A 27-year-old man is brought to the emergency department by ambulance 20 minutes after sus… — USMLE Step 2 CK

A 27-year-old man is brought to the emergency department by ambulance 20 minutes after sustaining a stab wound to the abdomen during an altercation. On arrival, he is lethargic and confused. His temperature is $36.5^\circ\text{C}$ ( $97.7^\circ\text{F}$ ), blood pressure is $80/45\text{ mmHg}$ , pulse is $135/\text{min}$ , and respiratory rate is $22/\text{min}$ . Pulse oximetry is $97\%$ on room air. Two large-bore intravenous lines are established, and a bolus of warmed isotonic crystalloid is initiated. The airway is patent, and breath sounds are clear and equal bilaterally. Physical examination reveals a 4-cm transverse laceration in the left lower quadrant of the abdomen. The abdomen is distended, and there is generalized guarding and rebound tenderness across all four quadrants. Which of the following is the most appropriate next step in management?

Exploratory laparotomyCevap
B
Computed tomography of the abdomen and pelvis
C
Focused assessment with sonography for trauma
D
Serial abdominal examinations and observation
E
Administration of broad-spectrum antibiotics and tetanus toxoid

Cevap

Exploratory laparotomy

This patient presents with a penetrating abdominal injury, severe hemorrhagic shock (hypotension, marked tachycardia, lethargy), and diffuse peritonitis (distension, guarding, rebound tenderness). According to Advanced Trauma Life Support (ATLS) guidelines, the presence of 'hard signs'—specifically hemodynamic instability, peritonitis, or evisceration—following penetrating abdominal trauma mandates immediate surgical intervention. Definitively controlling hemorrhage and repairing hollow viscus injuries in the operating room is the paramount priority. Any delay for imaging or further diagnostic testing in this scenario significantly increases the risk of mortality.

Adım Adım Çözüm

Analyze the patient's hemodynamic status.

The patient is in Class III/IV hemorrhagic shock with a blood pressure of

80/45\text{ mmHg}

and a pulse of

135/\text{min}

Hemodynamic stability is the primary initial decision point in trauma management algorithms.

Evaluate the physical examination findings.

The patient has a left lower quadrant stab wound accompanied by generalized guarding and rebound tenderness.

These specific findings indicate diffuse peritonitis, likely due to an intra-abdominal hollow viscus perforation.

Determine the appropriate intervention based on Advanced Trauma Life Support (ATLS) algorithms.

The combination of penetrating abdominal trauma, hemodynamic instability, and peritonitis dictates immediate transfer to the operating room.

Delaying definitive surgical source control for imaging or further diagnostic testing in a patient with hard signs of intra-abdominal injury significantly increases mortality.

Anahtar Kavram

Patients presenting with penetrating abdominal trauma and 'hard signs' of injury (hemodynamic instability, peritonitis, or evisceration) require immediate exploratory laparotomy.

Soru

Cevap

Adım Adım Çözüm

Anahtar Kavram

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