This patient is presenting with stable vitals following a motor vehicle accident. Since this patient is hemodynamically stable but cannot cooperate with an exam, the best next step is an abdominal CT.
This patient’s motor vehicle accident (MVA) is considered a blunt mechanism of injury. Since this patient has an unremarkable head CT and is moving all extremities spontaneously, it is most likely that his injury, if present, is localized to the abdomen. In blunt abdominal trauma, the next step in management depends upon whether the patient is hemodynamically stable. With a normotensive blood pressure and pulse within the normal range, this patient would be considered hemodynamically stable enough to undergo imaging to evaluate for injury to the abdominal organs. Because the patient cannot cooperate with an exam due to his intoxication, the best diagnostic test is an abdominal CT. If the patient were alert and cooperative, the best test would be a bedside ultrasound known as the FAST exam. If the patient had been hemodynamically unstable, the best test would be a FAST exam if the patient could cooperate, or a diagnostic peritoneal lavage if unable to cooperate.
Figure A demonstrates a brain CT without any acute abnormalities.
Answer 1: Chest radiograph has limited utility in the setting of blunt abdominal trauma and is not routinely performed. However, findings on chest radiograph could suggest abdominal injury, such as lower rib fractures or free air under the diaphragm, which would suggest intestinal perforation.
Answer 2: FAST exam would be the diagnostic test of choice in patients able to cooperate with the exam.
Answer 4: Diagnostic peritoneal lavage is typically used in patients who are hemodynamically unstable.
Answer 5: Diagnostic laparoscopy may play a role in evaluating for injury in penetrating traumas, such as gunshot wounds or stabbing wounds but would not be indicated as the best initial step in management in a stable patient.
In a patient who has experienced blunt abdominal trauma the best initial step in a stable patient is an abdominal CT scan and in an unstable patient who is able to cooperate (alert and non-intoxicated) is an ultrasound FAST exam.