robin082006
Forum Hero
Topics: 471
Posts: 5,125
|
A 43-year-old female is rescued from a car accident site. On arrival to the emergency room she has T: 95.6 F; PR: 150/min; RR: 24/min; BP: 70/0 mm Hg and JVP: 0 cm H2O. She is shivering and perspiring profusely. On abdominal examination she has mild distention but not tenderness. On further examination she also has a scalp laceration but no other signs of external bleeding. Her chest x-ray, x-ray of pelvis and x-ray of extremities are normal. Her airway is secured and she is given rapid intravenous isotonic fluid but she remains hypotensive. What would be the next step in management of this patient?
A. Do a diagnostic peritoneal lavage
B. Do a CT scan of abdomen
C. Do an exploratory laparotomy
D. Do a MRI of abdomen
E. Do a CT scan of head
___________________
The Key to Succeed is Patience.
|
| CocaCola
Forum Guru
Topics: 35
Posts: 908
|
c - explorotory laparotomy
Intracranial bleeding could not lead to massive blood loss like we see here, so can't be E... the patient is unstable and needs emergent care so rule out A, D, B
___________________
There is one thing we can do, and the happiest people are those who can do it to the limit of their ability. We can be completely present. We can be all here. We can give all our attention to the opportunity before us!!!
|
| sarika
Forum Guru
Topics: 195
Posts: 1,200
|
it can be A. Do a diagnostic peritoneal lavage it tells us rapidly if theres blood in peritoneum or not...which is all thats needed to preceed to laprotomy.
|
| Guptashutosh
Forum Elite
Topics: 35
Posts: 354
|
wel DPL wil only diagnose this condition, whereas laprotomy will be a therapeutic approach , we will not win by simply sorting out the cause of (impending) death we need to cure her and with such a situation where every second counts we shd not waste time in just diagnosing it , our approach shd be therapeutic..
|
| sarika
Forum Guru
Topics: 195
Posts: 1,200
|
there is no external bleeding, no signs of peritoneal irritation, and there is a possibility that she is bleeding elsewhere like pelvis. dpl can help us rule out intraabdominal bleeding.
|
| ed222
Forum Senior
Topics: 4
Posts: 147
|
car accident most likely rupture of the spleen. She did not fall to be suspicious of pelvis fracture. I think is C.
|
| chemamr
Moderator and PGY1
Topics: 703
Posts: 4,441
|
I think the answer is C.
pelvis was normal on XRs, so most likely source is abdominal, they could've done an abdom U/S or a CT if easily available and you don't lose much time doing it, but with this pt with these VS, not responding to IV fluids, I'd go for surgery.
___________________
Any time something is written against me, I not only share the sentiment but feel I could do the job far better myself.
|
| vanshita
Forum Guru
Topics: 21
Posts: 816
|
What right answer ? Robin
|
| anjushree
Forum Guru
Topics: 64
Posts: 386
|
i will go with A-----DPL will not take much time
|
| robin082006
Forum Hero
Topics: 471
Posts: 5,125
|
Answer is A as Sarika 's explannation.
___________________
The Key to Succeed is Patience.
|
| imgdig
Forum Newbie
Topics: 0
Posts: 7
|
In acute abdomen we go straigth to explore laparotomy even without the definite diagnosis because it is obvious that the pathology is there. in this case,it is only a hint that an intra abodominal bleeding is the cause of shock,patient being unstable, we can do DPL in the Or or ER simultaneous with resuscitation, then laparotomy.
|
| docnikki
Forum Guru
Topics: 93
Posts: 680
|
I agree too, Exploratory lap would have been answer if there were peritoneal signs of irritation or penetrating injuries to the abdomen.
here it will be USG or DPL.
|
| Diego Casali
Forum Elite
Topics: 7
Posts: 232
|
This patient remains hypotensive even with fluid resuscitation, so I would choose an exploratory laparotomy.
You can't do a DPL with such an instable patient: it would be a waste of time and the patient could die!
|
| gilbert
Forum Junior
Topics: 16
Posts: 45
|
Agree, C! Laparotomy for unstable patient.
|
| yu
Forum Junior
Topics: 2
Posts: 26
|
c
|
| damngood
Forum Newbie
Topics: 0
Posts: 79
|
major loss of bloodloss can occur either in the abdomen pelvis and lungs , lugs is ruled ou witha normal chest x ray
now we need to see if its frm abd or pelvis
soo doing a dpl would tell usif thereis bleeding in the abdomn soo its better we proceed that way
|
| ed222
Forum Senior
Topics: 4
Posts: 147
|
But blood pressure is 70/0. This is a sign of hypovolemia, a abdominal laparotomy will locate and solve the problem right away
|
| kotikoti
Forum Newbie
Topics: 3
Posts: 23
|
answer is C.
Indication for peritoneal lavage is a stable patient with abdominal pain. Prep for lavage will kill this patient
|
| chemamr
Moderator and PGY1
Topics: 703
Posts: 4,441
|
controversial, but maybe the best option and sort of consensus is surgery right away.
qbanks aren't always correct.
___________________
Any time something is written against me, I not only share the sentiment but feel I could do the job far better myself.
|
|
| |
| | | | | | | | | | | | | | | | | | | |
