What's the next step for a patient with persistent hypotension despite 1L of crystalloids, who was involved in a motor vehicle crash, has a Glasgow Coma Scale (GCS) of 14, clear breath sounds, a soft non-tender abdomen with a negative Focused Assessment with Sonography for Trauma (FAST) exam, and is intoxicated?

Immediate CT Imaging to Identify Occult Bleeding Source

In a persistently hypotensive trauma patient despite 1L crystalloid resuscitation with negative FAST exam, the next step is immediate whole-body CT scan (if hemodynamically stable enough for transport) or direct transfer to the operating room for exploratory laparotomy if unstable. 1

Critical Decision Point: Hemodynamic Stability Assessment

The patient's persistent hypotension after 1L crystalloid indicates either:

• Ongoing hemorrhage from an occult source not detected by FAST
• Inadequate volume resuscitation (1L represents only partial initial resuscitation for a 70kg patient who requires ≥30 mL/kg = 2.1L minimum) 2

A negative FAST exam does NOT exclude significant intra-abdominal or retroperitoneal hemorrhage. FAST has limitations in detecting hollow viscus injuries, mesenteric injuries, and retroperitoneal bleeding. 1

Immediate Management Algorithm

Step 1: Continue Aggressive Fluid Resuscitation

• Administer additional crystalloid boluses immediately - the patient has received inadequate initial volume (only 1L vs. required 2.1L for 70kg patient) 2, 3
• Target at least 30 mL/kg total crystalloid within first 3 hours 2, 3
• Reassess hemodynamic response every 15-30 minutes: look for ≥10% increase in blood pressure, ≥10% reduction in heart rate, improved mental status, and improved peripheral perfusion 2

Step 2: Initiate Vasopressor Therapy

If hypotension persists despite adequate fluid challenge (after completing 30 mL/kg), immediately initiate norepinephrine targeting MAP ≥65 mmHg. 1, 2, 4

• Critical caveat: The FDA label states norepinephrine should NOT be given to patients hypotensive from blood volume deficits except as emergency measure to maintain coronary and cerebral perfusion until blood volume replacement completed 4
• However, in trauma with persistent hypotension after adequate crystalloid (30 mL/kg), vasopressor initiation is appropriate while continuing resuscitation 1, 5
• Norepinephrine dosing: Start 2-3 mL/min (8-12 mcg/min) of 4 mcg/mL solution, titrate to MAP ≥65 mmHg 4

Step 3: Definitive Imaging vs. Surgery Decision

If patient can be stabilized to MAP ≥65 mmHg with fluids ± vasopressors:

• Proceed immediately to whole-body MSCT (multi-slice CT) with IV contrast 1
• CT will identify occult sources: retroperitoneal hemorrhage, solid organ injuries with contained hematomas, pelvic fractures with bleeding, mesenteric injuries 1
• Do NOT transport to CT if patient cannot maintain MAP ≥65 mmHg despite vasopressors - this indicates need for immediate surgical hemorrhage control 1

If patient remains hypotensive (SBP <90 mmHg or MAP <65 mmHg) despite completing 30 mL/kg crystalloid AND vasopressor initiation:

• Transfer directly to operating room for exploratory laparotomy 1
• "Correction of major hemorrhage takes precedence over transfer" to imaging 1
• Persistent hypotension despite resuscitation indicates uncontrolled hemorrhage requiring surgical intervention 1

Special Considerations for This Patient

GCS 14 with Intoxication

• Maintain MAP ≥65 mmHg minimum - do NOT pursue permissive hypotension strategy 1
• The altered mental status (GCS 14) may represent traumatic brain injury, and hypotension will worsen neurological outcomes 1
• "Low volume approach in hypotensive patients is contraindicated in TBI" 1

Negative FAST Limitations

• FAST sensitivity is excellent for free fluid in hypotensive patients (near 100%), BUT it cannot detect: 1
  • Retroperitoneal hemorrhage
  • Contained solid organ hematomas
  • Mesenteric injuries
  • Hollow viscus injuries
• CT is mandatory if patient can be stabilized 1

Clear Breath Sounds and Soft Abdomen

• These findings do NOT exclude life-threatening hemorrhage 1
• Retroperitoneal bleeding, pelvic fractures, and contained solid organ injuries may present without peritoneal signs 1

Common Pitfalls to Avoid

1. Stopping resuscitation at 1L crystalloid - this is inadequate initial volume 2, 3
2. Delaying vasopressors - if hypotension persists after adequate fluid challenge, vasopressors prevent ongoing hypoperfusion and worsening coagulopathy 1, 5
3. Transporting unstable patient to CT - if MAP cannot be maintained ≥65 mmHg, patient needs OR not imaging 1
4. Trusting negative FAST alone - CT is required to exclude occult hemorrhage sources 1
5. Pursuing permissive hypotension in head injury - maintain adequate MAP for cerebral perfusion 1