A 24-year-old man is brought to the emergency department after the all-terrain vehicle he was driving rolled over and landed on him. Blood pressure is 82/50 mm Hg, pulse is 128/min, and respirations are 24/min. The patient is alert but anxious and diaphoretic. He has a scalp laceration that has stopped bleeding. The pupils are equal and reactive to light. The trachea is midline. Bruising is present over the chest wall and abdomen. Breath sounds are present bilaterally. Heart sounds are normal. The abdomen is distended and has diffuse tenderness. Portable chest x-ray shows fracture of multiple ribs, including the right eighth and ninth ribs and the left fourth rib, with no pneumothorax. Focused Assessment with Sonography for Trauma shows no pericardial effusion but a large amount of intraperitoneal free fluid. Pelvic x-ray is negative for fractures. The patient remains hypotensive after the rapid infusion of 2 L of intravenous crystalloid and is taken for emergency exploratory laparotomy. Which of the following injuries is the most likely cause of this patient's persistent hypotension?

Question

A 24-year-old man is brought to the emergency department after the all-terrain vehicle he was driving rolled over and landed on him.  Blood pressure is 82/50 mm Hg, pulse is 128/min, and respirations are 24/min.  The patient is alert but anxious and diaphoretic.  He has a scalp laceration that has stopped bleeding.  The pupils are equal and reactive to light.  The trachea is midline.  Bruising is present over the chest wall and abdomen.  Breath sounds are present bilaterally.  Heart sounds are normal.  The abdomen is distended and has diffuse tenderness.  Portable chest x-ray shows fracture of multiple ribs, including the right eighth and ninth ribs and the left fourth rib, with no pneumothorax.  Focused Assessment with Sonography for Trauma shows no pericardial effusion but a large amount of intraperitoneal free fluid.  Pelvic x-ray is negative for fractures.  The patient remains hypotensive after the rapid infusion of 2 L of intravenous crystalloid and is taken for emergency exploratory laparotomy.  Which of the following injuries is the most likely cause of this patient's persistent hypotension?

Quizplus · Accepted Answer

11ec25c8_d8de_325c_bc81_99391480476e_MD0003_00 This patient with blunt abdominal trauma (BAT) has signs of hypovolemic shock (eg, severe hypotension, tachycardia) due to intraabdominal hemorrhage (eg, abdominal distension, intraperitoneal free fluid). Given the patient's concomitant fractures of the right lower ribs, which signal likely trauma of the right upper quadrant (RUQ), this presentation is most consistent with liver laceration. The liver is one of the most frequently injured organs in BAT, with the spectrum of injury ranging from subcapsular hematoma to parenchymal disruption (ie, laceration) causing bleeding into the peritoneum. Trauma to the RUQ, right lower rib cage (eg, right eighth and ninth ribs), or right flank should raise suspicion for hepatic injury. Triage of patients with BAT without frank peritonitis (eg, abdominal rigidity, rebound tenderness) includes bedside Focused Assessment with Sonography for Trauma (FAST) to assess for intraperitoneal free fluid, a marker of intraabdominal organ injury. As in this case, hemodynamically unstable (eg, systolic blood pressure <90 mm Hg) patients with a positive FAST should undergo exploratory laparotomy. Triage of patients with BAT (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. (Choices B and E) BAT can cause duodenal and splenic hematoma from intraluminal and subcapsular bleeding, respectively. However, because the bleeding is contained within the lumen or capsule, hematoma formation often tamponades further bleeding, making such a severe degree of shock (eg, unresponsive to 2 L of volume resuscitation) less common. In addition, neither type of hematoma would cause intraperitoneal free fluid. (Choice D) Pancreatic injuries can occur with BAT, especially when the pancreas is crushed against the vertebral column by an anterior blow to the central abdomen. However, because of its retroperitoneal location, even severe injuries to the pancreas (eg, transection with pancreatic fluid leakage) typically do not cause intraperitoneal free fluid. (Choice F) Urinary bladder rupture can occur from BAT, especially with pelvic fractures. Patients often have evidence of intraperitoneal free fluid (ie, urine) on FAST, but significant hemodynamic instability is uncommon. In addition, gross hematuria is typically present. Educational objective: The liver is one of the most commonly injured organs in blunt abdominal trauma. Patients with severe liver laceration causing intraabdominal hemorrhage may have shock and intraperitoneal free fluid on Focused Assessment with Sonography for Trauma. References: Management of blunt liver injury: what is new? (http://www.ncbi.nlm.nih.gov/pubmed/26038039) Western Trauma Association/critical decisions in trauma: operative management of adult blunt hepatic trauma. (http://www.ncbi.nlm.nih.gov/pubmed/21818009)

A 24-Year-Old Man Is Brought to the Emergency Department After