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Zorluk: OrtaTrauma and Burns

An 81-year-old woman is transported to the trauma bay via ambulance after sustaining a ground-level fall, striking her left flank against a heavy wooden bench. She has a history of essential hypertension and hyperlipidemia. On initial evaluation, her temperature is 36.4°C (97.5°F), blood pressure is 82/46 mmHg, pulse is 126/min, and respiratory rate is 24/min. Her airway is patent and breath sounds are equal bilaterally. Her abdomen is distended and exhibits severe guarding over the left upper and lower quadrants. Pelvic compression does not elicit instability. She is given 1 L of warmed lactated Ringer fluid via two large-bore peripheral intravenous catheters. Reassessment shows a blood pressure of 80/44 mmHg and a pulse of 130/min. A bedside ultrasound examination demonstrates a large amount of free anechoic fluid in the hepatorenal and splenorenal spaces. Which of the following is the most appropriate next step in management?

  1. Transfer to the operating room for celiotomyCevap
  2. B
    Multidetector helical imaging of the abdomen and pelvis
  3. C
    Diagnostic peritoneal aspiration and lavage
  4. D
    Transfer to the intensive care unit for serial abdominal examinations
  5. E
    Endovascular angiographic embolization

Cevap

Transfer to the operating room for celiotomy is the most appropriate next step in management.
The correct next step is to transfer the patient to the operating room for a celiotomy (exploratory laparotomy). In the Advanced Trauma Life Support (ATLS) algorithm, patients presenting with blunt abdominal trauma are initially evaluated for hemodynamic stability. This patient presents with class III hemorrhagic shock (hypotension, tachycardia) and remains unstable despite an initial fluid bolus. The presence of free fluid on a focused assessment with sonography for trauma (FAST) exam in an unstable patient is highly indicative of active, life-threatening intra-abdominal hemorrhage. The definitive management is immediate surgical exploration to locate and arrest the bleeding.

Adım Adım Çözüm

1
Assess the patient's hemodynamic status based on initial and post-resuscitation vitals.
The patient is hemodynamically unstable (hypotensive and tachycardic) and fails to respond to an initial fluid bolus of 1 L of crystalloid.
Hemodynamic stability dictates the algorithmic pathway for blunt abdominal trauma management.
2
Determine the source of shock based on primary survey adjuncts.
The bedside ultrasound (FAST) reveals free fluid in the abdomen, indicating intra-abdominal hemorrhage as the primary cause of her hemorrhagic shock.
Identifying the anatomical compartment of bleeding rapidly directs definitive therapy.
3
Select the definitive treatment modality.
The correct action is urgent surgical exploration (celiotomy).
A hemodynamically unstable patient with blunt abdominal trauma and a positive FAST requires immediate operative intervention to control hemorrhage.

Anahtar Kavram

Hemodynamically unstable patients with blunt abdominal trauma and a positive focused assessment with sonography for trauma (FAST) examination require immediate exploratory laparotomy (celiotomy).
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Trauma and Burns

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