, which often prevents unnecessary surgical exploration.

Key Concept

Advanced Trauma Life Support (ATLS) algorithm for blunt trauma evaluation
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Topics

Trauma and Burns

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