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Difficulty: MediumTrauma and Burns

A 22-year-old man is transported to the emergency department after falling approximately 20 feet from a roof. Upon arrival, he is moaning in pain and clutching his left torso. His airway is unobstructed, and breath sounds are clear and symmetric bilaterally. His heart rate is 142/min and his blood pressure is 78/40 mmHg. Supplemental oxygen is applied, and two large-bore intravenous catheters are placed. Following a 1-liter infusion of warmed crystalloid, his blood pressure remains 80/42 mmHg. A bedside ultrasonographic evaluation of the abdomen reveals a significant anechoic fluid collection in the splenorenal recess. Radiographic evaluation of the chest and pelvis demonstrates no acute fractures or abnormalities. Which of the following is the most appropriate next step in the management of this patient?

  1. Urgent surgical exploration via midline incisionAnswer
  2. B
    Intravenous contrast-enhanced cross-sectional imaging of the abdomen
  3. C
    Endovascular intervention for arterial embolization
  4. D
    Percutaneous peritoneal fluid evaluation
  5. E
    Admission to the intensive care unit for serial hemoglobin monitoring

Answer

Urgent surgical exploration via midline incision
The correct approach for a patient with blunt abdominal trauma who remains hemodynamically unstable (hypotensive, tachycardic) despite initial fluid resuscitation and has a positive FAST exam is immediate surgical intervention. The positive FAST scan confirms intraperitoneal hemorrhage, and the ongoing instability indicates active, uncontrolled bleeding. Urgent surgical exploration via midline incision is necessary to identify and repair the bleeding source.

Step-by-Step Solution

1
Evaluate the patient's hemodynamic status following initial fluid resuscitation.
The patient remains hypotensive and tachycardic (blood pressure 80/42 mmHg, heart rate 142/min) after a 1-liter crystalloid bolus, classifying him as a non-responder.
Determining hemodynamic stability is the critical branch point in the ATLS algorithm for blunt abdominal trauma.
2
Interpret the results of the primary survey and adjunct imaging.
The bedside ultrasound (FAST) shows anechoic fluid in the splenorenal recess, indicating intraperitoneal bleeding, while chest and pelvic radiographs are negative.
Identifying the source of hemorrhage guides the definitive intervention. A positive FAST confirms the abdomen as the source.
3
Determine the definitive management based on hemodynamic status and FAST results.
The combination of hemodynamic instability and a positive FAST examination mandates immediate surgical intervention.
Delaying surgery for further diagnostics in an actively bleeding, hypotensive patient significantly increases mortality.

Key Concept

Hemodynamically unstable patients with blunt abdominal trauma and a positive FAST examination require immediate surgical exploration.
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Topics

Trauma and Burns

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