Question Of The Day #64

This patient arrives in the Emergency Department after an assault and has pallor (paleness), hypotension, and tachycardia on exam.  The first step in evaluating any trauma patient involves the primary survey.  The primary survey is also known as the “ABCDEFs” of trauma.  This stands for Airway, Breathing, Circulation, Disability, Exposure, and FAST exam (Focused Assessment with Sonography in Trauma).  Each letter should be assessed in alphabetical order to avoid missing a time sensitive life-threatening condition.  The primary survey should be conducted prior to taking a full history.  After the primary survey, a more detailed physical exam (secondary survey) is conducted, followed by interventions and a focused patient history. 

The FAST exam is a quick sonographic exam that requires the practitioner to look at 4 anatomical areas for signs of internal injuries.  The 4 areas are the right upper abdominal quadrant, left upper abdominal quadrant, pelvis, and subxiphoid (cardiac) areas.  The addition of views for each lung (1 view for each lung) is known as an E-FAST, or extended FAST exam.  The presence of an anechoic (black) stripe on ultrasound indicates the presence of free fluid.  In the setting of trauma, free fluid is assumed to be blood.  The presence of free fluid on a FAST exam is considered a “positive FAST exam”.   This patient has free fluid between the left kidney and spleen in combination with hypotension and tachycardia.  This patient is in hemorrhagic shock until proven otherwise and needs prompt operative management.  See labelling of the FAST exam image below.

A CT scan of the chest, abdomen, and pelvis (Choice A) and a CT scan of the head (Choice C) may be helpful in the evaluation of this patient, but this patient is hemodynamically unstable.  Radiographic tests that require the patient to leave the Emergency Department should be avoided if the patient is unstable.  The specific location or cause of the hemodynamic instability can be diagnosed in the operating theater where there are opportunities to control the intraperitoneal bleeding (i.e., splenectomy, vessel ligation or cautery, etc.).  Bedside diagnostic peritoneal lavage (Choice D) is not indicated in penetrating abdominal trauma when there is a negative FAST exam and CT scanning is available.  This patient sustained blunt abdominal trauma, so a DPL is less informative.  The best next step for this patient is exploratory laparotomy (Choice B) in the operating theater.  Hemodynamically unstable patients with a positive FAST exam should always go to the operating theater for further diagnosis and treatment.  See the algorithm below for further detail.