A 34-year-old man is brought to the emergency department after a head-on motor vehicle collision. On arrival, blood pressure is 78/40 mm Hg and pulse is 134/min. On physical examination, the patient is alert but intoxicated. Pupils are equal and reactive to light. Ecchymosis in the distribution of a seat belt is present over the chest and abdominal wall. The left chest wall is tender to palpation. Breath sounds are equal bilaterally. Heart sounds are normal. The abdomen is distended and diffusely tender. Portable chest x-ray reveals multiple left rib fractures without pneumothorax or effusion. Cervical spine and pelvic radiographs are negative for fractures and dislocations. Focused Assessment with Sonography for Trauma is negative for pericardial effusion but positive for free intraperitoneal fluid. After rapid infusion of 2 L of intravenous crystalloid, blood pressure is 80/50 mm Hg and pulse is 118/min. Transfusion of uncrossmatched blood is pending. Which of the following is the best next step in management of this patient?

Question

A 34-year-old man is brought to the emergency department after a head-on motor vehicle collision.  On arrival, blood pressure is 78/40 mm Hg and pulse is 134/min.  On physical examination, the patient is alert but intoxicated.  Pupils are equal and reactive to light.  Ecchymosis in the distribution of a seat belt is present over the chest and abdominal wall.  The left chest wall is tender to palpation.  Breath sounds are equal bilaterally.  Heart sounds are normal.  The abdomen is distended and diffusely tender.  Portable chest x-ray reveals multiple left rib fractures without pneumothorax or effusion.  Cervical spine and pelvic radiographs are negative for fractures and dislocations.  Focused Assessment with Sonography for Trauma is negative for pericardial effusion but positive for free intraperitoneal fluid.  After rapid infusion of 2 L of intravenous crystalloid, blood pressure is 80/50 mm Hg and pulse is 118/min.  Transfusion of uncrossmatched blood is pending.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d911_76af_bc81_f5b1549f6f01_MD0003_00 This hemodynamically unstable patient with blunt chest and abdominal trauma and no life-threatening intrathoracic injuries has free intraperitoneal fluid on Focused Assessment with Sonography for Trauma (FAST) examination. This warrants exploratory laparotomy to control likely intraabdominal hemorrhage. During the trauma survey of hemodynamically unstable (eg, systolic blood pressure <90 mm Hg) patients, the source(s) of instability should be investigated quickly. This includes ruling out rapidly fatal intrathoracic conditions (eg, tension pneumothorax, cardiac tamponade) and identifying major sources of hemorrhage. This patient's bilateral breath sounds and lack of pericardial effusion make tension pneumothorax and tamponade unlikely, respectively. However, his distended abdomen with diffuse tenderness is concerning for intraabdominal hemorrhage due to blunt abdominal trauma (BAT). For patients with BAT (regardless of hemodynamic status), frank peritonitis (eg, rigidity) warrants immediate laparotomy. In the absence of peritonitis (as in this patient), FAST examination should be performed to identify intraperitoneal free fluid (eg, blood, urine, spilled enteric contents). In hemodynamically unstable patients, a positive FAST confirms significant intraabdominal injury and therefore warrants emergent laparotomy. If FAST is negative or inconclusive, additional investigations should be considered: CT scan can often visualize the site and severity of intraabdominal injury but requires improved hemodynamic stability following resuscitation due to the risk of rapid deterioration in the CT scanner (Choice A). Bedside diagnostic peritoneal lavage (DPL) may be considered in patients who remain too hemodynamically unstable for CT scan despite resuscitation (Choice C). (Choice B) Contrast angiography (with embolization) is sometimes used for BAT patients with intraabdominal hemorrhage due to splenic or hepatic laceration. However, this is only appropriate for hemodynamically stable patients with isolated, lower-grade injuries (typically identified by CT scan). (Choice E) Vasopressor therapy is contraindicated in the setting of isolated hemorrhagic shock because peripheral vascular tone is already increased (ie, vasoconstriction) to compensate for decreased blood volume. Continued volume resuscitation (eg, crystalloid, blood products) is more appropriate. Educational objective: For patients with blunt abdominal trauma who are hemodynamically unstable, emergent laparotomy is indicated in the presence of peritonitis or intraperitoneal free fluid on Focused Assessment with Sonography for Trauma (FAST) examination. References: Radiology for trauma and the general surgeon. (http://www.ncbi.nlm.nih.gov/pubmed/28958364) Blunt abdominal trauma: imaging and intervention. (http://www.ncbi.nlm.nih.gov/pubmed/25801463)

A 34-Year-Old Man Is Brought to the Emergency Department After