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 Trauma 2  



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Author16 Posts
  #1

A 36 year old man is brought to the ED after being involved in a mva. He is in obvious distress. His temp is normal. BP is 80/30, pulse is 140 rest is 23/min. Exan shows his JVP is diminished and neck veins are collapsed. Bilateral breath sounds are present, and heart sounds are normal. Trachea is central. He is semi-conscious. and his pupils are bilaterally reactive. He localizes pain and there is no obvious head injury. Abdominal exam shows distention with tenderness in all four quadrants with muscle guarding and rigidity. After initial resuscitation of the airway, breathing adn circulation, which of the following is the most appropriate next step in management?

A. Neck X-ray to R/O neck injury
B. CXR to R/O aortic rupture
C. CT of the abdomen
D. Exploratory laparotomy
E. Diagnostic peritoneal lavage







  #2

D. Exploratory laparotomy

peritoneal sign-->laparotomy


  #3

C


  #4

i think its d


  #5

me too think it is D.


  #6

D is right...

Blunt trauma to the abdomen and signs of peritoneal irritation gets an exp. lap.

he has these signs plus hypotension which is most likely due to intraperitoneal hemorrhage. An exp lap gives the best option to deal with the hemorrhage and to look for other intraabdominal injuries and repair them..

NOTE: if there were NO signs of peritoneal irritation, and just hemorrhagic shock or hypovolemic shock and abdom. bleed was suspected then the right answer would be DPL. Everyone agree?



  #7

nice explanation Dr virgo
GOOD LUCK


  #8

(D)


  #9

DrVirgo wrote:
D is right...

Blunt trauma to the abdomen and signs of peritoneal irritation gets an exp. lap.

he has these signs plus hypotension which is most likely due to intraperitoneal hemorrhage. An exp lap gives the best option to deal with the hemorrhage and to look for other intraabdominal injuries and repair them..

NOTE: if there were NO signs of peritoneal irritation, and just hemorrhagic shock or hypovolemic shock and abdom. bleed was suspected then the right answer would be DPL. Everyone agree?


And just to add: you would do CT of the abdomen if you suspect an abdominal bleed, and the patient is STABLE.





  #10

Since he'll need general anesthesia (intubation), wouldn't that warrant exclusion of cervical spine trauma? Just a thought.
However, I would pick laparotomy too.


  #11

unstable patient abdominal features
do a DPL
soo D is the right answer


  #12

sorry meant explo lap


  #13

Stable patients with inconclusive physical examination findings should undergo radiographic studies of the abdomen. DPL is indicated in blunt trauma as follows:
  • Patients with a spinal cord injury
  • Those with multiple injuries and unexplained shock

  • Obtunded patients with a possible abdominal injury

  • Intoxicated patients in whom abdominal injury is suggested

  • Patients with potential intra-abdominal injury who will undergo prolonged anesthesia for another procedure

An indication for immediate blood transfusion is hemodynamic instability despite the administration of 2 L of fluid to adult patients; this instability indicates ongoing blood loss. Indications for laparotomy in a patient with blunt abdominal injury include the following:
  • Signs of peritonitis
  • Uncontrolled shock or hemorrhage

  • Clinical deterioration during observation

  • Hemoperitoneum findings after FAST or DPL examinations

Finally, surgical intervention is indicated in patients with evidence of peritonitis based on physical examination findings.



  #14

Save life first,then when stable do the rest
agree laparatomy


  #15

Neck collar is not included in the answers, in which case I think that would be the number 1 priority.


  #16

and in regards to post number 6, abdominal bleed does cause peritoneal irritation and if there is no signs of peritoneal irritation, there I think is no intraabdominal bleed. (at least no intraperitoneal bleed, it can be though retroperitoneal bleed.)





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