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Zorluk: OrtaTrauma and Burns

An emergency response team brings a 45-year-old male industrial worker to the trauma center after a heavy steel beam collapsed, briefly pinning his lower torso against a concrete floor. On arrival, he is groggy but vigorously localizes to painful stimuli. His temperature is 36.5°C (97.7°F), blood pressure is 82/44 mmHg, heart rate is 134/min, and respiratory rate is 24/min. Pulse oximetry shows 98% on high-flow oxygen. Primary survey reveals a patent airway and bilateral breath sounds without adventitious noises. The trachea is midline, and neck veins are flat. Radial pulses are barely palpable, while femoral pulses are weak but present. A large ecchymosis is visible across the infraumbilical region, and the abdomen appears distended. Pelvic rock testing reveals no mechanical instability. Intravenous access is established with two large-bore peripheral catheters, and rapid crystalloid resuscitation is initiated. Which of the following is the most appropriate next step in the evaluation of this patient?

  1. A
    Contrast-enhanced cross-sectional imaging of the torso
  2. Bedside abdominal and thoracic ultrasonographyCevap
  3. C
    Immediate transfer to the operating theater for laparotomy
  4. D
    Application of a noninvasive circumferential pelvic binder
  5. E
    Closed diagnostic peritoneal lavage

Cevap

Bedside abdominal and thoracic ultrasonography
The correct answer is bedside abdominal and thoracic ultrasonography, commonly known as the FAST (Focused Assessment with Sonography for Trauma) exam. In any blunt trauma patient presenting with hemodynamic instability, the primary goal after the initial primary survey and fluid resuscitation is to identify the source of hemorrhage. FAST is noninvasive, can be performed simultaneously with resuscitation in the trauma bay, and rapidly detects the presence of hemoperitoneum or cardiac tamponade. If the FAST exam is positive in an unstable patient, it immediately indicates the need for an emergent exploratory laparotomy.

Adım Adım Çözüm

1
Identify the patient's hemodynamic status
The patient is in class III/IV hypovolemic shock with a blood pressure of 82/44 mmHg and a heart rate of 134/min.
Hemodynamic instability dictates the entire diagnostic algorithm in trauma, precluding tests that require transport away from the resuscitation area.
2
Determine the mechanism and suspected region of injury
The patient suffered a severe blunt crush injury to the torso with resulting abdominal distension and large ecchymosis.
This physical exam strongly suggests intra-abdominal hemorrhage, but thoracic and retroperitoneal sources remain possible.
3
Select the safest, most rapid initial diagnostic test
Bedside ultrasonography is selected to immediately image the abdomen and pericardium.
The FAST exam rapidly identifies intraperitoneal fluid or pericardial effusion without moving the unstable patient from the trauma bay, definitively guiding the need for operative intervention.

Anahtar Kavram

In hemodynamically unstable patients with blunt abdominal trauma, bedside ultrasonography (FAST exam) is the initial diagnostic modality of choice to rapidly identify intraperitoneal bleeding.
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Trauma and Burns

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