A 44-year-old man is brought to the emergency department after a motor vehicle collision. He was restrained in the driver's seat when a truck hit his car on the driver's side. The patient did not lose consciousness but was dazed for several minutes after the collision. Subsequently, he began to experience severe left leg pain. On arrival, blood pressure is 102/62 mm Hg and pulse is 118/min. Oxygen saturation is 96% on room air. The patient is conscious and answers questions appropriately. On physical examination, the pupils are equal and reactive to light. Multiple small facial lacerations are present. A cervical collar is in place. Breath sounds are symmetric and heart sounds are normal. The abdomen is diffusely tender. There is obvious deformity and tenderness of the left thigh. Portable chest x-ray reveals no pneumothorax or widened mediastinum. Rapid infusion of isotonic fluids is ongoing. Which of the following is the best immediate step in management of this patient?

Question

A 44-year-old man is brought to the emergency department after a motor vehicle collision.  He was restrained in the driver's seat when a truck hit his car on the driver's side.  The patient did not lose consciousness but was dazed for several minutes after the collision.  Subsequently, he began to experience severe left leg pain.  On arrival, blood pressure is 102/62 mm Hg and pulse is 118/min.  Oxygen saturation is 96% on room air.  The patient is conscious and answers questions appropriately.  On physical examination, the pupils are equal and reactive to light.  Multiple small facial lacerations are present.  A cervical collar is in place.  Breath sounds are symmetric and heart sounds are normal.  The abdomen is diffusely tender.  There is obvious deformity and tenderness of the left thigh.  Portable chest x-ray reveals no pneumothorax or widened mediastinum.  Rapid infusion of isotonic fluids is ongoing.  Which of the following is the best immediate step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d1a0_40cb_bc81_7572bcd70336_MD0003_00 This patient with diffuse abdominal tenderness and a deformed left lower extremity following a motor vehicle collision has polytrauma including blunt abdominal trauma (BAT). For polytrauma patients, a trauma survey can quickly identify serious injuries and triage them for possible emergency surgery. When BAT is present, intraabdominal injury and hemorrhage must be investigated. The initial approach is similar in both hemodynamically stable (HDS) (eg, systolic blood pressure >90 mm Hg) and hemodynamically unstable (HDUS) patients: Peritonitis (eg, rigidity, rebound tenderness) is an indication for immediate surgery (not seen in this patient). In the absence of peritonitis, Focused Assessment with Sonography for Trauma (FAST) is typically the first step in abdominal imaging. This noninvasive, ultrasound-based examination can be rapidly performed at the bedside to detect significant intraperitoneal free fluid (eg, blood, urine [bladder rupture]). A positive FAST strongly suggests intraabdominal injury. In HDS patients, such as this one, there is time to pursue more definitive imaging (eg, CT scan) to visualize the site and extent of injury. In contrast, HDUS patients with a positive FAST require immediate laparotomy. A negative FAST does not rule out intraabdominal organ injury because injuries that do not produce large amounts of free fluid (eg, bowel perforation, diaphragmatic rupture) can be missed. Therefore, if FAST is negative or equivocal, further investigations (eg, CT scan) may be required depending on the patient's hemodynamic status and the clinician's level of suspicion for intraabdominal injury. (Choices A and B) HDS patients with polytrauma often undergo a CT of the head and chest following a trauma survey. However, in this patient with diffuse abdominal tenderness (ie, higher likelihood of intraabdominal injury) and no emergency indications for CT of the head (eg, low Glasgow Coma Scale score) or chest (eg, widened mediastinum concerning for thoracic aortic injury), FAST should precede these studies. (Choice D) Although this patient will require further radiographic evaluation of his femur fracture, ruling out life-threatening injuries (eg, intraabdominal hemorrhage) is a higher priority. (Choice E) Chest radiography is routinely performed as part of the trauma survey and may reveal intraabdominal injury (eg, subdiaphragmatic free air). Abdominal radiography cannot detect intraperitoneal free fluid and would not provide additional pertinent information in this patient. Educational objective: Patients with blunt abdominal trauma should be assessed for intraabdominal injury, beginning with Focused Assessment with Sonography for Trauma (FAST), a rapid, noninvasive examination that can be performed at the bedside. References: Correlation between intra-abdominal free fluid and solid organ injury in blunt abdominal trauma. (http://www.ncbi.nlm.nih.gov/pubmed/26566511) Radiology for trauma and the general surgeon. (http://www.ncbi.nlm.nih.gov/pubmed/28958364)

A 44-Year-Old Man Is Brought to the Emergency Department After