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Difficulty: MediumTrauma and Burns

Following an industrial accident where he was struck in the torso by a swinging steel pipe, a 48-year-old construction worker is transported to the trauma bay. Upon arrival, his blood pressure is 82/48 mm Hg, heart rate is 126/min, and respiratory rate is 22/min. Oxygen saturation is 97% on room air. The patient is lethargic but appropriately protects his airway. The trachea is midline, and breath sounds are clear and equal bilaterally. Heart sounds are normal. The abdomen is distended and exhibits diffuse tenderness to palpation, with involuntary guarding. Anteroposterior and lateral compression of the pelvis does not elicit pain or instability. Peripheral pulses are weak and thready. Two large-bore intravenous lines are established, and isotonic fluid resuscitation is initiated. Which of the following is the most appropriate next step in management?

  1. Focused assessment with sonography for traumaAnswer
  2. B
    Computed tomography scan of the abdomen and pelvis
  3. C
    Nasogastric tube decompression and serial abdominal examinations
  4. D
    Delay intervention to obtain informed consent from the patient's next of kin
  5. E
    Intravenous administration of broad-spectrum antibiotics

Answer

Focused assessment with sonography for trauma
The patient is presenting with hemorrhagic shock (hypotension, tachycardia) following blunt torso trauma. According to Advanced Trauma Life Support (ATLS) protocols, after securing the airway and breathing and initiating fluid resuscitation, the immediate next step in a hemodynamically unstable patient is to rapidly identify the source of bleeding. The Focused Assessment with Sonography for Trauma (FAST) is a bedside ultrasound examination that can quickly detect free intraperitoneal fluid. Because the patient is unstable, confirming that the abdomen is the source of hemorrhage is critical to justifying an emergent exploratory laparotomy.

Step-by-Step Solution

1
Evaluate the patient's hemodynamic status and primary survey.
The patient is in class III/IV hemorrhagic shock (BP 82/48 mm Hg, HR 126/min) with an intact airway and clear lungs.
Determining hemodynamic stability dictates the diagnostic algorithm in blunt trauma.
2
Correlate physical exam findings with potential sources of bleeding.
The abdomen is distended and tender, pointing to intra-abdominal hemorrhage, while the pelvis is stable and chest is clear.
Identifying the most likely compartment of hemorrhage focuses the diagnostic workup.
3
Select the appropriate initial diagnostic modality for an unstable patient.
FAST exam is chosen to rapidly confirm the presence of intraperitoneal fluid before proceeding to the operating room.
Unstable patients cannot tolerate transport for advanced imaging; bedside evaluation is mandatory.

Key Concept

In hemodynamically unstable patients with blunt abdominal trauma, a Focused Assessment with Sonography for Trauma (FAST) is the next best step to rapidly identify intraperitoneal hemorrhage prior to emergency laparotomy.
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Topics

Trauma and Burns

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