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Difficulty: EasyTrauma and Burns

A 30-year-old male is evaluated in the trauma center shortly after sustaining a stab wound to the left anterior abdomen during an altercation. On arrival, he is lethargic and diaphoretic. Vital signs are temperature 36.7°C (98.1°F), pulse 142/min, and blood pressure 72/40 mmHg. His airway is secure, and breath sounds are present and equal bilaterally. The abdomen is rigid with severe, diffuse guarding and rebound tenderness. Intravenous access is rapidly obtained and isotonic fluid resuscitation is initiated. Which of the following is the most appropriate next step in the management of this patient?

  1. A
    Cross-sectional computed tomography of the abdomen
  2. B
    Bedside focused assessment with sonography for trauma
  3. Immediate surgical exploration of the abdomenAnswer
  4. D
    Local wound exploration of the anterior abdominal wall
  5. E
    Diagnostic peritoneal lavage to assess for hemorrhage

Answer

Immediate surgical exploration of the abdomen
The correct answer is immediate surgical exploration of the abdomen. This patient presents with a penetrating abdominal injury (stab wound) and displays classic hard signs of intra-abdominal injury, specifically severe hemodynamic instability (blood pressure 72/40 mmHg, pulse 142/min) and peritonitis (rigid abdomen, diffuse guarding, rebound tenderness). The presence of shock, peritonitis, or evisceration following penetrating abdominal trauma dictates the need for an immediate exploratory laparotomy to identify and surgically control hemorrhage and hollow viscus injury. Any further diagnostic studies, such as imaging or wound exploration, would inappropriately delay definitive life-saving surgical care.

Step-by-Step Solution

1
Evaluate the mechanism of injury and patient presentation.
The patient has sustained a penetrating abdominal injury (stab wound).
The mechanism of injury dictates the appropriate ATLS evaluation algorithm.
2
Assess hemodynamic status and physical examination findings.
The patient is in hemorrhagic shock (BP 72/40 mmHg, HR 142/min) and has generalized peritonitis (rigidity, diffuse guarding, rebound tenderness).
Vital signs and abdominal examination help identify immediate life threats that require intervention.
3
Determine the definitive management based on the findings.
Immediate exploratory laparotomy is required.
Penetrating abdominal trauma complicated by hemodynamic instability, evisceration, or peritonitis requires urgent operative intervention without delay for further diagnostic imaging.

Key Concept

Hemodynamically unstable patients with penetrating abdominal trauma and clinical signs of peritonitis require immediate exploratory laparotomy.
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Topics

Trauma and Burns

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