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Zorluk: OrtaTrauma and Burns

A 31-year-old woman is evaluated in the emergency department after a paragliding collision with a mountain ridge. Upon arrival, she is lethargic and diaphoretic. Her temperature is 36.4°C (97.5°F), blood pressure is 78/42 mm Hg, pulse is 134/min, and respiratory rate is 24/min. Oxygen saturation is 96% on 15 L/min via non-rebreather mask. The airway is unobstructed, and breath sounds are clear and symmetric bilaterally. There is no active external bleeding. Physical examination reveals a large ecchymosis over the left flank. The abdomen is markedly distended, rigid, and diffusely tender with guarding. A focused assessment with sonography for trauma (FAST) demonstrates a large volume of anechoic fluid in the hepatorenal space (Morison pouch) and splenorenal recess. Intravenous access is rapidly secured and fluid resuscitation is initiated. Which of the following is the most appropriate next step in the management of this patient?

  1. A
    Multidetector computed tomography of the abdomen
  2. B
    Diagnostic peritoneal lavage
  3. C
    Continuous observation with serial hemoglobin assessments
  4. Immediate celiotomyCevap
  5. E
    Percutaneous endovascular embolization

Cevap

Immediate celiotomy
The correct answer is immediate celiotomy. This patient presents with class III or IV hemorrhagic shock following severe blunt abdominal trauma. The combination of hemodynamic instability (hypotension, tachycardia) and a positive FAST scan indicating intraperitoneal free fluid (blood) constitutes an absolute indication for immediate surgical exploration. Celiotomy will allow the surgical team to rapidly identify the injured organ (e.g., spleen or liver) and obtain source control of the bleeding.

Adım Adım Çözüm

1
Identify the patient's hemodynamic status.
The patient is in hemorrhagic shock, evidenced by severe hypotension (78/42 mm Hg), tachycardia (134/min), and altered mental status (lethargy).
Determining hemodynamic stability is the critical branch point in the blunt abdominal trauma management algorithm.
2
Analyze the physical examination and imaging findings.
The patient has a rigid, distended abdomen and a FAST examination that is positive for significant free fluid in the peritoneal cavity.
A positive FAST in the setting of trauma confirms that the source of the patient's hemorrhagic shock is intra-abdominal bleeding.
3
Determine the definitive management based on established trauma guidelines.
The patient must be transferred directly to the operating room for an immediate celiotomy.
Hemodynamically unstable patients with confirmed intra-abdominal hemorrhage require immediate surgical intervention for bleeding control.

Anahtar Kavram

Hemodynamically unstable patients with blunt abdominal trauma and a positive focused assessment with sonography for trauma (FAST) require immediate surgical exploration to control life-threatening hemorrhage.
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Trauma and Burns

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