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Difficulty: EasyTrauma and Burns

A 22-year-old woman is brought to the emergency department by paramedics after falling from a horse. The horse reportedly stepped directly on her mid-abdomen. She is groaning in pain and appears confused. Her temperature is 36.5°C (97.7°F), heart rate is 134/min, blood pressure is 82/50 mm Hg, and respiratory rate is 24/min. Pulse oximetry is 97% on room air. The patient is lethargic but is actively protecting her airway. Breath sounds are clear and equal bilaterally. The abdomen is visibly distended, tense, and diffusely tender to palpation with guarding. The pelvis is stable to gentle compression. Two large-bore intravenous lines are established, and a 1-liter bolus of warm crystalloid is rapidly administered. Reassessment reveals a heart rate of 128/min and a blood pressure of 84/52 mm Hg. Which of the following is the most appropriate next step in management?

  1. Focused assessment with sonography for traumaAnswer
  2. B
    Computed tomography of the abdomen and pelvis
  3. C
    Anteroposterior radiography of the abdomen
  4. D
    Placement of a nasogastric tube and clinical observation
  5. E
    Measurement of serial hemoglobin and hematocrit levels

Answer

Focused assessment with sonography for trauma (FAST)
The correct action is to perform a bedside sonographic evaluation. The patient has blunt abdominal trauma and is hemodynamically unstable, evidenced by hypotension and tachycardia that do not resolve with initial fluid resuscitation. The visibly distended and tense abdomen strongly points to intra-abdominal hemorrhage. A rapid, bedside sonogram will confirm the presence of free intraperitoneal fluid (blood), which in an unstable patient is an absolute indication for an immediate exploratory laparotomy. This approach avoids moving an unstable patient out of the resuscitation area.

Step-by-Step Solution

1
Identify the patient's hemodynamic status.
The patient remains hypotensive (84/52 mm Hg) and tachycardic (128/min) after an initial 1-liter fluid bolus, classifying her as a hemodynamically unstable trauma patient.
Hemodynamic stability dictates the diagnostic and treatment pathway in trauma; unstable patients require rapid bedside interventions.
2
Localize the most likely source of shock based on primary survey findings.
The patient has a distended, tense abdomen following a direct kick/step injury. The lungs are clear, and the pelvis is stable.
This highly suggests massive intra-abdominal hemorrhage as the primary cause of the hypovolemic shock.
3
Determine the optimal diagnostic test for an unstable patient with suspected abdominal bleeding.
Select bedside sonography (FAST exam) to rapidly confirm the presence of free intraperitoneal fluid.
Unstable patients cannot safely be transported for advanced imaging (like CT scans). A bedside sonogram quickly confirms the need for an emergency exploratory laparotomy without delaying care.

Key Concept

In hemodynamically unstable patients with blunt abdominal trauma, a FAST (Focused Assessment with Sonography for Trauma) exam is the next best step to rapidly detect hemoperitoneum and expedite transfer to the operating room for exploratory laparotomy.
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Topics

Trauma and Burns

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