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Difficulty: MediumTrauma and Burns

A 24-year-old man is brought to the emergency department after a high-speed collision while snowboarding, during which he struck a tree. On arrival, he is confused and complains of severe abdominal pain. His temperature is 36.5°C (97.7°F), blood pressure is 82/45 mmHg, pulse is 134/min, and respirations are 24/min. Pulse oximetry is 96% on room air. Primary survey reveals a patent airway and clear breath sounds bilaterally. Cardiac auscultation shows a rapid, regular rhythm with no murmurs. The abdomen is distended with diffuse tenderness, guarding, and rebound tenderness. Examination of the pelvis reveals stability to anteroposterior and lateral compression. Intravenous access is established, and the patient receives 1 L of warmed lactated Ringer solution, after which his blood pressure is 86/48 mmHg and pulse is 128/min. A bedside focused assessment with sonography for trauma (FAST) demonstrates a significant amount of anechoic fluid in the splenorenal and hepatorenal recesses. Which of the following is the most appropriate next step in management?

  1. A
    Computed tomography of the abdomen and pelvis
  2. B
    Diagnostic peritoneal lavage
  3. Exploratory laparotomyAnswer
  4. D
    Angiography with therapeutic embolization
  5. E
    Diagnostic laparoscopy

Answer

Exploratory laparotomy
The correct management for this patient is immediate surgical exploration. The patient has sustained blunt abdominal trauma (BAT) and is in hemorrhagic shock, evidenced by persistent hypotension and tachycardia despite an initial fluid challenge. In the setting of BAT, a bedside ultrasound (FAST) is used to rapidly identify free intraperitoneal fluid (blood). When a patient is hemodynamically unstable and has a positive FAST examination, the diagnosis of life-threatening intra-abdominal hemorrhage is established. The absolute next best step is an emergency exploratory laparotomy to achieve surgical source control. Any delay for further diagnostic testing increases mortality.

Step-by-Step Solution

1
Assess hemodynamic status
The patient remains hypotensive (86/48 mmHg) and tachycardic (128/min) despite initial crystalloid resuscitation.
Hemodynamic instability dictates the urgency and type of subsequent interventions in trauma protocols.
2
Evaluate the mechanism of injury and primary survey findings
Blunt abdominal trauma with a stable pelvis and no signs of intrathoracic hemorrhage or tension pneumothorax.
Localizes the likely source of hemorrhagic shock to the abdominal cavity.
3
Interpret the bedside ultrasound (FAST) results
Positive for anechoic fluid in the splenorenal and hepatorenal recesses, indicating hemoperitoneum.
Confirms the abdomen as the source of life-threatening internal hemorrhage.
4
Determine the definitive management
Immediate transfer to the operating room for surgical exploration.
A hemodynamically unstable patient with confirmed intraperitoneal bleeding requires emergency surgical source control without further diagnostic delay.

Key Concept

Hemodynamically unstable patients with blunt abdominal trauma and a positive FAST examination require immediate exploratory laparotomy.
Estimated Time:1m 30s
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Topics

Trauma and Burns

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