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Difficulty: MediumTrauma and Burns

A 68-year-old man is evaluated in the surgical intensive care unit for sudden-onset hypotension and altered mental status. He was admitted 3 days ago after a severe motor vehicle collision. His initial injuries included multiple left-sided rib fractures, bilateral pulmonary contusions, and a grade III liver laceration that was managed nonoperatively. His past medical history includes heart failure with preserved ejection fraction and chronic obstructive pulmonary disease (COPD).

Currently, his blood pressure is 76/45 mm Hg and his heart rate is 135/min. Oxygen saturation is 89% on 4 L/min via nasal cannula. His temperature is 38.3°C (100.9°F). Physical examination reveals a rigid, distended abdomen with involuntary guarding and rebound tenderness. Auscultation of the lungs reveals decreased breath sounds at the bases with scattered wheezes.

Which of the following is the most appropriate next step in management?

  1. Exploratory laparotomyAnswer
  2. B
    Computed tomography scan of the abdomen and pelvis
  3. C
    Nasogastric tube decompression and serial abdominal examinations
  4. D
    Duplex ultrasonography of the lower extremities
  5. E
    Intravenous furosemide and noninvasive positive-pressure ventilation

Answer

Exploratory laparotomy
The correct answer is exploratory laparotomy. This patient is exhibiting clear signs of peritonitis (a rigid abdomen, guarding, and rebound tenderness) along with profound hemodynamic instability (blood pressure 76/45 mm Hg, heart rate 135/min). In the setting of recent blunt abdominal trauma, these findings strongly suggest a catastrophic intra-abdominal event, such as the delayed rupture of his previously managed liver laceration or a missed hollow viscus injury leading to septic shock. Any trauma patient who is hemodynamically unstable with a clear intra-abdominal source (evident by peritonitis or a positive FAST exam) must be taken immediately to the operating room for an exploratory laparotomy to control hemorrhage and limit viscous contamination.

Step-by-Step Solution

1
Analyze the patient's vital signs and clinical stability.
The patient is in profound shock, indicated by a blood pressure of 76/45 mm Hg and a heart rate of 135/min.
Hemodynamic status determines whether a trauma patient can safely undergo cross-sectional imaging.
2
Evaluate the physical examination findings.
The examination reveals a rigid, distended abdomen with guarding and rebound tenderness.
These findings are hallmark signs of peritonitis, indicating an intra-abdominal catastrophe.
3
Synthesize the findings to determine the next best step.
The combination of hemodynamic instability and peritonitis requires immediate operative intervention.
Delayed rupture of a solid organ or a missed hollow viscus injury with subsequent sepsis must be addressed directly in the operating room.

Key Concept

Trauma patients who exhibit hemodynamic instability along with peritonitis (e.g., rigid abdomen, guarding) must undergo immediate exploratory laparotomy, bypassing further diagnostic imaging.
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Topics

Trauma and Burns

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