A 19-year-old man is brought to the emergency department by ambulance after a motor vehicle collision. The accident occurred 1 hour ago when his vehicle spun out of control and rolled over. He was wearing his seatbelt and his airbag deployed. The patient is alert and reports abdominal pain. Blood pressure is 110/70 mm Hg, pulse is 106/min, and respirations are 16/min. On examination, lungs are clear to auscultation bilaterally and the chest wall is nontender. Heart sounds are normal. The abdomen is nondistended with tenderness to palpation in the left upper quadrant. There are no gross deformities of the extremities. A Focused Assessment with Sonography for Trauma (FAST) examination reveals free fluid in the left subphrenic space. Which of the following is the best next step in management?

Question

A 19-year-old man is brought to the emergency department by ambulance after a motor vehicle collision.  The accident occurred 1 hour ago when his vehicle spun out of control and rolled over.  He was wearing his seatbelt and his airbag deployed.  The patient is alert and reports abdominal pain.  Blood pressure is 110/70 mm Hg, pulse is 106/min, and respirations are 16/min.  On examination, lungs are clear to auscultation bilaterally and the chest wall is nontender.  Heart sounds are normal.  The abdomen is nondistended with tenderness to palpation in the left upper quadrant.  There are no gross deformities of the extremities.  A Focused Assessment with Sonography for Trauma (FAST) examination reveals free fluid in the left subphrenic space.  Which of the following is the best next step in management?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d84c_049c_bc81_b7ce5fce0a70_MD0003_00 This patient who sustained blunt abdominal trauma during a motor vehicle collision now has abdominal pain, left upper quadrant tenderness, and intraperitoneal free fluid on Focused Assessment with Sonography for Trauma (FAST) examination. This presentation is concerning for intraabdominal hemorrhage, possibly from splenic injury. Management of suspected intraabdominal hemorrhage (eg, positive FAST) depends on the patient's hemodynamic status: Hemodynamically unstable (eg, systolic blood pressure <90 mm Hg) patients should undergo emergency exploratory laparotomy because hemodynamic instability implies rapid, ongoing hemorrhage that may be fatal without immediate surgical intervention (Choice C). Hemodynamically stable patients, such as this one, can likely tolerate a trip to the CT scanner without clinical deterioration. These patients should undergo further imaging (eg, CT scan of the abdomen and pelvis with contrast) to visualize the site of injury and determine whether there is ongoing bleeding (seen as contrast extravasation). Some injuries that cause hemoperitoneum (eg, some splenic and hepatic lacerations) can be managed nonoperatively with angiography and arterial embolization or, if prior bleeding has stopped, close observation (eg, serial hematocrits and abdominal examinations). (Choice B) Diagnostic peritoneal lavage is used at the bedside to rapidly evaluate hemodynamically unstable patients with equivocal FAST results for intraabdominal hemorrhage (which would require immediate laparotomy). This patient is hemodynamically stable and can tolerate undergoing CT scan to better visualize his intraabdominal injuries and determine whether nonoperative management (eg, embolization) is possible. Diagnostic peritoneal lavage (Choice D) A positive FAST exam in the setting of blunt abdominal trauma usually indicates intrabdominal hemorrhage (although visualized fluid can also be ascites or urine). To visualize the source of the fluid, determine the extent of injury, and guide further management, further workup (eg, CT scan) is necessary. Visualizing ongoing bleeding is critical because it may require intervention (eg, surgery, embolization). (Choice E) Serial abdominal examinations are useful in hemodynamically stable patients with a negative FAST exam and low suspicion for intraabdominal injury (eg, minimal abdominal pain, benign abdominal examination). However, this patient has a positive FAST exam, so further imaging (eg, CT scan) is indicated. Educational objective: Patients with blunt abdominal trauma and suspected intraabdominal hemorrhage (eg, free intraperitoneal fluid) on Focused Assessment with Sonography for Trauma examination are managed according to their hemodynamic status. Hemodynamically stable patients can tolerate further imaging and should undergo contrast CT scan of the abdomen and pelvis. References: Point-of-care ultrasonography for diagnosing thoracoabdominal injuries in patients with blunt trauma. (http://www.ncbi.nlm.nih.gov/pubmed/30548249) Should we perform a FAST exam in haemodynamically stable patients presenting after blunt abdominal injury: a retrospective cohort study. (http://www.ncbi.nlm.nih.gov/pubmed/28049498) Radiology for trauma and the general surgeon. (http://www.ncbi.nlm.nih.gov/pubmed/28958364)

A 19-Year-Old Man Is Brought to the Emergency Department by Ambulance