A 31-year-old woman is transported via helicopter to the regional trauma center after bein… — USMLE Step 2 CK

A 31-year-old woman is transported via helicopter to the regional trauma center after being extricated from a severe motor vehicle collision. En route, she received 1 liter of crystalloid solution. Upon arrival, she is lethargic but moans to pain.

Vital Sign	Value
Temperature	$36.0^\circ\text{C}$ ( $96.8^\circ\text{F}$ )
Blood pressure	$76/40\text{ mm Hg}$
Heart rate	$138/\text{min}$
Respiratory rate	$26/\text{min}$

The trachea is midline, and bilateral breath sounds are equal. A portable anteroposterior chest radiograph reveals a widened upper mediastinum, left apical pleural capping, and a fracture of the left first rib. Bedside focused assessment with sonography for trauma (FAST) demonstrates a 4-centimeter pocket of anechoic fluid in the Morison pouch and additional free fluid in the pelvis. The patient's blood pressure drops to $68/35\text{ mm Hg}$ despite the initiation of a massive transfusion protocol. Which of the following is the most appropriate next step in management?

A
Computed tomography angiography of the chest
B
Thoracic endovascular aortic repair
Exploratory laparotomyCevap
D
Intravenous esmolol infusion
E
Bedside echocardiography and dobutamine infusion

Cevap

Exploratory laparotomy

This patient presents with signs of multiple life-threatening injuries following severe blunt trauma. The chest radiograph findings (widened mediastinum, apical capping) are highly suspicious for a blunt thoracic aortic injury (BTAI). However, the patient is in profound and worsening hemorrhagic shock with a frankly positive FAST exam, indicating massive intra-abdominal bleeding. In multisystem trauma, active abdominal exsanguination is the most immediate threat to life. BTAI typically results in a contained rupture (pseudoaneurysm) temporarily constrained by the intact adventitia and surrounding mediastinal tissues. The definitive next step must prioritize immediate hemostasis of the actively bleeding source. Therefore, emergent exploratory laparotomy is required. Once the abdominal bleeding is controlled and the patient is stabilized, further imaging (CTA) and delayed repair of the BTAI can be safely performed.

Adım Adım Çözüm

Identify the primary pathophysiological threat.

The patient is in profound, worsening hemorrhagic shock (

68/35\text{ mm Hg}

) with a positive FAST exam indicating massive intra-abdominal bleeding.

Recognizing the type and location of shock is the first step in the trauma algorithm.

Evaluate competing injuries.

The widened mediastinum, left apical capping, and first rib fracture strongly suggest a concurrent blunt thoracic aortic injury (BTAI).

Multisystem trauma requires prioritizing interventions based on the most immediate threat to life.

Apply Advanced Trauma Life Support (ATLS) priorities.

Active exsanguination from the abdomen is immediately lethal. BTAI typically presents as a contained hematoma (pseudoaneurysm) restricted by the adventitia layer.

Uncontrolled intra-abdominal hemorrhage must be addressed surgically before definitive evaluation or repair of a contained thoracic injury.

Determine the definitive next management step.

Select exploratory laparotomy to achieve rapid hemostasis.

Surgical control of the abdominal bleeding is the only viable option to save the patient's life in this critical state.

Anahtar Kavram

Management priorities in multisystem trauma with suspected blunt thoracic aortic injury

Soru

Cevap

Adım Adım Çözüm

Anahtar Kavram

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