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Difficulty: MediumTrauma and Burns

A 29-year-old man is brought to the emergency department after a high-speed motorcycle collision. On presentation, he is lethargic and only opens his eyes to painful stimuli. Vital signs are temperature 36.2°C (97.2°F), blood pressure 78/45 mm Hg, heart rate 138/min, and respiratory rate 24/min. Oxygen saturation is 95% on a non-rebreather mask. The patient undergoes rapid sequence intubation for airway protection. Following intubation, a portable chest radiograph shows clear lung fields without pneumothorax or hemothorax. A pelvic radiograph reveals no fractures. Focused assessment with sonography for trauma (FAST) demonstrates a large amount of anechoic fluid in the hepatorenal and splenorenal recesses. The patient receives warmed intravenous crystalloid fluids and uncrossmatched type O-negative blood, but his blood pressure remains 80/48 mm Hg. Which of the following is the most appropriate next step in management?

  1. A
    Computed tomography of the head without contrast
  2. B
    Computed tomography of the abdomen and pelvis with intravenous contrast
  3. C
    Diagnostic peritoneal lavage
  4. Exploratory laparotomyAnswer
  5. E
    Administration of norepinephrine infusion

Answer

Exploratory laparotomy
This patient has sustained blunt abdominal trauma, is hemodynamically unstable (hypotensive, tachycardic), and has a positive FAST exam indicating intraperitoneal hemorrhage. According to Advanced Trauma Life Support (ATLS) protocols, the most appropriate next step is immediate exploratory laparotomy to identify and stop the source of bleeding. Delaying surgical hemostasis in a patient with refractory hemorrhagic shock leads to the lethal triad of coagulopathy, hypothermia, and acidosis, ultimately resulting in death.

Step-by-Step Solution

1
Identify the primary clinical problem
The patient is in hemorrhagic shock due to blunt trauma, evidenced by severe hypotension and tachycardia despite initial fluid and blood resuscitation.
Vital signs dictate the Advanced Trauma Life Support (ATLS) management algorithm.
2
Analyze the diagnostic findings
The positive FAST exam confirms the presence of significant intraperitoneal hemorrhage as the source of the shock.
A source of bleeding must be rapidly identified in an unstable trauma patient.
3
Determine the next best step in management
Immediate surgical intervention is required to control the bleeding.
A hemodynamically unstable patient with a positive FAST exam must go directly to the operating room; other imaging is deferred.

Key Concept

Hemodynamically unstable patients with blunt abdominal trauma and a positive FAST exam require immediate exploratory laparotomy.
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Topics

Trauma and Burns

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