Trauma: The Daily PANCE Blueprint
A 68-year-old woman is brought to the emergency department after being involved in a high-speed motor vehicle collision. According to the paramedics, the patient was a restrained driver. She has superficial lacerations on her arms and blunt force trauma to the chest and abdomen. She complains of diffuse abdominal pain but is alert and oriented. Blood pressure is 100/60 mm Hg, pulse is 110/min, and respirations are 22/min. Oxygen saturation is 98% on 40% oxygen via face mask. Examination shows bruising over the lower abdomen and tenderness to palpation without guarding or rebound. Lung fields are clear bilaterally. No murmurs or abnormal heart sounds are heard. Which of the following is the best next step in evaluation of this patient?
A. Plain abdominal radiograph
B. Focused Assessment with Sonography for Trauma (FAST)
C. Computed tomography (CT) scan of the abdomen and pelvis
D. Diagnostic peritoneal lavage
E. Exploratory laparotomy
Answer and topic summary
The answer is Focused Assessment with Sonography for Trauma (FAST)
The best next step in the evaluation of this patient is a Focused Assessment with Sonography for Trauma (FAST). The FAST exam is a rapid bedside ultrasound that is used to identify free fluid (likely blood) in the peritoneal, pericardial, or pleural cavities. It is particularly useful in hemodynamically unstable patients with blunt abdominal trauma to quickly assess for internal bleeding.
Incorrect Answer Explanations:
- A. Plain abdominal radiograph: Plain abdominal radiographs have limited utility in the acute setting of blunt abdominal trauma. They are not sensitive for detecting free fluid or organ injury.
- C. Computed tomography (CT) scan of the abdomen and pelvis: A CT scan is very useful for detailed evaluation of abdominal injuries but should be reserved for patients who are hemodynamically stable or after initial FAST exam if the patient remains stable.
- D. Diagnostic peritoneal lavage: Diagnostic peritoneal lavage is an invasive procedure used to detect intraperitoneal hemorrhage but has largely been replaced by the FAST exam in modern trauma assessment.
- E. Exploratory laparotomy: Exploratory laparotomy is indicated if there is evidence of significant intra-abdominal injury or ongoing hemorrhage, typically identified by FAST or CT scan findings. It is not the immediate next step in a hemodynamically stable patient without clear signs of peritonitis or hemorrhagic shock.
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