A 27-year-old man is brought to the emergency department after sustaining a single stab wo… — USMLE Step 2 CK

A $27$ -year-old man is brought to the emergency department after sustaining a single stab wound during an altercation. The wound is located in the left $7\text{th}$ intercostal space at the midaxillary line. On arrival, he is lethargic and noticeably diaphoretic. His temperature is $36.8^\circ\text{C}$ ( $98.2^\circ\text{F}$ ), heart rate is $132/\text{min}$ , blood pressure is $75/45\text{ mmHg}$ , and respiratory rate is $24/\text{min}$ .

On primary survey, his airway is patent. Breath sounds are equal and clear bilaterally. A portable chest radiograph shows a normal mediastinal silhouette and no evidence of pneumothorax or hemothorax. The abdomen is moderately distended, but there is no evisceration. A Focused Assessment with Sonography for Trauma (FAST) examination reveals a significant amount of free fluid in the splenorenal recess.

The patient receives a rapid infusion of $1\text{ L}$ of warmed lactated Ringer solution and $1$ unit of emergency-release type O-negative blood. Reassessment reveals a blood pressure of $78/40\text{ mmHg}$ and a heart rate of $128/\text{min}$ .

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

A
Computed tomography scan of the abdomen and pelvis
B
Diagnostic peritoneal lavage
Immediate exploratory laparotomyCevap
D
Left-sided tube thoracostomy
E
Local wound exploration

Cevap

Immediate exploratory laparotomy

The correct answer is immediate exploratory laparotomy. This patient has sustained a penetrating stab wound to the thoracoabdominal region (the "box," extending from the

4\text{th}

intercostal space down to the costal margins), which carries a high risk of intra-abdominal injury due to diaphragmatic excursion. He presents in hemorrhagic shock that is unresponsive to initial fluid and blood resuscitation. The primary survey and normal portable chest radiograph effectively rule out a massive hemothorax or tension pneumothorax as the cause of his shock. Concurrently, the Focused Assessment with Sonography for Trauma (FAST) examination confirms the presence of intraperitoneal hemorrhage. According to standard trauma protocols, any patient with penetrating trauma who is hemodynamically unstable and has evidence of intraperitoneal bleeding (e.g., a positive FAST) or peritonitis must bypass further diagnostic testing and proceed directly to the operating room for an immediate exploratory laparotomy to surgically control the hemorrhage.

Adım Adım Çözüm

Evaluate the patient's hemodynamic status and mechanism of injury.

The patient has a penetrating stab wound to the left

7\text{th}

intercostal space and is in hemorrhagic shock (BP

75/45\text{ mmHg}

, HR

132/\text{min}

) that is unresponsive to initial fluid and blood resuscitation.

Hemodynamic instability determines the urgency of intervention and strictly precludes time-consuming diagnostic tests like CT scans.

Assess the primary survey and imaging adjuncts to localize the source of bleeding.

Clear breath sounds and a normal chest radiograph effectively rule out life-threatening intrathoracic bleeding. The FAST examination is positive for free fluid in the splenorenal recess.

Stab wounds below the

4\text{th}

intercostal space can involve the abdomen due to diaphragmatic excursion. The positive FAST confirms an intraperitoneal source for the hemorrhagic shock.

Determine the next best step in management based on the algorithmic approach to trauma.

Proceed directly to immediate exploratory laparotomy.

Any hemodynamically unstable patient with penetrating thoracoabdominal trauma and evidence of intraperitoneal bleeding requires immediate surgical exploration for hemorrhage control.

Anahtar Kavram

Hemodynamically unstable patients with penetrating thoracoabdominal trauma and a positive FAST examination require immediate exploratory laparotomy.

Soru

Cevap

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