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Difficulty: MediumTrauma and Burns

Following a high-speed collision with a commercial vehicle, a 29-year-old male cyclist is evaluated in the emergency department. He reports severe pain on the left side of his chest and abdomen. Vital signs show a blood pressure of 82/48 mm Hg, a heart rate of 132/min, and a respiratory rate of 24/min. Oxygen saturation is 98% on supplemental oxygen. The airway is secure, and the trachea is midline. Auscultation reveals clear and equal breath sounds bilaterally. There is a prominent transverse contusion across the left upper quadrant of the abdomen, consistent with a handlebar impact. The abdomen is tender to deep palpation in this region, but there is no involuntary guarding or rebound tenderness. The pelvis is mechanically stable to compression. Intravenous access is established, and a bolus of warmed isotonic crystalloid is initiated. Which of the following is the most appropriate next step in the management of this patient?

  1. Focused assessment with sonography for traumaAnswer
  2. B
    Computed tomography of the abdomen and pelvis
  3. C
    Immediate exploratory laparotomy
  4. D
    Diagnostic peritoneal lavage
  5. E
    Observation with serial abdominal examinations

Answer

Focused assessment with sonography for trauma
The correct answer is focused assessment with sonography for trauma (FAST). In the management of blunt trauma, hemodynamically unstable patients require rapid identification of the source of hemorrhage. FAST is the gold standard initial diagnostic test because it can be performed at the bedside within minutes, does not require transporting the patient, and reliably detects clinically significant intra-abdominal bleeding. If the FAST is positive, this patient should be taken immediately to the operating room for an exploratory laparotomy.

Step-by-Step Solution

1
Assess the patient's hemodynamic status.
The patient is hemodynamically unstable (blood pressure 82/48 mm Hg, heart rate 132/min), indicating significant hemorrhagic shock.
Hemodynamic instability dictates the entire trauma management algorithm, precluding time-consuming or off-unit imaging modalities.
2
Evaluate the primary survey findings to localize potential sources of bleeding.
Breath sounds are equal and the trachea is midline (ruling out tension pneumothorax). The pelvis is stable. The abdomen has a contusion and tenderness but lacks peritonitis.
Bleeding in blunt trauma can occur in multiple compartments (intrathoracic, intra-abdominal, retroperitoneal, or from pelvic fractures). The source must be identified rapidly.
3
Select the appropriate diagnostic adjunct to identify intra-abdominal bleeding in an unstable patient.
Focused assessment with sonography for trauma (FAST) is selected as the next step.
FAST is rapid, non-invasive, can be performed at the bedside during resuscitation, and is highly sensitive for detecting intraperitoneal free fluid.

Key Concept

In hemodynamically unstable patients with blunt abdominal trauma, a bedside FAST examination is the most appropriate next step to quickly identify intraperitoneal hemorrhage. CT scans are strictly contraindicated in unstable patients.
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Topics

Trauma and Burns

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