What is the best course of action for a patient in shock with tachycardia, hypotension, tachypnea, and hypoxemia after a road traffic accident (RTA) with no obvious external injuries and a normal chest examination?

From the Guidelines

The most appropriate action for this patient is option A, CT abdomen, as this patient presents with signs of shock (tachycardia with pulse of 130, hypotension with BP 90/70) and tachypnea (RR 30) following a road traffic accident (RTA), but with a normal chest examination and no obvious external injuries. The combination of shock without visible external trauma strongly suggests internal bleeding, with the abdomen being the most likely source given the normal chest exam. A CT abdomen would quickly identify intra-abdominal hemorrhage, solid organ injuries (liver, spleen), or hollow viscus injuries that require intervention, as recommended by the European guideline on management of major bleeding and coagulopathy following trauma: sixth edition 1.

While preparing for the CT, the patient should receive IV fluid resuscitation with a 0.9% NaCl or balanced crystalloid solution, as suggested by the guideline 1, and blood typing and cross-matching, and continuous monitoring. The guideline also recommends a restricted volume replacement strategy with a target systolic blood pressure of 80-90 mmHg until major bleeding has been stopped 1.

Exploration (option B) would be premature without diagnostic imaging to guide the intervention. Expectant management (option C) is inappropriate for an unstable trauma patient. Needle thoracotomy (option D) is not indicated since the chest exam is normal and there are no clinical signs of tension pneumothorax.

The patient's management should also consider the administration of tranexamic acid as soon as possible, as recommended by the guideline 1, to reduce the risk of bleeding. Additionally, the guideline suggests that damage-control surgery should be performed in the severely injured patient presenting with haemorrhagic shock, signs of ongoing bleeding, coagulopathy, vascular and pancreatic injuries 1.

In summary, the patient's presentation and the guideline recommendations support the use of CT abdomen as the most appropriate initial step in management, followed by targeted intervention based on the findings.

From the Research

Patient Assessment and Management

The patient is presenting with symptoms of shock, including tachycardia (pulse 130), hypotension (BP 90/70), tachypnea (RR 30), and decreased oxygen saturation (O2 sat 90), despite a normal chest examination and no obvious lacerations or bruises.

Diagnostic Considerations

Given the patient's presentation, it is essential to consider the possibility of internal injuries, particularly in the abdominal region. The studies suggest that computed tomography (CT) scans can be a valuable diagnostic tool in this scenario:

• A study published in the Japanese Journal of Radiology in 2014 2 highlights the importance of early recognition and prompt management of hypovolemic shock in patients with multiple injuries.
• Another study published in Abdominal Radiology in 2022 3 emphasizes the role of CT scans in identifying abdominopelvic hemorrhage and notes that CT is the best first-line imaging tool for detecting intra-abdominal bleeding.
• A review article published in the European Journal of Trauma and Emergency Surgery in 2022 4 concludes that multislice computed tomography (MSCT) has the highest sensitivity and specificity for detecting relevant intra-abdominal injuries in patients with blunt abdominal trauma.

Management Options

Based on the patient's presentation and the diagnostic considerations, the management options are:

• CT abdomen: This option is supported by the studies, which highlight the importance of CT scans in diagnosing internal injuries and guiding management decisions 2, 3, 4.
• Exploration: While exploration may be necessary in some cases, it is not the initial management step in this scenario, as the patient's presentation suggests the need for further diagnostic evaluation.
• Expectant management: This option is not appropriate, as the patient's symptoms suggest the need for prompt intervention.
• Needle thoracotomy: This option is not indicated, as the patient's presentation does not suggest a thoracic injury requiring immediate intervention.

Recommended Course of Action

Given the patient's presentation and the diagnostic considerations, the recommended course of action is to perform a CT abdomen to further evaluate the patient's condition and guide management decisions 2, 3, 4, 5, 6.