A 24-year-old man is brought to the emergency department after being shot during a street fight. On the way to the hospital, the patient became obtunded and required intubation. He also received 2 L of normal saline. On arrival, blood pressure is 86/40 mm Hg and pulse is 130/min. The trachea is midline, and breath sounds are equal bilaterally. Heart sounds are normal. Two gunshot wounds are present: one in the left sixth intercostal space just lateral to the midclavicular line and another in the left seventh intercostal space posteriorly. Portable chest x-ray shows irregular opacities at the left lung base. Focused Assessment with Sonography for Trauma reveals no pericardial effusion and is equivocal for intraperitoneal free fluid. Transfusion of uncrossmatched blood is pending. Which of the following is the best next step in management of this patient?

Question

A 24-year-old man is brought to the emergency department after being shot during a street fight.  On the way to the hospital, the patient became obtunded and required intubation.  He also received 2 L of normal saline.  On arrival, blood pressure is 86/40 mm Hg and pulse is 130/min.  The trachea is midline, and breath sounds are equal bilaterally.  Heart sounds are normal.  Two gunshot wounds are present: one in the left sixth intercostal space just lateral to the midclavicular line and another in the left seventh intercostal space posteriorly.  Portable chest x-ray shows irregular opacities at the left lung base.  Focused Assessment with Sonography for Trauma reveals no pericardial effusion and is equivocal for intraperitoneal free fluid.  Transfusion of uncrossmatched blood is pending.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d912_12f0_bc81_b5675cc4f0b2_MD0003_00 This patient with gunshot wounds to the left thoracoabdominal region has shock (ie, severe hypotension and tachycardia) despite initial crystalloid resuscitation. Based on the location of his wounds (left sixth and seventh intercostal spaces), both intrathoracic and intraabdominal causes of shock should be investigated because the diaphragm and intraabdominal contents can rise as high as approximately the fourth thoracic dermatome (ie, nipple level) on expiration. In this patient, there is no evidence of cardiac tamponade (eg, no pericardial effusion) or hemothorax (eg, equal breath sounds, no pleural effusion), and the irregular opacities revealed on chest x-ray likely represent a pulmonary contusion that does not require immediate intervention. Given the absence of an intrathoracic source of shock, intraabdominal organ (eg, spleen) injury due to penetrating abdominal trauma (PAT) should be suspected. For patients with PAT, immediate exploratory laparotomy is indicated for: hemodynamic instability (systolic blood pressure <90 mm Hg). peritonitis (eg, rigidity, rebound tenderness). evisceration (ie, externally exposed intestines). Because this patient already has an indication for laparotomy, the abdominal portion of the Focused Assessment with Sonography for Trauma examination is not necessary as it does not change management. However, it is sometimes performed in practice (eg, immediately following the cardiac portion) because a positive result (ie, intraperitoneal free fluid) further confirms the need for laparotomy. (Choices A, B, and E) CT scan of the abdomen (commonly used, noninvasive) and diagnostic peritoneal lavage (rarely used, invasive) can help detect intraabdominal injury and determine the need for laparotomy in hemodynamically stable patients with PAT. Plain radiographs of the abdomen may help determine the trajectory and resting location of a bullet. However, this patient requires immediate laparotomy rather than additional imaging or testing because of hemodynamic instability. (Choice D) Local wound exploration to determine whether violation of the peritoneum has occurred is inappropriate in this patient with an indication for immediate exploratory laparotomy. In addition, this technique is rarely performed in patients with gunshot wounds (vs abdominal stab wounds) because tissue destruction makes following the wound tract difficult. Educational objective: Any penetrating wound below the fourth thoracic dermatome (ie, nipple level) can involve the intraabdominal organs. Patients with penetrating abdominal trauma and any of the following indications-hemodynamic instability, peritonitis, evisceration-should undergo immediate exploratory laparotomy. References: Evaluation and management of abdominal gunshot wounds: a Western Trauma Association critical decisions algorithm. (http://www.ncbi.nlm.nih.gov/pubmed/31233440) Management guidelines for penetrating abdominal trauma. (http://www.ncbi.nlm.nih.gov/pubmed/25315088)

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