Examkin

Soru

Zorluk: ZorTrauma and Burns

A 38-year-old male is brought to the emergency department via ambulance after his compact car was struck on the driver's side by a commercial truck. On arrival, he is pale and lethargic but follows simple commands. Vitals show a temperature of 36.5∘36.5^{\circ} C (97.7∘97.7^{\circ} F), blood pressure of 82/4682/46 mm Hg, pulse of 130130/min, and respiratory rate of 2828/min.

Primary survey reveals a patent airway. Breathing assessment demonstrates markedly diminished breath sounds over the left lower hemithorax, and the trachea appears slightly deviated to the right. The abdomen is diffusely tender with involuntary guarding. A focused assessment with sonography for trauma (FAST) reveals an anechoic collection in the splenorenal recess.

An orogastric tube is placed to decompress the stomach. A portable anteroposterior chest radiograph is immediately obtained in the resuscitation bay, which demonstrates the radiopaque tip of the orogastric tube coiled within the left lower thorax and a shift of the mediastinal structures toward the right.

Which of the following is the most appropriate next step in the management of this patient?

  1. Immediate exploratory laparotomyCevap
  2. B
    Left-sided tube thoracostomy
  3. C
    Computed tomography of the chest, abdomen, and pelvis
  4. D
    Needle decompression of the left pleural space
  5. E
    Immediate left anterior thoracotomy

Cevap

Immediate exploratory laparotomy
The correct step is immediate exploratory laparotomy. This patient presents with hemorrhagic shock (hypotension, tachycardia) following significant blunt trauma. The positive FAST exam identifies the abdomen as the source of bleeding. According to Advanced Trauma Life Support (ATLS) protocols, a hemodynamically unstable patient with a positive FAST requires immediate transport to the operating room for an exploratory laparotomy. Furthermore, the chest radiograph demonstrates an orogastric tube coiled in the left hemithorax, confirming a left-sided diaphragmatic rupture with gastric herniation. This explains the diminished breath sounds and mediastinal shift. Acute traumatic diaphragmatic ruptures are optimally approached via laparotomy, which facilitates reduction of the herniated viscera, repair of the diaphragmatic defect, and management of any concurrent intra-abdominal injuries (e.g., splenic laceration).

Adım Adım Çözüm

1
Evaluate the patient's hemodynamic status.
The patient is in hemorrhagic shock, evidenced by a blood pressure of 82/46 mm Hg and a heart rate of 130/min.
Hemodynamic instability dictates whether a trauma patient proceeds to advanced imaging or requires immediate surgical exploration.
2
Correlate the physical exam and FAST findings.
Diffuse abdominal guarding and free fluid in the splenorenal recess confirm an active intra-abdominal source of hemorrhage.
A positive FAST in the setting of shock mandates an immediate laparotomy.
3
Interpret the chest radiograph findings.
An orogastric tube coiled in the left thorax with a rightward mediastinal shift indicates a left-sided diaphragmatic rupture with gastric herniation.
This explains the diminished breath sounds and tracheal deviation, effectively ruling out a simple tension pneumothorax.
4
Determine the definitive surgical approach.
Select immediate exploratory laparotomy.
Laparotomy is the correct approach to arrest intra-abdominal bleeding (from suspected solid organ injury) and allows for the reduction of the herniated stomach and repair of the acute diaphragmatic defect.

Anahtar Kavram

Management of blunt trauma causing hemorrhagic shock and diaphragmatic rupture
Bu soruyu puanla

Konular

Trauma and Burns

Bu konudan daha fazla soru