What is the next step in managing a patient with a shrapnel injury to the abdomen, presenting with hypotension, tachycardia, and abdominal pain?

Immediate Exploratory Laparotomy

This patient requires immediate exploratory laparotomy without delay for CT imaging—every minute counts, as mortality increases by 1% for every 3 minutes of delay in a hemodynamically unstable patient with penetrating abdominal trauma and large peritoneal effusion. 1

Clinical Reasoning

This 22-year-old presents with the classic triad mandating emergency surgery:

• Hemodynamic instability (BP 90/42, HR 135) despite 1L fluid resuscitation 1
• Penetrating abdominal trauma (shrapnel injury to right upper quadrant) 1
• Positive FAST examination showing large peritoneal effusion (free fluid) 1

Why Immediate Surgery is Critical

Time-dependent mortality: In patients with hemodynamic instability after penetrating abdominal trauma with large peritoneal effusion, every 10-minute delay from admission to laparotomy increases 24-hour mortality by a factor of 1.5 and in-hospital mortality by a factor of 1.4. 1 The probability of death increases approximately 1% for every 3 minutes spent in the emergency department before laparotomy. 2

CT scanning is contraindicated: Obtaining whole-body CT in this hemodynamically unstable patient with penetrating trauma would delay laparotomy by up to 90 minutes and may increase mortality up to 70%. 1 CT scanning is reserved exclusively for hemodynamically stable patients. 1

Surgical Approach Considerations

Damage control laparotomy should be strongly considered given the penetrating mechanism, hemodynamic instability, and likely need for massive transfusion (already received 1L crystalloid en route). 3 The initial operation should focus on:

• Control of hemorrhage
• Control of contamination
• Rapid abdominal packing if needed
• Abbreviated closure for ICU resuscitation 3

Non-therapeutic laparotomy risk is minimal: When systolic blood pressure is below 90 mmHg with positive FAST, the incidence of non-therapeutic laparotomy is only 2.6%, and no patient undergoes a pointless laparotomy under these conditions. 1

Critical Pitfalls to Avoid

• Do not obtain CT imaging in this hemodynamically unstable patient—transport directly to the operating room 1
• Do not delay for additional resuscitation—definitive hemorrhage control is the priority 1
• Do not assume tachycardia alone indicates the severity—35% of hypotensive trauma patients are not tachycardic, but this patient's combined hypotension and tachycardia indicates higher mortality risk (15% versus 2%) 4

Concurrent Resuscitation

While preparing for immediate laparotomy:

• Activate massive transfusion protocol 1
• Maintain permissive hypotension (avoid aggressive fluid resuscitation that delays surgery) 5
• Prepare for potential damage control sequence with planned return to OR after ICU resuscitation 3