What is the most appropriate management for a patient with diffuse abdominal tenderness, hypotension, tachycardia, and tachypnea following a motor vehicle collision?

Exploratory Laparotomy is the Most Appropriate Management

This patient requires immediate exploratory laparotomy based on the combination of diffuse abdominal tenderness, persistent hemodynamic instability despite fluid resuscitation, and a positive FAST exam indicating intra-abdominal hemorrhage. 1

Clinical Assessment

This patient presents in Class III hemorrhagic shock based on ATLS classification:

• Blood pressure 78/58 mmHg (decreased) after 2L crystalloid resuscitation
• Heart rate 118 bpm (>100)
• Respiratory rate 24 (20-30 range)
• Persistent hypotension despite adequate initial fluid resuscitation 1

The diffuse abdominal tenderness combined with hemodynamic instability following blunt trauma from a motor vehicle collision strongly suggests intra-abdominal hemorrhage as the source of shock. 1

Diagnostic Interpretation

The positive FAST exam showing free intra-abdominal fluid in a hemodynamically unstable patient is an absolute indication for urgent surgical intervention. 1

• FAST has high specificity (0.97-1.0) and accuracy (0.92-0.99) for detecting intra-abdominal free fluid in trauma patients 1
• Patients with significant free intra-abdominal fluid on FAST and hemodynamic instability require urgent surgery 1, 2
• Every 3-minute delay from FAST to laparotomy increases mortality by 1%, and every 10-minute delay from admission to laparotomy increases 24-hour mortality by a factor of 1.5 2

Why Not the Other Options?

Norepinephrine (Option B) is contraindicated as the primary intervention because:

• Blood volume depletion must be corrected as fully as possible before any vasopressor is administered 3
• This patient has ongoing hemorrhage requiring source control, not vasopressor support
• Vasopressors should only be used after fluid resuscitation and concurrently with definitive hemorrhage control 2, 3

Pericardiocentesis (Option C) would only be indicated if the FAST exam showed pericardial fluid with signs of cardiac tamponade, which is not described in this case. 4

Tube thoracostomy (Option D) would be appropriate for hemothorax, but the clinical presentation points to intra-abdominal hemorrhage as the primary source of shock given the diffuse abdominal tenderness and FAST findings. 4

Critical Management Principles

Time-sensitive surgical intervention is paramount:

• Patients presenting with hemorrhagic shock and identified intra-abdominal bleeding require immediate bleeding control procedures 1
• CT imaging should be avoided in unstable patients as it may delay definitive treatment by up to 90 minutes and increase mortality up to 70% 2
• The patient should proceed directly from the emergency department to the operating room 1, 2

Concurrent resuscitation measures while preparing for surgery:

• Continue large-bore IV crystalloid resuscitation targeting MAP ≥65 mmHg 2
• Activate massive transfusion protocol given Class III shock 2
• Vasopressors may be initiated if MAP cannot be maintained with fluids alone, but only as a bridge to definitive surgical control 2, 3