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Difficulty: MediumSurgical and Procedural Interventions

A 32-year-old man is brought to the trauma bay via ambulance after losing control of his motorcycle at highway speeds. He was wearing a helmet. On arrival, he is pale and diaphoretic. He is groaning and protecting his airway. His temperature is 36.2°C (97.2°F), blood pressure is 74/40 mm Hg, heart rate is 142/min, and respiratory rate is 24/min. Oxygen saturation is 96% on room air. Breath sounds are equal and clear bilaterally. His abdomen is visibly distended, tense, and diffusely tender with guarding. The pelvis is mechanically stable to anteroposterior and lateral compression. A focused assessment with sonography for trauma (FAST) demonstrates a large amount of anechoic fluid in the hepatorenal and splenorenal recesses. Two large-bore peripheral intravenous catheters have been established. Which of the following are the most appropriate immediate next steps in the management of this patient? (Select all that apply)

  1. Administration of uncrossmatched blood productsAnswer
  2. Immediate transfer to the operating suite for abdominal explorationAnswer
  3. C
    Administration of intravenous norepinephrine to restore mean arterial pressure
  4. D
    Cross-sectional imaging of the torso with intravenous contrast
  5. E
    Diagnostic peritoneal aspiration and lavage

Answer

The correct management involves simultaneous administration of uncrossmatched blood products and immediate transfer to the operating suite for abdominal exploration.
The patient is experiencing severe hemorrhagic shock due to blunt abdominal trauma, as evidenced by marked hypotension, tachycardia, diaphoresis, and a positive FAST examination. In this scenario, the absolute immediate priorities are hemostatic resuscitation and definitive source control. Initiating uncrossmatched blood products restores oxygen-carrying capacity and vital coagulation factors. Simultaneously, emergent abdominal exploration (laparotomy) provides direct mechanical hemostasis. Both interventions must occur concurrently to prevent the lethal trauma triad of hypothermia, coagulopathy, and acidosis.

Step-by-Step Solution

1
Assess hemodynamic status and primary survey
The patient is in class III/IV hemorrhagic shock (hypotension, marked tachycardia) with a secured airway and adequate breathing.
To identify immediate life-threatening physiologic derangements.
2
Identify the source of hemorrhage
FAST examination is definitively positive for significant intra-abdominal free fluid in the setting of a distended, rigid abdomen.
To quickly locate the compartment requiring intervention to halt exsanguination.
3
Determine the appropriate intervention sequence
The patient requires concurrent hemostatic resuscitation with blood products and definitive mechanical hemostasis via laparotomy.
Prolonged attempts at stabilization or unnecessary diagnostic testing significantly increase mortality in exsanguinating patients.

Key Concept

Hemodynamically unstable trauma patients with evidence of intra-abdominal hemorrhage require concurrent hemostatic resuscitation with blood products and emergent surgical exploration without delay for further advanced imaging.
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Topics

Surgical and Procedural Interventions

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