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  #1  
Old 01-17-2013
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ER Stab wound to the left flank?

A 19-year-old woman was attacked while coming home from a party and is brought to the emergency department. She recalls being punched in the side of the head and stabbed in the left flank. Her speech is slow and she complains of a bad headache. Her pulse is 110/min, blood pressure is 90/50 mm Hg, and respiratory rate is 25/min. On examination she
has a stab wound at the left costal margin in the midaxillary line. Two large-bore intravenous lines are inserted, and after infusion of 2 L of lactated Ringer’s solution her blood pressure rises to 95/55 mm Hg. What is the most appropriate next step in management?

(A) Abdominal ultrasound
(B) Diagnostic peritoneal lavage
(C) Exploratory laparotomy
(D) Noncontrast CT of the head
(E) Peritoneal laparoscopy
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Old 01-17-2013
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Am thinkn about c
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Old 01-17-2013
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(A) Abdominal ultrasound..i don't think it has any value in penetrating injuries...more useful in Blunt Abd trauma
(B) Diagnostic peritoneal lavage...same reason as for abd USG
(C) Exploratory laparotomy....Hemodynamic Instabiity despite Fluid boluses...warrants Exploratory Laprotomy....and to add---she has penetrating wound injury, which is always treated by laparotomy
(D) Noncontrast CT of the head..bleeding in the head will not cause shock, so ruled out
(E) Peritoneal laparoscopy..useless in penetrating wounds
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Old 01-18-2013
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Default (C) Exploratory laparotomy

(C) Exploratory laparotomy
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Old 01-18-2013
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Quote:
Her speech is slow , and respiratory rate is 25/min.
(D) Noncontrast CT of the head

Since she might be having an ongoing intracranial bleed ( Punched in side of the head-->MMA) which is likely to lead to problems (coning) while under general aneasthetic once her BP is up.
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Last edited by Novobiocin; 01-18-2013 at 01:43 PM.
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Old 01-18-2013
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(C) Exploratory laparotomy.......stab wound with hemodynamically unstable.
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Old 01-18-2013
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Quote:
Originally Posted by aknz View Post
(C) Exploratory laparotomy.......stab wound with hemodynamically unstable.
Damn............I had an "overthought moment" there.
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Old 01-18-2013
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no significant change in bp after transfusing 2L of RL , we should look for the site of bleed.
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Quote:
Originally Posted by Novobiocin View Post
(D) Noncontrast CT of the head

Since she might be having an ongoing intracranial bleed ( Punched in side of the head-->MMA) which is likely to lead to problems (coning) while under general aneasthetic once her BP is up.
@novobiocin : intracranial bleed will not cause hypotension as it is a closed space. most likely the bleed is from the site of stab wound.
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Old 01-21-2013
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Dis is a NO-BRAINER ------Ex Lap
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