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Difficulty: Very hardTrauma and Burns

A 41-year-old construction worker is brought to the emergency department after falling approximately 25 feet from a scaffold. On arrival, he is moaning and only withdraws his extremities in response to painful stimuli. His temperature is 36.1°C (97.0°F), blood pressure is 74/40 mm Hg, pulse is 142/min, and respiratory rate is 26/min. Pulse oximetry is 94% on high-flow oxygen. The airway is patent, and breath sounds are present and equal bilaterally. A chest radiograph demonstrates no pneumothorax or hemothorax. The pelvis is mechanically stable to anterior-posterior and lateral compression. Abdominal examination reveals diffuse rigidity and involuntary guarding. Bilateral thigh deformities are noted. Intravenous access is established, and a massive transfusion protocol is initiated. A bedside focused assessment with sonography for trauma (FAST) is attempted but is technically inadequate due to massive subcutaneous emphysema and overlying bowel gas. Which of the following is the most appropriate next step in management?

  1. A
    Diagnostic peritoneal aspiration
  2. B
    Computed tomography of the head without contrast
  3. Immediate exploratory laparotomyAnswer
  4. D
    Computed tomography of the abdomen and pelvis
  5. E
    Application of a pelvic binder

Answer

Immediate exploratory laparotomy
The correct next step is immediate exploratory laparotomy. This patient is in severe hemorrhagic shock following blunt trauma. According to Advanced Trauma Life Support (ATLS) protocols, clinical signs of peritonitis—such as a diffusely rigid abdomen and involuntary guarding—in a hemodynamically unstable trauma patient constitute an absolute indication for immediate surgical exploration. Although the FAST examination is technically inadequate (which would algorithmically prompt a diagnostic peritoneal aspiration to evaluate for intraperitoneal blood in an otherwise equivocal abdomen), the unequivocal physical examination findings of an acute abdomen supersede the need for further diagnostic testing. Proceeding directly to the operating room is critical to achieve prompt hemorrhage control and manage a likely hollow viscus or solid organ injury.

Step-by-Step Solution

1
Assess the patient's hemodynamic status and primary survey.
The patient is in class IV hemorrhagic shock (BP 74/40 mm Hg, HR 142/min) with a patent airway and intact breathing.
To prioritize life-threatening injuries according to the ATLS ABCDE algorithm.
2
Evaluate the abdominal physical examination and FAST results.
The FAST exam is inconclusive, but the physical examination reveals a rigid abdomen with involuntary guarding.
To determine the source of hemorrhage and the need for operative intervention.
3
Determine the next best step based on the clinical findings.
The presence of frank peritonitis (rigidity, guarding) in an unstable patient mandates immediate exploratory laparotomy, bypassing further diagnostic steps like diagnostic peritoneal aspiration.
Peritonitis indicates a ruptured hollow viscus or massive hemoperitoneum requiring urgent surgical control.

Key Concept

In a hemodynamically unstable trauma patient, the presence of frank peritonitis (e.g., rigid abdomen, involuntary guarding) is an absolute indication for immediate exploratory laparotomy, regardless of ultrasound (FAST) findings.
Estimated Time:1m 30s
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Topics

Trauma and Burns

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