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. This patient presents with signs of shock following a road traffic accident (RTA) with tachycardia (pulse 130), hypotension (BP 90/70), tachypnea (RR 30), and mild hypoxemia (O2 sat 90%), despite a normal chest examination and no obvious external injuries. These findings strongly suggest internal bleeding, most likely intra-abdominal hemorrhage. A CT abdomen would quickly identify the source of bleeding, such as liver, spleen, or mesenteric injuries, allowing for targeted intervention 1.

Some key points to consider in the management of this patient include:

• The patient's blood pressure is currently 90/70, which is within the target range of 80-90 mmHg recommended for the initial phase of trauma management without brain injury, as per the European guideline on management of bleeding and coagulopathy following major trauma 1.
• The use of CT scans in trauma patients is supported by the guideline, which recommends that CT scanners may replace conventional radiographic imaging techniques during the primary survey in selected centers 1.
• While echocardiography may be useful in patients with isolated chest trauma, hypotension, and tachycardia to exclude pericardial tamponade or tension pneumothorax, it is not the most appropriate initial step in this patient with suspected intra-abdominal hemorrhage 1.
• The patient should receive IV fluid resuscitation, oxygen supplementation, and close monitoring while being prepared for CT.
• Needle thoracotomy (option D) is not indicated without clinical evidence of tension pneumothorax.
• Exploration (option B) would be premature without identifying the bleeding source first.
• Expectant management (option C) is inappropriate for an unstable trauma patient showing signs of shock. The CT findings will guide subsequent management, which may include surgical intervention or angioembolization depending on the specific injuries identified.

From the Research

Assessment and Management of Shock

The patient's presentation with tachycardia (pulse 130), hypotension (BP 90/70), tachypnea (RR 30), and low oxygen saturation (O2 sat 90) suggests shock, which is a state of acute circulatory failure leading to decreased organ perfusion 2, 3, 4. The mechanisms of shock can be divided into four categories: hypovolemic, distributive, cardiogenic, and obstructive 2.

Determining the Cause of Shock

Given the patient's history of RTA (road traffic accident) and the absence of obvious lacerations or bruises, it is essential to consider the possibility of internal injuries leading to hypovolemic shock. The patient's normal chest examination does not rule out the possibility of abdominal or pelvic injuries.

Diagnostic Approach

• Laboratory testing, especially serum lactate levels, and imaging studies can help determine the cause of shock 2.
• A CT abdomen may be useful in identifying internal injuries or bleeding that could be causing hypovolemic shock 5.
• The presence of a flat inferior vena cava, diminished aortic caliber, or other signs of hypovolemic shock on CT can indicate the need for prompt intervention 5.

Management Options

• CT abdomen (A): May be useful in identifying internal injuries or bleeding, but should not delay resuscitation efforts.
• Exploration (B): May be necessary if there is suspicion of internal injury or bleeding, but should be based on clinical judgment and imaging findings.
• Expectant management (C): Not appropriate in this case, as the patient is showing signs of shock and requires prompt intervention.
• Needle thoracotomy (D): Not indicated, as there is no evidence of tension pneumothorax or other thoracic injury requiring immediate decompression.