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Difficulty: MediumTrauma and Burns

Emergency medical services arrive at the trauma bay with a 22-year-old college student who crashed his mountain bike at high speed, striking his torso against the handlebars. He is awake but lethargic, complaining of severe pain in his left upper abdomen and left shoulder.

Vital signs include a heart rate of 135/min, blood pressure of 82/48 mm Hg, and respiratory rate of 22/min. Oxygen saturation is 96% on room air.

Physical examination reveals a large contusion over the left lower rib cage with marked tenderness and guarding in the left upper quadrant.

Intravenous access is established, and a bolus of warmed isotonic crystalloid is initiated. A focused assessment with sonography for trauma (FAST) demonstrates a large anechoic stripe between the spleen and the left kidney.

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

  1. Immediate exploratory laparotomyAnswer
  2. B
    Computed tomography of the abdomen and pelvis with intravenous contrast
  3. C
    Diagnostic peritoneal lavage
  4. D
    Splenic angiography with transcatheter embolization
  5. E
    Ongoing massive transfusion and serial abdominal examinations

Answer

Immediate exploratory laparotomy
This patient has suffered blunt abdominal trauma and is hemodynamically unstable (hypotensive and tachycardic). The positive focused assessment with sonography for trauma (FAST) exam confirms the presence of intraperitoneal fluid, which, in this clinical context, is blood. The combination of hemodynamic instability and a positive FAST dictates immediate transport to the operating room for an exploratory laparotomy to achieve mechanical hemostasis. The patient's left shoulder pain is Kehr sign, which represents referred pain from diaphragmatic irritation caused by splenic rupture.

Step-by-Step Solution

1
Assess the patient's hemodynamic status.
The patient has a blood pressure of 82/48 mm Hg and a heart rate of 135/min, indicating severe hemodynamic instability (hemorrhagic shock).
Hemodynamic stability is the primary decision point in trauma algorithms, determining if a patient can undergo advanced imaging or needs immediate intervention.
2
Analyze the findings of the primary survey and diagnostic adjuncts.
The FAST exam is positive, showing an accumulation of fluid (blood) in the splenorenal recess.
A positive FAST in a hemodynamically unstable trauma patient confirms that the abdomen is the source of the life-threatening hemorrhage.
3
Determine the definitive management.
The patient must be taken immediately to the operating room for an exploratory laparotomy.
Surgical exploration is the only definitive way to rapidly identify and control active intraperitoneal bleeding in an unstable patient.

Key Concept

Management of blunt abdominal trauma in hemodynamically unstable patients requires immediate exploratory laparotomy if the FAST exam is positive.
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Topics

Trauma and Burns

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