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Difficulty: MediumTrauma and Burns

A 10-year-old boy is brought to the emergency department via ambulance after falling forcefully onto the handlebars of his bicycle. He is pale and intermittently responsive. Heart rate is 155 /min155\text{ /min}, and blood pressure is 72/40 mm Hg72/40\text{ mm Hg}. Capillary refill time is 4 seconds4\text{ seconds}. Intravenous access is rapidly obtained, and an initial bolus of 20 mL/kg20\text{ mL/kg} of warm isotonic crystalloid is administered, but his vital signs do not improve. Primary survey reveals equal breath sounds bilaterally and no external bleeding. His abdomen is tightly distended with diffuse tenderness. Bedside focused assessment with sonography for trauma (FAST) demonstrates significant free fluid in the splenorenal and hepatorenal recesses.

Which of the following is the most appropriate next step in the management of this patient?

  1. A
    Computed tomography of the abdomen with intravenous contrast
  2. B
    Diagnostic peritoneal lavage
  3. Exploratory laparotomyAnswer
  4. D
    Administration of a second crystalloid bolus and pediatric intensive care unit admission
  5. E
    Angiography with selective arterial embolization

Answer

Exploratory laparotomy
The patient presents with blunt abdominal trauma and hemorrhagic shock that is unresponsive to an initial fluid bolus. The positive FAST exam localizes the source of life-threatening hemorrhage to the peritoneal cavity. While isolated solid organ injuries (such as splenic or hepatic lacerations) in hemodynamically stable children are typically managed conservatively with close observation, this patient's persistent instability and overt signs of peritonitis create an absolute indication for emergent exploratory laparotomy to achieve hemostasis.

Step-by-Step Solution

1
Assess the patient's hemodynamic status following initial fluid resuscitation.
The patient remains in refractory hemorrhagic shock (persistent hypotension, tachycardia, poor perfusion).
Vital signs determine whether a trauma patient requires immediate definitive intervention or can undergo further imaging.
2
Correlate the physical exam and diagnostic adjuncts to identify the source of bleeding.
The tightly distended abdomen and a positive FAST exam confirm large-volume intraperitoneal hemorrhage.
Locating the source of shock guides the surgical approach.
3
Determine the appropriate intervention path based on clinical stability and injury location.
The combination of blunt abdominal trauma, refractory hemodynamic instability, and confirmed intraperitoneal fluid mandates emergent surgery.
Although pediatric solid organ injuries are often managed non-operatively, hemodynamic instability overrides this paradigm.

Key Concept

In both pediatric and adult blunt abdominal trauma, hemodynamic instability with a positive FAST exam (indicating active intra-abdominal hemorrhage) mandates immediate exploratory laparotomy. Non-operative management is strictly reserved for hemodynamically stable patients.
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Topics

Trauma and Burns

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