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Difficulty: MediumTrauma and Burns

Paramedics bring a 28-year-old construction worker to the emergency department following a 15-foot (4.5-meter) fall from scaffolding. He is conscious but reports intense pain across his entire abdomen. Vital signs reveal a blood pressure of 82/50 mmHg, a heart rate of 128/min, and a respiratory rate of 24/min. Pulse oximetry is 96% on ambient air. Primary evaluation demonstrates an intact airway with bilateral breath sounds present and equal. No obvious sources of external blood loss are identified. Abdominal examination reveals marked distension, diffuse tenderness, and involuntary guarding. The pelvis is mechanically stable to manual compression. A bedside ultrasound examination (FAST) demonstrates a large anechoic collection in Morison's pouch. Which of the following is the most appropriate next step in management?

  1. A
    Helical CT scanning of the abdomen and pelvis
  2. B
    Peritoneal fluid aspiration and laboratory analysis
  3. Transfer to the operating room for abdominal explorationAnswer
  4. D
    Retrograde urethrography followed by pelvic radiography
  5. E
    Rapid intravenous crystalloid infusion with serial abdominal evaluations

Answer

Transfer to the operating room for abdominal exploration
This patient has sustained blunt abdominal trauma and is currently in hypovolemic shock (hypotension, tachycardia). His physical examination reveals a rigid abdomen, and his focused assessment with sonography for trauma (FAST) confirms the presence of free intraperitoneal fluid, which in this context represents life-threatening intra-abdominal hemorrhage. The definitive management for a hemodynamically unstable patient with a positive FAST scan is immediate transfer to the operating room for an exploratory laparotomy to achieve rapid hemostasis. Any further diagnostic testing is contraindicated as it unnecessarily delays life-saving surgical intervention.

Step-by-Step Solution

1
Assess the patient's hemodynamic status.
The patient is in class III hypovolemic shock, evidenced by marked hypotension (82/50 mmHg) and tachycardia (128/min).
Determining hemodynamic stability is the critical first branching point in the trauma management algorithm.
2
Evaluate the primary survey and adjunctive imaging.
The physical examination shows signs of peritonitis (rigidity, guarding), and the FAST scan is positive for free fluid in Morison's pouch.
These findings localize the source of the shock to intra-abdominal hemorrhage.
3
Determine the definitive intervention based on stability and imaging.
The combination of hemodynamic instability and a positive FAST scan necessitates immediate surgical exploration.
Ongoing hemorrhage in an unstable patient cannot be managed conservatively or delayed for further diagnostic imaging.

Key Concept

Management of hemodynamically unstable patients with blunt abdominal trauma and a positive FAST exam requires immediate surgical exploration.
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Topics

Trauma and Burns

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