Immediate Laparotomy is Indicated
This patient requires immediate laparotomy based on hemodynamic instability (hypotension and tachycardia) combined with a seat belt sign and diffuse abdominal tenderness following blunt trauma. 1
Primary Decision Algorithm
Hemodynamic Status Determines Management
Patients presenting with hemorrhagic shock (BP 90/60, HR 120) and suspected intra-abdominal injury should proceed directly to trauma laparotomy without delay for additional imaging or diagnostic procedures 1
This patient meets Class III hemorrhagic shock criteria: systolic BP decreased, pulse >120, tachypnea (R=25), indicating 1,500-2,000 mL blood loss 1
Every 3 minutes spent in the emergency department equates to a 1% increased death probability in hemodynamically unstable trauma patients 1
The Seat Belt Sign is a Critical Red Flag
The presence of a seat belt mark across the abdomen creates a high index of suspicion for serious visceral injury and should prompt immediate surgical consideration in unstable patients 1
Seat belt injuries are associated with an 8-fold increase in intra-abdominal trauma requiring intervention (23% vs 3% in patients without seat belt marks) 2
The classic triad includes: seat belt marks, bowel perforations, and potential lumbar spine fractures 3
Why Other Options Are Incorrect
Chest Tube Placement (Option A)
- The lungs are clear on examination, and there is no clinical evidence of hemothorax or pneumothorax requiring chest tube placement 1
- The primary problem is intra-abdominal hemorrhage, not thoracic injury
Intubation (Option B)
- While respiratory rate is elevated (25/min), this represents compensatory tachypnea from shock, not primary respiratory failure 1
- Intubation may be needed during laparotomy but is not the next immediate step
- Delaying surgery for airway management without proceeding to the operating room increases mortality 1
Pericardiocentesis (Option D)
- There are no clinical signs of cardiac tamponade (Beck's triad: hypotension, muffled heart sounds, jugular venous distension)
- The mechanism and physical findings point to intra-abdominal injury, not pericardial injury 1
Critical Management Principles
Time-Critical Nature of Intervention
Patients who are hemodynamically decompensated should proceed directly to trauma laparotomy to stop major abdominal bleeding 1
The World Journal of Emergency Surgery explicitly states that haemodynamically unstable patients with suspected intra-abdominal injury require urgent surgery 1
FAST Examination Role
While FAST can identify free fluid, patients with hemodynamic instability and positive clinical findings should not be delayed for imaging 1
A hypotensive patient (systolic BP <90 mmHg) presenting with free intra-abdominal fluid on FAST is a candidate for immediate surgery 1
Seat Belt Injury Patterns
Bowel and mesenteric injuries are the predominant findings in patients with abdominal seat belt marks requiring laparotomy 4, 5, 2
These injuries may not manifest immediately with peritoneal signs, but hemodynamic instability indicates active hemorrhage requiring immediate intervention 1, 5
Patients with solid organ injuries associated with seat belt trauma tend to have higher mortality and require urgent intervention 5
Common Pitfalls to Avoid
Never delay laparotomy for CT imaging in hemodynamically unstable patients - this increases mortality significantly 1
Do not be falsely reassured by a normal initial hemoglobin (13 g/dL) - acute hemorrhage may not immediately reflect in hemoglobin levels due to lack of hemodilution 1
Do not assume the absence of peritoneal signs rules out significant injury - seat belt injuries can cause delayed presentation of bowel perforation, but active bleeding presents with shock 1, 4
The combination of hypotension, tachycardia, seat belt sign, and diffuse tenderness mandates immediate surgical exploration regardless of imaging findings 1