Examkin

Soru

Zorluk: ZorTrauma and Burns

A 34-year-old woman is brought to the emergency department by paramedics after being assaulted at a local park. She sustained a single stab wound to her left flank with a pocket knife approximately 20 minutes ago. On arrival, she is lethargic and pale. Her temperature is 36.2°C (97.2°F), blood pressure is 82/40 mm Hg, pulse is 138/min, and respirations are 26/min. Pulse oximetry shows 96% on room air. The airway is patent, and breath sounds are clear and equal bilaterally. Physical examination reveals a 4-cm laceration located posterior to the left midaxillary line, midway between the 12th rib and the iliac crest. There is minimal active bleeding from the wound. A focused assessment with sonography for trauma (FAST) demonstrates no free fluid in the perihepatic, perisplenic, pelvic, or pericardial windows. Following the rapid intravenous infusion of 1 L of warmed lactated Ringer solution, her blood pressure is 84/42 mm Hg and pulse is 132/min. Which of the following is the most appropriate next step in management?

  1. A
    Computed tomography angiography of the abdomen and pelvis
  2. Immediate exploratory laparotomyCevap
  3. C
    Diagnostic peritoneal lavage
  4. D
    Local wound exploration
  5. E
    Diagnostic laparoscopy

Cevap

Immediate exploratory laparotomy
The most appropriate next step for this patient is immediate exploratory laparotomy. She has a penetrating wound to the flank and is exhibiting signs of severe hemorrhagic shock (hypotension, tachycardia, altered mental status) that has not improved following initial fluid resuscitation. In trauma management, any penetrating injury to the torso (anterior abdomen, flank, or back) accompanied by hemodynamic instability is an absolute indication for emergency surgical exploration. While the FAST exam is negative, this imaging modality primarily evaluates the intraperitoneal and pericardial spaces. It is highly insensitive for detecting retroperitoneal hemorrhage, which is a major concern with flank stab wounds (e.g., injuries to the kidney or retroperitoneal vasculature). Because the patient is unstable, further diagnostic workup must be bypassed in favor of immediate operative hemorrhage control.

Adım Adım Çözüm

1
Assess the patient's hemodynamic status and response to initial resuscitation.
The patient is in hemorrhagic shock (hypotensive, tachycardic, lethargic) and is a non-responder to initial crystalloid fluid resuscitation.
Determining hemodynamic stability is the most critical initial branch point in trauma management algorithms.
2
Evaluate the mechanism and anatomical location of the injury.
The patient has a penetrating wound to the left flank, which is considered part of the torso and poses a high risk to retroperitoneal structures (e.g., kidney, descending colon, major vasculature).
Mechanism (blunt vs. penetrating) and location dictate specific operative or diagnostic indications.
3
Interpret the adjunct imaging (FAST) within the clinical context.
FAST is negative, indicating no significant intraperitoneal or pericardial fluid. However, flank wounds frequently injure retroperitoneal structures.
FAST is highly insensitive for detecting retroperitoneal hemorrhage. A negative FAST does not rule out massive bleeding in this compartment.
4
Determine the definitive management step based on stability and mechanism.
Immediate exploratory laparotomy is indicated.
Any patient with a penetrating torso injury and persistent hemodynamic instability requires emergency surgical exploration to identify and control the source of bleeding.

Anahtar Kavram

Hemodynamically unstable patients with penetrating trauma to the torso (including the anterior abdomen, back, and flank) require immediate exploratory laparotomy. A negative FAST exam does not rule out massive retroperitoneal hemorrhage.
Bu soruyu puanla

Konular

Trauma and Burns

Bu konudan daha fazla soru