A 22-year-old male is brought to the emergency department via ambulance after being struck… — USMLE Step 2 CK

A 22-year-old male is brought to the emergency department via ambulance after being struck by a motor vehicle while riding his bicycle. He was reportedly thrown over the handlebars. On arrival, he is confused and diaphoretic. His temperature is $36.5^\circ\text{C}$ ( $97.7^\circ\text{F}$ ), blood pressure is $78/40\text{ mmHg}$ , pulse is $135\text{/min}$ , and respirations are $24\text{/min}$ . Oxygen saturation is $97\%$ on room air. The airway is clear, and breath sounds are equal bilaterally. Primary survey reveals marked abdominal distension with diffuse guarding and rebound tenderness. A focused assessment with sonography for trauma (FAST) demonstrates a large amount of free fluid in the hepatorenal recess (Morison's pouch). Intravenous fluid resuscitation is initiated with $1\text{ L}$ of warmed crystalloid, but his repeat blood pressure is $80/42\text{ mmHg}$ . Which of the following is the most appropriate next step in management?

Immediate exploratory laparotomyAnswer
B
Computed tomography of the abdomen and pelvis
C
Diagnostic peritoneal lavage (DPL)
D
Continued observation and serial abdominal examinations
E
Pelvic radiography

Answer

The correct management is immediate exploratory laparotomy.

The patient presents with blunt abdominal trauma, hemorrhagic shock that is unresponsive to initial fluid resuscitation, and a positive FAST scan showing intraperitoneal fluid. According to Advanced Trauma Life Support (ATLS) protocols, a hemodynamically unstable patient with a positive FAST has a definitive indication for immediate exploratory laparotomy to control the bleeding.

Step-by-Step Solution

Assess the patient's hemodynamic status.

The patient is in hemorrhagic shock, evidenced by hypotension (

78/40\text{ mmHg}

), tachycardia (

135\text{/min}

), and unresponsiveness to initial fluid resuscitation.

Hemodynamic stability dictates the diagnostic and therapeutic algorithm in trauma.

Evaluate the mechanism of injury and primary survey findings.

Blunt abdominal trauma with signs of peritonitis and a positive FAST scan indicating free intraperitoneal fluid.

Identifies the abdomen as the likely source of the life-threatening hemorrhage.

Determine the definitive next step for a hemodynamically unstable patient with blunt abdominal trauma and a positive FAST.

Proceed directly to the operating room for an exploratory laparotomy.

Hemodynamically unstable patients with confirmed intra-abdominal bleeding cannot safely undergo cross-sectional imaging (CT) and require immediate surgical control of hemorrhage.

Key Concept

Hemodynamically unstable patients with blunt abdominal trauma and a positive FAST require immediate exploratory laparotomy.

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