A 28-year-old man is brought to the emergency department 30 minutes after crashing his all… — USMLE Step 2 CK

A $28$ -year-old man is brought to the emergency department $30$ minutes after crashing his all-terrain vehicle (ATV) into a tree. The paramedics report that he was thrown approximately $20$ feet and landed in a muddy ditch. On arrival, he is lethargic and confused. His medical history is significant for an appendectomy at age $10$ . His estranged wife is present in the emergency department demanding to make all medical decisions, although his electronic medical record clearly lists his brother as his legally appointed healthcare proxy. The brother is currently $45$ minutes away. Vital signs are temperature $36.1^\circ\text{C}$ ( $97.0^\circ\text{F}$ ), blood pressure $78/40\text{ mm Hg}$ , pulse $138\text{/min}$ , and respirations $24\text{/min}$ . Physical examination reveals diffuse abdominal distension, rigidity, and rebound tenderness. There is a large area of ecchymosis over the left upper quadrant. A focused assessment with sonography for trauma (FAST) exam demonstrates a significant amount of anechoic fluid in the splenorenal and hepatorenal recesses. Which of the following is the most appropriate next step in the management of this patient?

Immediate exploratory laparotomyAnswer
B
Computed tomography scan of the abdomen and pelvis
C
Placement of a nasogastric tube and serial abdominal examinations
D
Obtain informed consent from the estranged wife before surgical intervention
E
Administration of broad-spectrum intravenous antibiotics for presumed sepsis

Answer

Immediate exploratory laparotomy

Immediate exploratory laparotomy is the correct next step in the management of this patient. The presentation of blunt abdominal trauma (ATV collision), profound hemodynamic instability (blood pressure

78/40\text{ mm Hg}

, marked tachycardia), and a positive FAST examination strongly indicate life-threatening intra-abdominal hemorrhage. In this scenario, the fluid seen in the splenorenal and hepatorenal recesses is acute blood, likely secondary to a splenic injury given the left upper quadrant ecchymosis. According to ATLS protocols, hemodynamically unstable patients with a positive FAST must bypass further diagnostic imaging and proceed directly to the operating room for definitive surgical hemorrhage control. Furthermore, under the ethical and legal doctrine of implied consent, life-saving emergency procedures must not be delayed to obtain formal consent from any surrogate when the patient lacks capacity and is facing imminent death.

Step-by-Step Solution

Assess the patient's hemodynamic status.

The patient is hemodynamically unstable, evidenced by a blood pressure of

78/40\text{ mm Hg}

and a heart rate of

138\text{/min}

Hemodynamic stability is the primary decision point in the Advanced Trauma Life Support (ATLS) algorithm for blunt abdominal trauma.

Evaluate the results of the FAST examination.

The FAST exam is positive, showing free intraperitoneal fluid (blood) in the dependent recesses.

A positive FAST in the setting of trauma confirms intra-abdominal hemorrhage as the likely cause of the patient's shock.

Determine the definitive management based on the algorithm.

The patient must be taken directly to the operating room for an exploratory laparotomy.

Unstable patients with a positive FAST require immediate surgical intervention to identify and control the source of bleeding (e.g., splenic or hepatic laceration).

Key Concept

Management of Hemodynamically Unstable Blunt Abdominal Trauma

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