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Difficulty: EasyTrauma and Burns

Following a collision with a tree while skiing, a 21-year-old man is transported to the trauma center by medical helicopter. Upon arrival, his blood pressure is 82/45 mm Hg and his heart rate is 128/min. His respiratory rate is 22/min, and oxygen saturation is 98% on high-flow oxygen. He appears pale and is confused, but localizes to painful stimuli. The airway is patent, and breath sounds are equal bilaterally. Examination reveals significant ecchymosis over the left lower chest wall and left upper quadrant of the abdomen. The abdomen is tender to palpation with involuntary guarding. The pelvis is mechanically stable to lateral and anteroposterior compression. 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
    Conservative management with serial abdominal examinations
  4. D
    Intravenous administration of broad-spectrum antibiotics
  5. E
    Arterial blood gas analysis to determine acid-base status

Answer

Focused assessment with sonography for trauma
The correct answer is focused assessment with sonography for trauma (FAST). This patient is presenting with hemorrhagic shock following blunt trauma. His airway and breathing are intact, and his pelvis is stable, making the abdomen the most likely source of life-threatening bleeding (likely a splenic laceration given the left-sided impact). According to Advanced Trauma Life Support (ATLS) protocols, the most appropriate next step to evaluate the abdomen in a hemodynamically unstable patient is a FAST exam. It is rapid, non-invasive, and can be performed at the bedside in the trauma bay to detect free intraperitoneal fluid (blood).

Step-by-Step Solution

1
Identify the patient's hemodynamic status based on vital signs.
The patient is hemodynamically unstable (hypotensive at 82/45 mm Hg and tachycardic at 128/min), indicating Class III or IV hemorrhagic shock.
Hemodynamic status dictates the algorithmic approach to blunt trauma; unstable patients cannot leave the trauma bay.
2
Determine the most likely source of bleeding and the best modality to confirm it.
Given the left upper quadrant ecchymosis, tenderness, and clear breath sounds, intra-abdominal hemorrhage (e.g., splenic rupture) is highly suspected. A FAST exam is the best modality.
A FAST exam can be performed rapidly at the bedside to detect hemoperitoneum without delaying potential surgical intervention.

Key Concept

In hemodynamically unstable patients with blunt abdominal trauma, the immediate diagnostic test of choice is bedside ultrasonography (FAST) to rapidly identify intra-abdominal hemorrhage without transporting the patient out of the resuscitation area.
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Topics

Trauma and Burns

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