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Difficulty: Very hardTrauma and Burns

A 30-year-old G1P0 woman at 35 weeks gestation is brought to the trauma center after being involved in a high-speed motor vehicle collision as the unrestrained driver. On arrival, she is lethargic but conversant and protecting her airway. She is placed on a backboard with left lateral tilt and receives 2 liters of warmed intravenous crystalloids. Reassessment reveals a blood pressure of 78/42 mm Hg and a heart rate of 135/min. Breath sounds are clear and equal bilaterally. Her abdomen is gravid, rigid, and diffusely tender with rebound and guarding. Bedside focused assessment with sonography for trauma (FAST) demonstrates a large volume of free fluid in the hepatorenal recess. Fetal monitoring shows a baseline heart rate of 115/min with recurrent late decelerations. Arterial blood gas analysis reveals a pH of 7.21, pCO2pCO_2 of 25 mm Hg, and HCO3−HCO_3^- of 10 mEq/L. Which of the following is the most appropriate next step in management?

  1. Exploratory laparotomyAnswer
  2. B
    Computed tomography of the abdomen and pelvis
  3. C
    Immediate cesarean delivery
  4. D
    Intravenous sodium bicarbonate infusion
  5. E
    Nasogastric tube placement and serial abdominal examinations

Answer

Exploratory laparotomy
The patient is in hemorrhagic shock due to blunt abdominal trauma, as evidenced by hypotension, tachycardia, and a positive FAST examination. According to Advanced Trauma Life Support (ATLS) protocols, the most appropriate next step for a hemodynamically unstable patient with a positive FAST is emergent exploratory laparotomy to identify and control the source of hemorrhage. In a pregnant trauma patient, maternal stabilization is always the paramount priority. The fetal late decelerations indicate uteroplacental insufficiency directly caused by maternal hypovolemia and shock. Restoring maternal hemodynamics through surgical hemorrhage control is the most effective way to address the fetal distress.

Step-by-Step Solution

1
Assess the patient's hemodynamic status following initial fluid resuscitation.
The patient remains in profound shock with a blood pressure of 78/42 mm Hg and heart rate of 135/min.
Persistent hemodynamic instability dictates an urgent, definitive intervention pathway in the ATLS algorithm.
2
Identify the source of the shock using primary survey adjuncts.
The positive FAST exam and rigid abdomen confirm significant intra-abdominal hemorrhage.
Identifying the compartment of hemorrhage directs the surgical team to the correct operative intervention.
3
Evaluate fetal status in the context of maternal trauma and shock.
Late decelerations indicate uteroplacental hypoperfusion directly caused by maternal hypovolemia.
Fetal distress in this setting is a secondary complication; maternal survival and hemodynamic restoration dictate fetal survival.
4
Determine the definitive next step for hemorrhage control.
Exploratory laparotomy is urgently indicated.
According to ATLS guidelines, unstable trauma patients with a positive FAST require immediate laparotomy to stop the bleeding.

Key Concept

Maternal stabilization via exploratory laparotomy is the paramount priority in an unstable pregnant trauma patient with a positive FAST, as treating the maternal hemorrhagic shock is the only effective way to resolve secondary fetal distress.
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Topics

Trauma and Burns

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