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Difficulty: MediumTrauma and Burns

A 42-year-old construction worker is transported to the trauma bay shortly after falling from a height of approximately 20 feet (6 meters). On arrival, his airway is secure, and breath sounds are present and equal bilaterally. His heart rate is 135/min, and blood pressure is 78/50 mm Hg. Oxygen saturation is 97% on ambient air. The patient is confused and appropriately localizes to painful stimuli. Two large-bore intravenous catheters are placed, and warmed isotonic crystalloid fluids are rapidly infused. Physical examination reveals a rigid, distended abdomen with diffuse tenderness. The pelvis is mechanically stable to anteroposterior and lateral compression. A focused assessment with sonography for trauma (FAST) reveals a significant collection of anechoic fluid in the hepatorenal recess. Which of the following is the most appropriate next step in the management of this patient?

  1. Urgent surgical exploration of the abdomenAnswer
  2. B
    Multidetector computed tomography of the abdomen
  3. C
    Pelvic angiography and embolization
  4. D
    Bedside diagnostic peritoneal aspiration
  5. E
    Massive transfusion protocol and serial abdominal examinations

Answer

Urgent surgical exploration of the abdomen
The correct answer is urgent surgical exploration of the abdomen. This patient presents with hemorrhagic shock following blunt trauma. In the evaluation of blunt abdominal trauma, the patient's hemodynamic status dictates the appropriate algorithm. Hemodynamically stable patients may undergo computed tomography (CT) to precisely identify and grade intra-abdominal injuries. However, hemodynamically unstable patients (e.g., blood pressure 78/50 mm Hg) must remain in the trauma bay or operating room and should rapidly undergo a FAST examination. A positive FAST in an unstable patient confirms the abdomen as the source of bleeding and mandates immediate surgical exploration to achieve hemostasis. Delaying surgery for further diagnostic testing in this scenario is life-threatening.

Step-by-Step Solution

1
Assess the patient's hemodynamic status.
The patient is in hemorrhagic shock (blood pressure 78/50 mm Hg, heart rate 135/min).
Hemodynamic stability determines whether the patient can safely undergo advanced imaging or requires immediate surgical intervention.
2
Evaluate the mechanism of injury and primary survey findings.
The patient suffered blunt trauma from a fall. The abdomen is rigid, and FAST is positive for intraperitoneal fluid.
These findings identify the likely source of hemorrhage as intra-abdominal.
3
Determine the algorithmic next step for an unstable patient with a positive FAST.
The patient requires immediate operative intervention.
A positive FAST in a hemodynamically unstable patient with blunt abdominal trauma dictates immediate surgical exploration to control the bleeding.

Key Concept

In patients with blunt abdominal trauma and hemodynamic instability, a positive FAST examination is a definitive indication for immediate surgical exploration.
Estimated Time:1m 15s
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Topics

Trauma and Burns

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