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Difficulty: Very hardTrauma and Burns

A 34-year-old man is brought to the emergency department after sustaining a single stab wound to the left lateral chest during an altercation. On arrival, he is in severe respiratory distress. His blood pressure is 82/50 mmHg, heart rate is 128/min, and oxygen saturation is 88% on room air. Physical examination reveals a 3-cm linear laceration in the left 5th intercostal space at the mid-axillary line. Breath sounds are markedly diminished on the left side, and the trachea is deviated to the right. A needle thoracostomy is immediately performed, followed by placement of a left-sided tube thoracostomy. The chest tube yields a rush of air and 400 mL of dark blood. Following the procedure, the patient's oxygen saturation improves to 96% on supplemental oxygen, but his blood pressure remains 84/52 mmHg and heart rate is 125/min. A focused assessment with sonography for trauma (FAST) exam reveals no pericardial effusion but demonstrates a large amount of anechoic fluid in the splenorenal recess. Which of the following is the most appropriate next step in management?

  1. A
    Computed tomography of the chest, abdomen, and pelvis
  2. B
    Left anterolateral thoracotomy
  3. Exploratory laparotomyAnswer
  4. D
    Local wound exploration
  5. E
    Diagnostic peritoneal lavage

Answer

Exploratory laparotomy
The correct answer is exploratory laparotomy. The patient has a penetrating wound to the thoracoabdominal region (between the 4th intercostal space and the costal margin). This anatomical zone carries a high risk of simultaneous thoracic and abdominal organ injuries due to diaphragmatic excursion. The patient initially presented with a tension pneumothorax, which was correctly managed with decompression. However, his persistent hemodynamic instability (blood pressure 84/52 mmHg) despite resolving the tension pneumothorax indicates an ongoing source of hemorrhagic shock. The chest tube output (400 mL) does not meet the threshold for emergent thoracotomy (typically >1500 mL immediately or >200 mL/hr). The positive FAST exam showing fluid in the splenorenal recess confirms massive intra-abdominal hemorrhage, likely from a splenic or diaphragmatic injury. In any hemodynamically unstable patient with a positive abdominal FAST exam, the definitive management is immediate exploratory laparotomy.

Step-by-Step Solution

1
Evaluate the patient's initial presentation and response to treatment.
The patient had a tension pneumothorax treated with a chest tube, yielding 400 mL of blood. However, he remains hemodynamically unstable (BP 84/52 mmHg).
Identifying persistent instability after resolving the initial thoracic issue indicates an ongoing source of hemorrhagic shock.
2
Analyze the anatomic location of the injury.
The stab wound is at the left 5th intercostal space, which falls within the thoracoabdominal region (inferior to the 4th intercostal space).
Penetrating injuries in this zone frequently involve the diaphragm and intra-abdominal organs, making abdominal injury highly likely.
3
Interpret the focused assessment with sonography for trauma (FAST) exam results.
The FAST exam shows anechoic fluid in the splenorenal recess, confirming intraperitoneal bleeding.
A positive FAST exam in the setting of persistent hemodynamic instability localizes the life-threatening hemorrhage to the abdomen.
4
Determine the definitive next step in management.
The patient requires immediate exploratory laparotomy.
Hemodynamically unstable trauma patients with confirmed intra-abdominal hemorrhage must be taken directly to the operating room for surgical control.

Key Concept

Management of penetrating thoracoabdominal trauma with persistent hemodynamic instability and a positive abdominal FAST exam requires emergent exploratory laparotomy.
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Topics

Trauma and Burns

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