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Zorluk: ZorTrauma and Burns

A 62-year-old male with a history of chronic obstructive pulmonary disease and ischemic heart disease is brought to the trauma center after being struck by a forklift. He is lethargic and complains of severe abdominal pain. Vital signs show a temperature of 36.5∘36.5^\circ C (97.7∘97.7^\circ F), a blood pressure of 76/4076/40 mm Hg, a pulse of 128128/min, and a respiratory rate of 2626/min. Examination reveals large ecchymoses over the left lower ribs and severe diffuse abdominal tenderness with involuntary guarding. A focused assessment with sonography for trauma (FAST) demonstrates a substantial anechoic fluid collection in the splenorenal recess. A portable chest radiograph shows fractures of the left eighth, ninth, and tenth ribs with no pneumothorax. Which of the following is the most appropriate next step in the management of this patient?

  1. Transfer to the operating room for an abdominal celiotomyCevap
  2. B
    Multidetector computed tomography imaging of the torso
  3. C
    Nasogastric tube decompression and admission for serial examinations
  4. D
    Intravenous administration of furosemide and noninvasive ventilation
  5. E
    Intravenous administration of sodium bicarbonate

Cevap

Transfer to the operating room for an abdominal celiotomy
The correct management for a hemodynamically unstable patient (hypotension, tachycardia) following blunt abdominal trauma with evidence of intra-abdominal hemorrhage on a FAST exam is immediate surgical exploration. The patient's left lower rib fractures and fluid in the splenorenal recess strongly suggest a splenic injury. Delaying surgery for imaging or attempting conservative management in the setting of shock is contraindicated.

Adım Adım Çözüm

1
Assess the patient's hemodynamic status.
The patient has a blood pressure of 76/4076/40 mm Hg and a pulse of 128128/min, indicating hemodynamic instability and class III/IV shock.
Hemodynamic status determines whether the patient can safely undergo advanced imaging or requires immediate intervention.
2
Evaluate the source of instability using bedside diagnostics.
A FAST exam reveals an anechoic fluid collection in the splenorenal recess, indicating hemoperitoneum (likely a splenic laceration due to overlying rib fractures).
Rapid identification of the bleeding source is required in the primary survey of trauma patients.
3
Determine the definitive management.
The patient requires immediate surgical exploration (celiotomy) to arrest the intra-abdominal hemorrhage.
According to ATLS protocols, hemodynamically unstable patients with intra-abdominal bleeding require emergent operative intervention.

Anahtar Kavram

Hemodynamically unstable patients with blunt abdominal trauma and a positive FAST exam require emergent surgical exploration (celiotomy).
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Trauma and Burns

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