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Zorluk: KolayTrauma and Burns

An ambulance brings a 27-year-old female to the emergency department after she was thrown from a horse, landing forcefully on her left side. She is fully alert and complains of severe left-sided abdominal pain. Her temperature is 36.8°C (98.2°F), blood pressure is 78/42 mm Hg, pulse is 138/min, and respiratory rate is 22/min. Physical examination reveals guarding and rigidity in the left upper quadrant. Intravenous fluid resuscitation is initiated with 1 liter of warm crystalloid, but a repeat blood pressure reading is 80/45 mm Hg. A focused assessment with sonography for trauma (FAST) demonstrates a large amount of anechoic fluid in the splenorenal recess. Which of the following is the most appropriate next step in management?

  1. A
    Computed tomography scan of the abdomen and pelvis
  2. Immediate surgical explorationCevap
  3. C
    Diagnostic peritoneal lavage
  4. D
    Percutaneous angiography with embolization
  5. E
    Admission to the intensive care unit for serial examinations

Cevap

Immediate surgical exploration is required for a hemodynamically unstable patient with a positive FAST exam following blunt abdominal trauma.
The correct answer is immediate surgical exploration. The patient has sustained blunt abdominal trauma and is in hemorrhagic shock, evidenced by persistent hypotension and tachycardia despite an initial fluid bolus. The positive FAST exam localizes the bleeding to the peritoneal cavity (likely splenic rupture). According to Advanced Trauma Life Support (ATLS) guidelines, a hemodynamically unstable patient with a positive FAST exam must be taken immediately to the operating room to achieve hemorrhage control.

Adım Adım Çözüm

1
Assess the patient's hemodynamic status.
The patient is hypotensive (BP 78/42 mm Hg) and tachycardic (pulse 138/min), and remains unstable after receiving 1 liter of intravenous crystalloid fluids.
Hemodynamic stability is the primary decision point in the ATLS algorithm for blunt abdominal trauma.
2
Evaluate the results of the initial diagnostic workup.
The FAST exam is positive, showing anechoic fluid in the splenorenal recess, which indicates intraperitoneal hemorrhage.
A positive FAST in the setting of instability confirms the abdomen as the source of life-threatening bleeding.
3
Determine the definitive management.
The patient must be taken for immediate surgical exploration.
Hemodynamically unstable patients with confirmed intraperitoneal bleeding require immediate operative hemorrhage control.

Anahtar Kavram

Patients with blunt abdominal trauma who are hemodynamically unstable and have a positive FAST examination require immediate surgical exploration.
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