A 28-year-old man is brought to the emergency department after a high-speed motor vehicle collision in which he was the restrained driver. The patient is awake and has left chest pain and vague abdominal discomfort. Blood pressure is 114/74 mm Hg and pulse is 112/min. Physical examination shows chest and abdominal ecchymoses and tenderness in the distribution of the seat belt. Breath sounds are equal bilaterally. Heart sounds are normal. The abdomen is mildly tender. Chest x-ray reveals a left sixth rib fracture without pneumothorax. Focused assessment with sonography is negative for free abdominal fluid. CT scan of the abdomen shows thickened proximal small bowel and a small mesenteric hematoma. The patient is hospitalized for monitoring and supportive care. Over the next 24 hours, he develops worsening abdominal pain, nausea, vomiting, and abdominal tenderness with guarding. Repeat CT scan of the abdomen is shown in the image below: Which of the following is the best next step in management of this patient?

Question

A 28-year-old man is brought to the emergency department after a high-speed motor vehicle collision in which he was the restrained driver.  The patient is awake and has left chest pain and vague abdominal discomfort.  Blood pressure is 114/74 mm Hg and pulse is 112/min.  Physical examination shows chest and abdominal ecchymoses and tenderness in the distribution of the seat belt.  Breath sounds are equal bilaterally.  Heart sounds are normal.  The abdomen is mildly tender.  Chest x-ray reveals a left sixth rib fracture without pneumothorax.  Focused assessment with sonography is negative for free abdominal fluid.  CT scan of the abdomen shows thickened proximal small bowel and a small mesenteric hematoma.  The patient is hospitalized for monitoring and supportive care.  Over the next 24 hours, he develops worsening abdominal pain, nausea, vomiting, and abdominal tenderness with guarding.  Repeat CT scan of the abdomen is shown in the image below:  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d8de_f5ae_bc81_0d115e819779_MD0003_00 This patient with blunt abdominal trauma (eg, ecchymoses and tenderness in a seatbelt distribution) from a motor vehicle collision has worsening abdominal pain and signs of peritoneal inflammation (eg, tenderness with guarding). Repeat abdominal CT scan reveals accumulation of a hepatic subcapsular hematoma and-most important-intraperitoneal free air. The free air establishes the diagnosis of perforated viscus, which warrants immediate surgical exploration (Choice B). Although gastrointestinal (GI) perforation is more frequently associated with penetrating abdominal trauma, it can also result from blunt abdominal trauma. Perforation may occur acutely (eg, during rapid compression of the GI tract that causes high intraluminal pressure) or in a delayed fashion (eg, several hours to days following trauma), as in this patient. Delayed perforation can be due to the following: Bowel contusion (eg, thickened [edematous] proximal small bowel on initial CT scan) progressing to full-thickness injury Injured mesenteric vasculature (eg, mesenteric hematoma on initial CT scan) progressing to ischemia and necrosis Many patients with bowel contusion or mesenteric hematoma do not need further intervention. However, an extended period of observation should be considered due to the risk of progression to perforation, as occurred in this patient. (Choice A) The role of diagnostic peritoneal lavage (DPL) has been largely reduced to evaluating for intraabdominal hemorrhage in hemodynamically unstable patients with questionable bedside ultrasound results. This patient has clear evidence of GI perforation, indicating the need for emergent surgical intervention rather than DPL. (Choice C) Mesenteric angiography can evaluate the blood supply to the small and large intestines in cases of suspected injury, occlusion, or bleeding. Although this patient may have had injury to his mesenteric vessels (eg, mesenteric hematoma) that led to necrosis and perforation, angiography should not delay surgical intervention once perforation is confirmed. (Choice E) An upper GI series uses contrast to outline the lumen of the upper GI tract and, depending on the exact location of this patient's perforation, may demonstrate contrast leaking through the perforation. However, this study is time-consuming (eg, time to drink contrast, time for contrast to pass through the GI system) and unnecessary because the diagnosis of perforation has already been established by CT scan. Educational objective: Blunt abdominal trauma can cause gastrointestinal perforation in an acute or a delayed (eg, progression of bowel contusion, mesenteric ischemia) fashion. Confirmation of perforation (eg, intraperitoneal free air on imaging) should prompt emergent surgical exploration. References: Blunt small bowel perforation (SBP): an Eastern Association for the Surgery of Trauma multicenter update 15 years later. (http://www.ncbi.nlm.nih.gov/pubmed/30633100) Delayed small bowel perforation following blunt abdominal trauma: a case report and review of the literature. (http://www.ncbi.nlm.nih.gov/pubmed/27016786)

A 28-Year-Old Man Is Brought to the Emergency Department After