During the second day of hospitalization, a patient who suffered deep partial-thickness an… — USMLE Step 2 CK

During the second day of hospitalization, a patient who suffered deep partial-thickness and full-thickness burns over $55\%$ of the total body surface area experiences sudden clinical deterioration. The thermal injuries predominantly involve the posterior torso and bilateral lower extremities. The patient is intubated, deeply sedated, and paralyzed with continuous neuromuscular blockade in the intensive care unit. An orogastric tube is in place and set to low continuous suction. Fluid resuscitation with isotonic crystalloids has been ongoing per standard burn protocols. Over the last three hours, urine output has decreased to $5\text{ mL/hr}$ . Vital signs now show a blood pressure of $78/45\text{ mm Hg}$ and a heart rate of $138/\text{min}$ . The abdomen is severely distended and tense to palpation. Mechanical ventilation parameters reveal a new increase in peak inspiratory pressures to $46\text{ cm H}_2\text{O}$ . A transurethral bladder pressure measurement reveals a value of $32\text{ mm Hg}$ . Which of the following is the most appropriate next step in the management of this patient?

Decompressive laparotomyCevap
B
Computed tomography of the abdomen and pelvis
C
Increase the rate of intravenous crystalloid administration
D
Anterior abdominal escharotomy
E
Initiation of a norepinephrine infusion

Cevap

Decompressive laparotomy

The correct answer is decompressive laparotomy. This patient has developed abdominal compartment syndrome (ACS), a life-threatening complication of massive volume resuscitation in severe burn injuries. ACS is defined by an intra-abdominal pressure

> 20\text{ mm Hg}

(measured here via a transurethral bladder catheter at

32\text{ mm Hg}

) combined with new-onset organ dysfunction. The massive intra-abdominal mechanical compression restricts diaphragmatic excursion (causing high peak inspiratory pressures), compresses the renal veins (causing oliguria), and compresses the inferior vena cava (decreasing venous return and causing hypotension). Because this patient is already medically optimized with deep sedation, continuous neuromuscular blockade, and gastric decompression, the definitive and immediate next step is surgical decompression via laparotomy.

Adım Adım Çözüm

Analyze the clinical deterioration in the context of massive fluid resuscitation for severe burns.

Recognize the classic triad of oliguria, significantly elevated peak inspiratory pressures, and hypotension in a patient with a distended abdomen.

Massive third-spacing during burn resuscitation can lead to severe visceral edema and ascites.

Evaluate the transurethral bladder pressure measurement.

The pressure is

32\text{ mm Hg}

, which heavily exceeds the diagnostic threshold of

> 20\text{ mm Hg}

Bladder pressure

> 20\text{ mm Hg}

combined with new organ dysfunction definitively diagnoses Abdominal Compartment Syndrome (ACS).

Determine the most appropriate intervention for refractory ACS in an unstable patient.

Select decompressive laparotomy as the definitive treatment.

Medical optimizations (neuromuscular blockade, deep sedation, and gastric decompression) are already in place; mechanical surgical decompression is immediately required to restore venous return and organ perfusion.

Anahtar Kavram

Abdominal Compartment Syndrome in burn resuscitation

Tahmini Süre:1m 30s

Soru

Cevap

Adım Adım Çözüm

Anahtar Kavram

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