Match the following clinical presentations of trauma patients to the most appropriate next step in management. Assume airway and breathing have been assessed and secured in all patients.
- Blunt abdominal trauma; BP 75/40 mm Hg, HR 130/min; FAST exam reveals intraperitoneal free fluidImmediate exploratory laparotomy
- High-speed motor vehicle collision; BP 80/50 mm Hg, HR 125/min; severe pelvic pain; FAST exam is negativePelvic binder application and potential angiography
- Fall from 10 feet; BP 125/80 mm Hg, HR 88/min; FAST exam demonstrates fluid in the splenorenal recessComputed tomography (CT) of the abdomen and pelvis with contrast
- Blunt thoracic trauma; BP 130/85 mm Hg, HR 90/min; portable chest radiograph demonstrates a widened mediastinumComputed tomography (CT) angiography of the chest
Answer
Unstable + positive FAST matches to exploratory laparotomy. Unstable + pelvic fracture + negative FAST matches to pelvic binder and angiography. Stable + positive FAST matches to CT of the abdomen and pelvis. Stable + widened mediastinum matches to CT angiography of the chest.
Appropriate trauma management relies on the Advanced Trauma Life Support (ATLS) algorithms. The algorithm branches sharply based on hemodynamic stability. Unstable patients with intra-abdominal bleeding (positive FAST) must go to the operating room for an exploratory laparotomy. Unstable patients with severe pelvic fractures and a negative FAST usually bleed into the retroperitoneum, which is managed mechanically (pelvic binder) and endovascularly (angiography). Conversely, stable patients, even with abnormal preliminary findings (positive FAST or widened mediastinum), can and should undergo definitive cross-sectional imaging (CT scan) to properly grade the injury and avoid unnecessary surgery.
Step-by-Step Solution
Key Concept
The primary determinant of the diagnostic and therapeutic algorithm in trauma is the patient's hemodynamic stability, followed by the identification of the bleeding source using adjuncts like the FAST exam.