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  #1  
Old 04-30-2012
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Question trauma patient with hypotension and abdomen tenderness

A 36-year-old man is brought to the emergency department after being involved in a motor vehicle
collision. He is in obvious distress. His blood pressure is 80/30 mm Hg, pulse is 140/min and respirations
are 23/min. Examination reveals collapsed neck veins. Breath sounds are present bilaterally, heart sounds
are normal and the trachea is midline. He is semiconscious and his pupils are bilaterally reactive. There is
no obvious head injury. Abdominal examination shows distention with tenderness in all four quadrants with
guarding and rigidity. After initial resuscitation including control of his airway, breathing and circulation, which
of the following is the most appropriate next step in management?
A. Diagnostic laparoscopy
B. Chest x-ray
C. CT of the abdomen
D. Exploratory laparotomy
E. Diagnostic peritoneal lavage
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  #2  
Old 04-30-2012
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I would say D. EXPLORATORY LAP since the patient is unstable and presenting with guarding and rigidity (must think of perforation)
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Old 04-30-2012
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D. Exploratory laparotomy..is the answer.
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Old 04-30-2012
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-once resuscitation was done & circulation controlled, CT is appropriate
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Old 05-02-2012
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Answer is exploratory laparotomy because pt has developed signs of peritonitis.
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Old 05-02-2012
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E.) this patient is most likely bleeding in the abdomen and he is in acute distress. There is no time to do CT given his hemoddynamically unstable status. We can now do diagnostic peritoneal lavage or sonogram( Focused Abdominal Sonogram of Trauma). And if either of these tests are postive, we do exploratory laparotomy.

Please correct me if i am wrong.

Thank you!
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Old 05-02-2012
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• For hemodynamically unstable patients in whom blunt abdominal trauma is suspected, fluid resuscitation should be initiated, followed by FAST examination, If ultrasound reveals intraperitoneal blood, the patient should then undergo urgent laparotomy for surgical repair. If FAST is inconclusive, then diagnostic peritoneal lavage (DPL) IF no peritoneal signs.
• If the case dose's mention US after ABC, BUT the pt had Acute abdomen (guarding/rigidity/rebound tenderness) then go directly to laparotomy (don’t choose DPL; its obvious)
SO the ans is laparotomy

If the pt respond to fluid resuscitation, an Abdominal CT is the best next step to look for dense organ injury.
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Peritonitis( abdomen tenderness guarding and rigidity) increases mortality so do do exploratory laparotomy.
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Old 05-05-2012
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D ) Correct answer
In blunt trauma if the pt going into shock with no obvious external bleeding think of :-
(1) intra-abdominal bleeding (2) pelvic fracture or(3) femur fracture
In this scenario , Mention nothing about lower limb or pelvic injury so assume that not fractured . Plus pt developed abdominal distention , tenderness , guarding , and rigidity , So intra-abdominal bleeding is cause of shock in this pt , So put pt in NPO , NG suction , I.V fluid , I.V antibiotics , and prepare blood and go foreword for exploratory labrotomy bcz pt is shock.

C) CT scan is most accurate investigation to diagnose of intra-abdominal bleeding which is confirm presence and site of bleeding and allow decision of surgery or conservative management but it's only done in hemodynamically stable pt .

E) Diagnostic peritoneal lavage done in unconscious pt with suspected of intra-abdominal bleeding . Also can use sonogram

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Default D. Exploratory laparotomy

D. Exploratory laparotomy
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