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Difficulty: EasyTrauma and Burns

A 25-year-old male is brought to the emergency department via ambulance after a high-speed motorcycle collision. Upon arrival, his airway is patent and his breathing is spontaneous but rapid. His blood pressure is 75/40 mmHg, heart rate is 135/min, and respiratory rate is 24/min. Physical examination reveals a distended and rigidly tense abdomen with diffuse tenderness. Intravenous access is established, and 1 liter of warmed crystalloid solution is administered rapidly without improvement in his blood pressure. A Focused Assessment with Sonography for Trauma (FAST) examination reveals a large amount of free fluid in the hepatorenal and splenorenal recesses. Which of the following is the most appropriate next step in management?

  1. Exploratory laparotomyAnswer
  2. B
    Computed tomography (CT) scan of the abdomen and pelvis
  3. C
    Observation with serial abdominal examinations and vital sign monitoring
  4. D
    Administration of intravenous broad-spectrum antibiotics and obtaining blood cultures
  5. E
    Postponement of invasive procedures until a healthcare proxy provides informed consent

Answer

Exploratory laparotomy is the most appropriate next step for a hemodynamically unstable patient with blunt abdominal trauma and a positive FAST exam.
This patient presents with hemorrhagic shock (hypotension, tachycardia) after blunt abdominal trauma. His lack of response to an initial fluid bolus indicates ongoing, active bleeding. In the Advanced Trauma Life Support (ATLS) algorithm, a hemodynamically unstable patient with blunt abdominal trauma and a positive FAST examination (indicating hemoperitoneum) requires immediate transport to the operating room for an exploratory laparotomy. The primary goal is prompt surgical control of the bleeding source.

Step-by-Step Solution

1
Assess hemodynamic status and injury mechanism.
The patient is hemodynamically unstable (BP 75/40 mmHg, HR 135/min) following blunt trauma.
Identifying instability determines whether the patient can safely undergo time-consuming advanced imaging like a CT scan.
2
Interpret the adjunct primary survey diagnostics.
The FAST exam is positive for free intra-abdominal fluid.
In the setting of trauma and shock, free fluid on FAST represents hemorrhage until proven otherwise.
3
Determine the definitive management.
Immediate exploratory laparotomy is indicated.
An unstable patient with confirmed intra-abdominal bleeding requires emergent surgical source control.

Key Concept

Management of hemodynamically unstable blunt abdominal trauma
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Topics

Trauma and Burns

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