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Difficulty: EasyTrauma and Burns

A 33-year-old male is transported to the trauma bay by paramedics after sustaining a gunshot wound to the left lower quadrant of his abdomen. On arrival, he appears pale and diaphoretic. His temperature is 36.5°C (97.7°F), blood pressure is 82/50 mm Hg, pulse is 135/min, and respirations are 24/min. Physical examination reveals a single penetrating wound just lateral to the umbilicus. The abdomen is distended, rigid, and diffusely tender to palpation with involuntary guarding. Intravenous access is established and fluid resuscitation is initiated. Which of the following is the most appropriate next step in management?

  1. Exploratory laparotomyAnswer
  2. B
    CT scan of the abdomen and pelvis
  3. C
    Focused assessment with sonography for trauma
  4. D
    Diagnostic peritoneal lavage
  5. E
    Local wound exploration

Answer

Exploratory laparotomy
The correct next step is immediate surgical exploration. This patient presents with a gunshot wound to the abdomen accompanied by hemodynamic instability (hypotension and tachycardia) and clear signs of peritonitis (abdominal rigidity and involuntary guarding). According to Advanced Trauma Life Support (ATLS) principles, either hemodynamic instability or peritonitis in the setting of penetrating abdominal trauma constitutes an absolute indication for an emergency exploratory laparotomy to identify and treat the source of bleeding or bowel injury.

Step-by-Step Solution

1
Identify the mechanism of injury and the patient's hemodynamic status.
The patient has a penetrating abdominal injury (gunshot wound) and is hemodynamically unstable (blood pressure 82/50 mm Hg, heart rate 135/min).
Hemodynamic status dictates whether the patient can safely undergo diagnostic imaging or requires immediate operative intervention.
2
Evaluate the physical examination findings.
The patient exhibits a distended, rigid abdomen with involuntary guarding, indicating acute peritonitis.
Peritonitis following penetrating abdominal trauma is a hard sign of severe intra-abdominal injury.
3
Determine the next best step in management based on ATLS protocols.
Immediate transport to the operating room for surgical exploration is required.
Hemodynamic instability and peritonitis in the setting of penetrating abdominal trauma are both absolute indications for emergency surgery.

Key Concept

Patients with penetrating abdominal trauma who present with hemodynamic instability or signs of peritonitis require immediate exploratory laparotomy. Diagnostic imaging should be avoided as it delays life-saving hemorrhage control.
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Topics

Trauma and Burns

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