Oral Board Case: Blunt Abdominal Trauma

Walk me through your immediate priorities as this patient arrives.

Expected answer

I run the ATLS primary survey: secure the airway with C-spine protection, assess breathing, then circulation. I place two large-bore IVs, draw blood including type and cross, CBC, coags, and lactate, and begin balanced resuscitation. Given hypotension and tachycardia in a trauma patient, I treat hemorrhagic shock—activate massive transfusion protocol with PRBC and FFP rather than crystalloid, and notify the OR. I obtain adjuncts: chest x-ray, pelvic x-ray, and a FAST exam, performed concurrently with resuscitation, not sequentially.

Your FAST is positive for free fluid and the patient remains hypotensive despite blood products. What do you do?

Expected answer

A hemodynamically unstable patient with a positive FAST goes directly to the operating room for exploratory laparotomy. There is no role for CT scan in the unstable patient—obtaining a CT here would be a critical error. I continue the massive transfusion protocol en route and prepare for a damage-control approach.

Why not CT this patient first to localize the injury?

Expected answer

CT requires transporting an unstable patient out of a monitored resuscitation area and delays definitive hemorrhage control. In a patient in shock with a positive FAST, the source of bleeding is intra-abdominal until proven otherwise, and the operating room is both diagnostic and therapeutic. CT is reserved for the hemodynamically stable patient who can tolerate transport with physician escort.

What is your operative plan and how do you open?

Expected answer

Midline laparotomy from xiphoid to pubis. I pack all four quadrants to control hemorrhage and identify the source. I follow a systematic exploration: control bleeding first (spleen, liver, mesentery), then identify hollow viscus injury, then retroperitoneum as indicated. In a physiologically depleted patient I follow damage-control principles—control hemorrhage and contamination, place a temporary abdominal closure, and return after resuscitation in the ICU.

The lower abdominal bruising suggests a seatbelt sign. What injuries are you specifically worried about?

Expected answer

A seatbelt sign markedly raises concern for hollow viscus injury—small bowel and mesenteric tears, blowout injuries—and the lumbar Chance fracture. These injuries are frequently missed on initial FAST and even early CT. The seatbelt sign mandates a high index of suspicion, careful bowel run at laparotomy, and prolonged observation with serial exams if managed non-operatively.

Suppose instead the patient was stable and responded to resuscitation. How does management change?

Expected answer

A stable patient can be transported with physician escort to CT with arterial and delayed (portal venous/delayed) phases. If CT shows a solid organ injury with active arterial extravasation in a stable patient, I pursue angioembolization. If CT shows free fluid without solid organ injury, I observe with serial hematocrits and serial abdominal exams, with a low threshold for DPL/DPA or laparoscopy/laparotomy, because free fluid without solid organ injury in blunt trauma strongly suggests bowel or mesenteric injury.

You manage a stable splenic injury non-operatively with embolization. What goes into the observation plan and when do you abandon non-op management?

Expected answer

Admit to a monitored setting, serial hemoglobin/hematocrit, serial abdominal exams, bed rest, and frequent vitals. I convert to operative management for hemodynamic instability not responsive to resuscitation, ongoing transfusion requirement, or development of peritoneal signs. Failure of non-operative management in an unstable patient mandates laparotomy.

How does a positive versus negative DPL/DPA change your decision in the stable patient with free fluid and no solid organ injury?

Expected answer

A positive aspirate—gross blood, enteric contents, bile, or a lavage with elevated WBC/RBC counts—indicates significant intra-abdominal injury and the patient should go to laparotomy (or laparoscopy with low threshold to convert). A negative DPA/DPL in an otherwise stable, reassuring patient supports continued observation and potential discharge.

Intraoperatively you find a destructive segment of small bowel injury with the patient acidotic, hypothermic, and coagulopathic. What do you do?

Expected answer

This is the lethal triad—I commit to damage control. Resect the injured segment with a stapler, leave the bowel in discontinuity, control any other hemorrhage, place a temporary vacuum-assisted closure, and take the patient to the ICU to correct hypothermia, acidosis, and coagulopathy. I return to the OR in 24–48 hours for bowel reconstruction and definitive closure once physiology is restored.