A 19-year-old man is brought to the emergency department by ambulance after a motor vehicle collision. The accident occurred 1 hour ago when his vehicle spun out of control and rolled over. He was wearing his seatbelt, and his airbag deployed. The patient is alert and reports abdominal pain. His vital signs are as follows: blood pressure is 110/70 mm Hg, pulse is 106/min, and respirations are 16/min. On examination, the lungs are clear to auscultation bilaterally, and the chest wall is non-tender. Heart sounds are normal. The abdomen is non-distended with tenderness to palpation in the left upper quadrant. There are no gross deformities of the extremities. A FAST examination reveals free fluid in the left subphrenic space.

Which of the following is the best next step in management?

A. CT scan of the abdomen and pelvis
B. Diagnostic peritoneal lavage
C. Exploratory laparotomy
D. No additional workup
E. Serial abdominal examinations

Answer:
A. CT scan of the abdomen and pelvis

🧠 Motor Vehicle Collision (MVC)
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Blunt Abdominal Trauma (Seatbelt and Airbag deployment provide some protection but do not eliminate risk)
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Trauma to Abdominal Organs
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Potential Injury to Solid Organs (Spleen, Liver) (Common in left upper quadrant trauma)
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🧠 Spleen Injury (most likely in left upper quadrant trauma)
↓
Hemorrhage and Free Fluid Formation (due to spleen laceration or rupture)
↓
🧠 Free Fluid in the Abdomen
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Positive FAST Exam (reveals free fluid in the left subphrenic space)

↓
Hemodynamic Stability (Blood pressure 110/70 mm Hg, pulse 106/min – stable but elevated due to pain or initial blood loss)
↓
Localized Tenderness (Left upper quadrant – spleen trauma or contusion)
↓
Normal Lung Examination (No pneumothorax, no rib fractures)
↓
🧠 Management Options:

A. CT Scan of the Abdomen and Pelvis
↓
🧠 CT Imaging provides detailed assessment of abdominal organs
↓
Detects Spleen/Liver Injuries and Severity
↓
Helps Guide Management (Conservative vs. Surgery depending on severity of injury)

B. Diagnostic Peritoneal Lavage (DPL)
↓
🧠 DPL used less commonly now with the availability of FAST and CT
↓
Invasive and less specific than CT
↓
Not indicated unless a CT is unavailable and the patient is unstable

C. Exploratory Laparotomy
↓
🧠 Laparotomy is invasive and performed for large, life-threatening injuries
↓
Not indicated in stable patients with no clear signs of need for immediate surgery (eg, hemodynamic instability, obvious peritonitis)

D. No Additional Workup
↓
🧠 Free Fluid on FAST suggests a need for further imaging (CT) to assess the extent of injury
↓
Not enough information to avoid imaging

E. Serial Abdominal Examinations
↓
🧠 Serial exams are useful, but the presence of free fluid on FAST warrants more definitive imaging like CT
↓
Not sufficient for accurate diagnosis in this scenario

Flashcards

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