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Difficulty: HardTrauma and Burns

A 3434-year-old woman is brought to the emergency department via helicopter after being thrown from a horse and subsequently trampled. She complains of severe right flank and abdominal pain. Her medical history is unremarkable. On arrival, her temperature is 36.6∘C36.6^\circ\text{C}, blood pressure is 85/50 mmHg85/50\text{ mmHg}, heart rate is 126/min126\text{/min}, and respiratory rate is 24/min24\text{/min}. She is pale and diaphoretic. Primary survey reveals a patent airway and clear, equal breath sounds bilaterally. There is significant ecchymosis and guarding over the right upper quadrant and right flank. A Foley catheter is placed and returns frankly bloody urine. Intravenous access is established, and the patient is resuscitated with 1 L1\text{ L} of warmed lactated Ringer solution and 11 unit of uncrossmatched packed red blood cells. Following the initial resuscitation, her blood pressure improves to 105/65 mmHg105/65\text{ mmHg} but rapidly drops back to 78/45 mmHg78/45\text{ mmHg} within ten minutes. A bedside focused assessment with sonography for trauma (FAST) reveals free fluid in the hepatorenal recess (Morison pouch). Which of the following is the most appropriate next step in management?

  1. A
    Diagnostic peritoneal lavage
  2. B
    Selective renal angiography and embolization
  3. C
    CT scan of the abdomen and pelvis with intravenous contrast
  4. Exploratory laparotomyAnswer
  5. E
    Retrograde cystogram

Answer

Exploratory laparotomy
The most appropriate next step for a hemodynamically unstable patient with blunt abdominal trauma and a positive focused assessment with sonography for trauma (FAST) is immediate exploratory laparotomy. This patient is a 'transient responder' (exhibiting an initial improvement in blood pressure followed by rapid, recurrent hypotension), which is a cardinal sign of ongoing, active hemorrhage. The positive FAST confirms the peritoneal cavity as the source of bleeding. Although the gross hematuria strongly suggests a concomitant genitourinary injury (e.g., renal laceration), definitive hemorrhage control takes absolute priority. The patient must be taken directly to the operating room; the renal injury can be assessed and managed directly during the laparotomy.

Step-by-Step Solution

1
Assess the patient's hemodynamic status and response to initial resuscitation.
The patient exhibits a transient response to fluids and blood (initial improvement followed by recurrent hypotension), which categorizes her as hemodynamically unstable with ongoing active hemorrhage.
Identifying hemodynamic instability dictates whether the trauma algorithm proceeds to advanced imaging (CT) or immediate definitive intervention.
2
Identify the primary source of the life-threatening hemorrhage.
The FAST examination demonstrates free fluid in the hepatorenal recess, confirming the peritoneal cavity as the source of bleeding.
In blunt trauma, the source of bleeding dictates the specific intervention (e.g., laparotomy for abdomen, thoracotomy for chest, binder/angiography for pelvis).
3
Determine the definitive management based on stability and bleeding source.
Immediate exploratory laparotomy is indicated.
An unstable patient with confirmed intraperitoneal bleeding must go directly to the operating room, bypassing secondary imaging, regardless of other suspected injuries like genitourinary trauma.

Key Concept

Hemodynamically unstable patients with blunt abdominal trauma and a positive FAST examination require immediate exploratory laparotomy. Concomitant signs of specific organ injury (such as gross hematuria) must not delay definitive hemorrhage control for advanced imaging.
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Topics

Trauma and Burns

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