An 18-year-old football player is brought to the emergency department due to persistent pain following a hard tackle. The patient had just caught a pass when he was tackled from the front, with the opponent landing all his weight on the patient's abdomen. Immediately afterward, he began to experience abdominal discomfort and nausea. Blood pressure is 92/64 mm Hg, pulse is 118/min, and respirations are 24/min. The patient is alert but appears anxious. Bilateral breath sounds are clear and equal. Heart sounds are normal without murmur. The abdomen is mildly distended and tender to palpation diffusely. Chest x-ray and pelvic x-ray are normal. Focused Assessment with Sonography for Trauma reveals intraperitoneal free fluid. Further evaluation of this patient is most likely to reveal which of the following?

Question

An 18-year-old football player is brought to the emergency department due to persistent pain following a hard tackle.  The patient had just caught a pass when he was tackled from the front, with the opponent landing all his weight on the patient's abdomen.  Immediately afterward, he began to experience abdominal discomfort and nausea.  Blood pressure is 92/64 mm Hg, pulse is 118/min, and respirations are 24/min.  The patient is alert but appears anxious.  Bilateral breath sounds are clear and equal.  Heart sounds are normal without murmur.  The abdomen is mildly distended and tender to palpation diffusely.  Chest x-ray and pelvic x-ray are normal.  Focused Assessment with Sonography for Trauma reveals intraperitoneal free fluid.  Further evaluation of this patient is most likely to reveal which of the following?

Quizplus · Accepted Answer

This patient with blunt abdominal trauma (BAT) now has a distended and diffusely tender abdomen, intraperitoneal free fluid on Focused Assessment with Sonography for Trauma (FAST), and signs of hypovolemic shock (eg, tachycardia, hypotension). This presentation is concerning for intraabdominal hemorrhage, most likely due to splenic laceration. Focused Assessment with Sonography for Trauma (FAST) The spleen is one of the most frequently injured organs in BAT, with the spectrum of injury ranging from contusion or subcapsular hematoma to laceration with life-threatening, intraperitoneal bleeding (due to the spleen's high vascularity). Management depends on the patient's hemodynamic status following resuscitation. In patients who are hemodynamically stable enough to undergo further imaging, CT scan of the abdomen and pelvis with intravenous contrast is ideal for visualizing the extent of injury and diagnosing ongoing bleeding (eg, contrast extravasation). Often, blunt splenic injury can be managed nonoperatively (eg, observation with serial hemoglobin measurement, embolization). However, continued hemodynamic instability (eg, despite initial resuscitation) or frank peritonitis are indications for exploratory laparotomy and potential splenectomy. further imaging (Choice A) Abdominal aortic injuries due to BAT are rare (<1%). Many patients with traumatic aortic injury die from exsanguination before reaching the hospital. Those who survive (because bleeding has been contained within the retroperitoneum) typically would not have a large amount of intraperitoneal free fluid on FAST. (Choice B) Urinary bladder rupture from BAT can cause intraperitoneal free fluid (ie, urine) on FAST. However, shock is uncommon, and difficulty voiding and/or gross hematuria are typically present. (Choice C) Diaphragmatic tearing can occur from BAT due to a sudden increase in intraabdominal pressure. However, this does not typically cause significant bleeding (eg, shock, intraperitoneal free fluid). In addition, chest x-ray often reveals elevated hemidiaphragm or intrathoracic migration of abdominal contents. (Choices D and E) Rapid compression of the upper abdomen against the vertebral column can crush the duodenum or pancreas, potentially causing duodenal hematoma or pancreatic transection. However, duodenal hematoma does not cause intraperitoneal free fluid because bleeding remains confined within the duodenal wall. Likewise, pancreatic transection does not cause an acute effusion of intraperitoneal fluid; even with leakage of pancreatic juice (ie, ductal injury), formation of a large, ultrasound-detectable peripancreatic fluid collection (eg, pseudocyst) typically takes days to weeks. Educational objective: The spleen is one of the most commonly injured organs in blunt abdominal trauma. Patients with severe splenic laceration causing intraabdominal hemorrhage may have shock and intraperitoneal free fluid on Focused Assessment with Sonography for Trauma. References: Splenic trauma: WSES classification and guidelines for adult and pediatric patients. (http://www.ncbi.nlm.nih.gov/pubmed/28828034) An update on nonoperative management of the spleen in adults. (http://www.ncbi.nlm.nih.gov/pubmed/29766085)

An 18-Year-Old Football Player Is Brought to the Emergency Department