What are the next steps for a young to middle-aged adult with abdominal pain after a ski accident, with unknown medical history?

Management of Abdominal Pain After Ski Accident

A young to middle-aged adult with abdominal pain after a ski accident requires immediate assessment with FAST ultrasound to detect free intraperitoneal fluid, followed by contrast-enhanced CT scan if hemodynamically stable, or immediate laparotomy if unstable with positive FAST. 1

Immediate Assessment and Hemodynamic Status

The first priority is determining hemodynamic stability, as this dictates the entire management pathway:

• Check vital signs immediately: Systolic blood pressure <90 mmHg or signs of hemorrhagic shock (tachycardia, altered mental status, poor perfusion) indicate hemodynamic instability 1
• Perform FAST examination within 8-10 minutes of presentation to rapidly detect free intraperitoneal fluid, which has high specificity (0.97-1.0) for intra-abdominal injury 1
• Assess for peritoneal signs: Rigidity, guarding, rebound tenderness suggest hollow viscus injury or active bleeding requiring urgent intervention 1

Critical Time-Sensitive Decision Point

If the patient has positive FAST (free fluid) AND remains hemodynamically unstable despite initial fluid resuscitation, proceed directly to emergency laparotomy without CT scan. Every 3-minute delay increases mortality by 1%, and every 10-minute delay from admission to laparotomy increases 24-hour mortality by a factor of 1.5 1

Hemodynamically Stable Patients

For stable patients (systolic BP ≥90 mmHg with adequate response to fluids), obtain contrast-enhanced thoraco-abdominal CT scan as the definitive diagnostic study 1

• CT scan reduces mortality with an odds ratio of 0.75 compared to no CT, despite detecting more injuries that increase injury severity scores 1
• The radiation risk (10-15 mSv per exam) is far outweighed by mortality benefit: it takes 20-40 CT scans to save one life versus 322-1250 scans to cause one lethal cancer 1
• CT allows identification of specific organ injuries (spleen, liver, kidney) and guides non-operative management versus surgical intervention 1

Ski-Specific Injury Patterns

Skiing trauma presents two distinct patterns that influence management:

• High-speed collisions (with trees, lift towers, other skiers): Associated with multiple organ injuries, higher transfusion requirements, and lower organ salvage rates (17% splenic salvage) 2, 3
• Low-speed falls (mogul injuries, simple falls): May present with delayed symptoms, patients often ski down themselves, but can still have serious injuries with higher salvage potential (68% splenic salvage) 3
• Concomitant renal injuries occur in 56% of splenic injuries from skiing, higher than other trauma mechanisms—look for hematuria as a delayed presenting sign 3

Surgical Indications

Proceed to immediate laparotomy if any of the following are present:

• Hemodynamic instability (systolic BP <90 mmHg) with positive FAST showing large peritoneal effusion 1, 4
• Clinical peritonitis (rigid abdomen, severe tenderness) 1, 4
• Evisceration or penetrating injury 4
• Uncontrolled gastrointestinal bleeding 4
• Pneumoperitoneum on imaging 4

Damage control surgery principles apply for patients with hemorrhagic shock, hypothermia (<34°C), severe acidosis (pH <7.2), or coagulopathy—prioritize hemorrhage control and contamination control over definitive repair 1, 4

Non-Operative Management

For hemodynamically stable patients with solid organ injuries (spleen, liver, kidney) on CT without active extravasation, non-operative management with close ICU monitoring is appropriate 1

• Requires 24-hour ICU surveillance with serial hemoglobin checks and abdominal exams 1
• Angioembolization should be considered for contrast blush on CT or hemoglobin drop despite stability 1
• Systematic secondary CT scan guides decision for delayed intervention versus continued observation 1

Common Pitfalls to Avoid

• Do not delay laparotomy for CT scan in unstable patients—this increases mortality up to 70% in penetrating trauma and significantly in blunt trauma 1
• Do not dismiss patients who "skied down themselves"—they may have delayed presentation of serious splenic or renal injury, particularly if they develop hematuria 3
• Do not assume negative initial FAST rules out injury—FAST has low sensitivity (0.56-0.71) and may miss injuries; stable patients still need CT 1
• Monitor for delayed splenic rupture within first 3 weeks post-injury (incidence 0.2%), especially in patients discharged after initial negative workup 1

Initial Resuscitation Protocol

While diagnostic workup proceeds, initiate simultaneous resuscitation for any signs of shock:

• Establish large-bore IV access (two 18-gauge or larger) 4
• Begin blood product transfusion if systolic BP <90 mmHg or signs of hemorrhagic shock 4
• Prevent hypothermia with warmed fluids and external warming devices 4
• Correct coagulopathy early with tranexamic acid if within 3 hours of injury and evidence of significant bleeding 1

The key algorithmic decision is hemodynamic status: unstable with positive FAST → immediate laparotomy; stable → CT scan → selective non-operative management or delayed surgery based on findings. 1, 4