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Zorluk: ZorTrauma and Burns

A 28-year-old female is brought to the emergency department by emergency medical services after a high-speed motorcycle collision. She was found approximately 30 feet from her vehicle. On arrival, her temperature is 36.5°C (97.7°F), blood pressure is 76/40 mm Hg, pulse is 138/min, and respirations are 28/min. The patient is lethargic and pale. The airway is intact, and breath sounds are present and equal bilaterally. A rigid cervical collar is in place. Abdominal examination reveals diffuse tenderness and guarding. The patient receives 1 L of warmed intravenous crystalloid solution and 1 unit of uncrossmatched packed red blood cells, but her blood pressure only improves to 82/45 mm Hg. A portable chest radiograph shows a widened mediastinum but no evidence of pneumothorax or hemothorax. A focused assessment with sonography for trauma (FAST) examination reveals a large anechoic fluid collection in the hepatorenal recess (Morison's pouch). An anteroposterior pelvic radiograph shows no fractures. Which of the following is the most appropriate next step in management?

  1. Immediate exploratory laparotomyCevap
  2. B
    Computed tomography angiography of the chest
  3. C
    Computed tomography of the abdomen and pelvis
  4. D
    Transesophageal echocardiography
  5. E
    Diagnostic peritoneal lavage

Cevap

Immediate exploratory laparotomy is the correct management for a hemodynamically unstable patient with a positive FAST exam.
The correct management is immediate exploratory laparotomy. This patient is in severe hemorrhagic shock (hypotension, tachycardia) that is unresponsive to initial fluid and blood resuscitation. The FAST exam confirms the presence of intra-peritoneal fluid, which in this context represents active intra-abdominal hemorrhage. The standard of care for a hemodynamically unstable patient with a positive FAST exam is an immediate trip to the operating room for an exploratory laparotomy. Although the portable chest radiograph shows a widened mediastinum—a classic sign of blunt thoracic aortic injury (BTAI) requiring further investigation—addressing the known, active intra-abdominal hemorrhage takes absolute precedence. Diagnostic evaluation of the aorta can be safely deferred until the abdominal bleeding is controlled, or it can be assessed concurrently in the operating room via transesophageal echocardiography (TEE).

Adım Adım Çözüm

1
Assess the patient's hemodynamic status and response to initial resuscitation.
The patient remains persistently hypotensive (BP 82/45 mm Hg) and tachycardic despite receiving crystalloid and blood products, classifying her as hemodynamically unstable.
Hemodynamic stability dictates the entire trauma algorithm (surgical intervention vs. further imaging).
2
Analyze the primary adjunct imaging findings.
The FAST exam is positive (fluid in Morison's pouch), identifying the abdomen as the source of major hemorrhage. The widened mediastinum indicates potential blunt thoracic aortic injury (BTAI).
Locating the primary source of bleeding is necessary to direct the surgical team.
3
Prioritize management of multiple life-threatening injuries.
The active, non-compressible intra-abdominal hemorrhage is the immediate cause of the refractory shock. Exploratory laparotomy must be performed instantly. The potential BTAI is managed concurrently or subsequently.
Securing active exsanguination in the abdomen takes precedence over diagnosing a thoracic vascular injury, as transporting an unstable patient for a CT scan is absolutely contraindicated.

Anahtar Kavram

In polytrauma patients, a positive FAST exam with persistent hemodynamic instability mandates immediate exploratory laparotomy, overriding the need to diagnostically evaluate other concerning but stable radiographic findings (e.g., widened mediastinum) prior to hemorrhage control.
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