An 18-year-old male is brought to the emergency department 30 minutes after falling from a… — USMLE Step 2 CK

An $18$ -year-old male is brought to the emergency department $30$ minutes after falling from a $15$ -foot scaffolding. He is groggy and responsive only to painful stimuli. Vital signs show a temperature of $36.5^\circ$ C, a heart rate of $142$ /min, a blood pressure of $78/45$ mmHg, and a respiratory rate of $24$ /min. An intravenous line is established, and $1$ L of warm crystalloid fluid is rapidly administered. Following resuscitation, his blood pressure remains $82/50$ mmHg. Primary survey reveals equal breath sounds bilaterally and a stable pelvis. There is extensive bruising over the left upper quadrant of the abdomen. Point-of-care abdominal ultrasonography reveals a significant amount of anechoic fluid in the hepatorenal and splenorenal spaces. Which of the following is the most appropriate next step in management?

Emergent celiotomyCevap
B
Abdominal and pelvic CT scan with intravenous contrast
C
Diagnostic peritoneal lavage
D
Percutaneous transcatheter arterial embolization
E
Insertion of a left-sided thoracostomy tube

Cevap

Emergent celiotomy

This patient is in hypovolemic shock due to blunt abdominal trauma, evidenced by severe hypotension and tachycardia that are refractory to initial fluid resuscitation. The point-of-care ultrasound demonstrates intraperitoneal free fluid, confirming the abdomen as the source of hemorrhage (likely a splenic laceration given the left upper quadrant bruising). In a hemodynamically unstable patient with a positive ultrasound for abdominal bleeding, the definitive and only appropriate management is emergent celiotomy (surgical exploration) to directly identify and control the bleeding source.

Adım Adım Çözüm

Identify the patient's hemodynamic status following initial resuscitation.

The patient remains in hemorrhagic shock with a blood pressure of

82/50

mmHg and a heart rate of

142

/min despite

1

L of crystalloid fluid.

Determining hemodynamic stability is the primary decision point in trauma algorithms for blunt abdominal injury.

Interpret the point-of-care abdominal ultrasonography findings.

The ultrasound demonstrates anechoic fluid in the hepatorenal and splenorenal spaces, indicating intraperitoneal bleeding.

Finding the source of the hemorrhage dictates the anatomical location requiring surgical intervention.

Select the appropriate intervention based on stability and ultrasound findings.

The combination of refractory hypotension and a positive abdominal ultrasound mandates immediate surgical exploration.

Unstable patients with intraperitoneal bleeding require urgent operative hemostasis.

Anahtar Kavram

Patients presenting with blunt abdominal trauma who remain hemodynamically unstable after initial fluid resuscitation and have evidence of intraperitoneal free fluid require immediate surgical exploration to control the hemorrhage.

Soru

Cevap

Adım Adım Çözüm

Anahtar Kavram

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