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Difficulty: EasyTrauma and Burns

Paramedics arrive at the trauma center with a 34-year-old construction worker who fell approximately 20 feet from a roof. The patient is moaning and clutching his abdomen. His temperature is 36.8°C (98.2°F), blood pressure is 82/45 mmHg, pulse is 128/min, and respirations are 22/min. Peripheral intravenous lines are placed, and fluid resuscitation is initiated. His airway is clear, and breath sounds are equal bilaterally. A bedside ultrasound evaluation of the abdomen demonstrates an anechoic fluid collection between the liver and right kidney. Which of the following is the most appropriate next step in the management of this patient?

  1. A
    Cross-sectional imaging of the abdomen and pelvis
  2. B
    Admit for continuous clinical monitoring and reassessment
  3. Urgent surgical exploration of the abdomenAnswer
  4. D
    Empiric administration of broad-spectrum antimicrobial therapy
  5. E
    Review advance directives for preferred resuscitative measures

Answer

The correct course of action is to proceed with urgent surgical exploration of the abdomen to identify and control the source of bleeding.
The patient presents with blunt abdominal trauma, hemodynamic instability (hypotension, tachycardia), and a positive bedside ultrasound indicating intra-abdominal fluid (likely blood). In this scenario, the standard of care dictates immediate surgical exploration to identify and control the source of hemorrhage. Delaying for any other intervention or imaging is potentially fatal.

Step-by-Step Solution

1
Assess the patient's hemodynamic status based on vital signs.
The patient is hypotensive (blood pressure 82/45 mmHg) and tachycardic (pulse 128/min).
Vital signs indicate the patient is hemodynamically unstable and in hemorrhagic shock.
2
Evaluate the findings of the bedside ultrasound.
The focused ultrasound demonstrates free fluid in Morison's pouch.
A positive focused assessment with sonography for trauma in a hypotensive patient strongly suggests intra-abdominal hemorrhage as the cause of shock.
3
Determine the appropriate definitive management.
The patient requires immediate operative intervention.
Hemodynamically unstable patients with confirmed intra-abdominal bleeding require urgent surgical exploration to control the hemorrhage.

Key Concept

Hemodynamically unstable patients with blunt abdominal trauma and a positive ultrasound for free intra-abdominal fluid require immediate surgical exploration.
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Topics

Trauma and Burns

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