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Difficulty: HardTrauma and Burns

Emergency medical services bring a 32-year-old man to the trauma bay 30 minutes after he sustained a gunshot wound to the left gluteal region during an altercation. On arrival, he appears pale, diaphoretic, and confused. Blood pressure is 74/40 mm Hg, heart rate is 135/min, and respiratory rate is 24/min. Oxygen saturation is 96% on room air. The primary survey reveals a patent airway and equal breath sounds bilaterally. Physical examination shows a single entry wound in the left upper outer quadrant of the buttock with no visible exit wound. The abdomen is tense, distended, and diffusely tender with involuntary guarding. A focused assessment with sonography for trauma (FAST) is technically limited due to overlying bowel gas. Bilateral large-bore intravenous lines are established, and he receives a rapid infusion of 1 L of warmed crystalloid and 1 unit of uncrossmatched group O blood. Five minutes later, his blood pressure is 78/42 mm Hg and heart rate is 130/min. Which of the following is the most appropriate next step in management?

  1. A
    Pelvic angiography with embolization
  2. B
    Computed tomography scanning of the abdomen and pelvis
  3. Emergent exploratory laparotomyAnswer
  4. D
    Exploratory laparoscopy
  5. E
    Bedside diagnostic peritoneal lavage

Answer

Emergent exploratory laparotomy
This patient presents in hemorrhagic shock following a penetrating injury to the gluteal region. A gunshot wound to the buttock can easily traverse tissue planes, cross the pelvic floor, and enter the peritoneal cavity, causing significant bowel or vascular perforation. The physical examination reveals a tense, distended abdomen with involuntary guarding, which are classic signs of peritonitis. The combination of hemodynamic instability that is refractory to initial volume resuscitation (crystalloid and blood) and clear signs of peritonitis is an absolute indication for immediate exploratory laparotomy. In this scenario, the priority is rapid surgical source control of hemorrhage and contamination.

Step-by-Step Solution

1
Assess the patient's hemodynamic status and response to initial fluid and blood resuscitation.
The patient remains profoundly hypotensive (BP 78/42 mm Hg) and tachycardic (HR 130/min), indicating refractory hemorrhagic shock.
Hemodynamic status determines whether a patient can safely undergo diagnostic imaging or requires immediate surgical intervention.
2
Correlate the mechanism of injury with the physical examination findings.
A gunshot wound to the buttock combined with a rigid, guarded abdomen indicates the bullet trajectory likely traversed into the peritoneal cavity, causing significant visceral or vascular injury and peritonitis.
Identifying the affected body cavity guides the anatomical focus of the definitive intervention.
3
Apply the standard trauma management algorithm for the identified clinical picture.
The combination of penetrating trauma, peritonitis, and refractory shock dictates immediate transfer to the operating room for surgical exploration.
Time spent on further diagnostic procedures (such as CT scans or DPL) increases mortality in actively exsanguinating patients with obvious indications for surgery.

Key Concept

Patients with penetrating trauma who present with hemodynamic instability and signs of peritonitis require immediate exploratory laparotomy; diagnostic imaging is contraindicated.
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Topics

Trauma and Burns

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