A 41-year-old man is admitted to the emergency room after being struck in the abdomen by a large cement plate while transporting it. On initial assessment by paramedics at the scene, his blood pressure was 110/80 mm Hg, heart rate 85/min, with no signs of respiratory distress. On admission, the patient is alert but in distress. He complains of severe, diffuse, abdominal pain and severe weakness. Vital signs are now: blood pressure 90/50 mm Hg, heart rate 96/min, respiratory rate 19/min, temperature 37.4℃ (99.3℉), and oxygen saturation of 95% on room air. His lungs are clear on auscultation. The cardiac exam is significant for a narrow pulse pressure. Abdominal examination reveals a large bruise over the epigastric and periumbilical regions. The abdomen is distended and there is diffuse tenderness to palpation with rebound and guarding, worst in the epigastric region. There is hyperresonance to percussion in the epigastric region and absence of hepatic dullness in the right upper quadrant. Aspiration of the nasogastric tube reveals bloody contents. Focused assessment with sonography for trauma (FAST) shows free fluid in the pelvic region. Evaluation of the perisplenic and perihepatic regions is impossible due to the presence of free air. Aggressive intravenous fluid resuscitation is administered but fails to improve upon the patient’s hemodynamics. Which of the following is the next best step in management?

Diagnostic peritoneal lavage (DPL)

A 34-year-old man is admitted to the emergency department after a motor vehicle accident in which he sustained blunt abdominal trauma. On admission, he is conscious, has a GCS score of 15, and has normal ventilation with no signs of airway obstruction. Vitals initially are blood pressure 95/65 mmHg, heart rate 87/min, respiratory rate 14/min, and oxygen saturation of 95% on room air. The physical exam is significant only for tenderness to palpation over the left flank. Noncontrast CT of the abdomen shows fractures of the 9th and 10th left ribs. Intravenous fluids are administered and the patient's blood pressure increases to 110/80 mm Hg. Three days later after admission, the patient suddenly complains of weakness and left upper quadrant (LUQ) pain. Vitals are blood pressure 80/50 mm Hg, heart rate 97/min, respiratory rate 18/min, temperature 36.2℃ (97.2℉) and oxygen saturation of 99% on room air. Prompt administration of 2L of IV fluids increases the blood pressure to 100/70 mm Hg. On physical exam, there is dullness to percussion and rebound tenderness with guarding in the LUQ. Bowel sounds are present. Raising the patient's left leg results in pain in his left shoulder. Stat hemoglobin level is 9.8 g/dL. Which of the following findings would be most likely seen if a CT scan were performed now?

Low-density areas within the splenic parenchyma

Subdiaphragmatic air collection

Heterogeneous parenchymal enhancement of the pancreatic tail

Herniation of the stomach into the thoracic cavity

Irregular linear areas of hypoattenuation in the liver parenchyma

A 24-year-old man is brought by ambulance to the emergency department after a motor vehicle accident. He was the front seat driver in a head on collision. He is currently unconscious. The patient’s past medical history is only notable for an allergy to amoxicillin as he developed a rash when it was given for a recent upper respiratory infection 1 week ago. Otherwise, he is a college student in good health. The patient is resuscitated. A FAST exam is notable for free fluid in Morrison’s pouch. An initial assessment demonstrates only minor bruises and scrapes on his body. After further resuscitation the patient becomes responsive and begins vomiting. Which of the following is the most likely diagnosis?

Rupture of the inferior vena cava

A previously healthy 27-year-old man is brought to the emergency department 35 minutes after being involved in a high-speed motor vehicle collision in which he was an unrestrained passenger. He was ambulatory at the accident scene, with stable vital signs and no major external injuries except abrasions to both upper extremities. On arrival, he is alert and oriented. His temperature is 37.3°C (99.1°F), pulse is 88/min, respirations are 14/min, and blood pressure is 128/74 mm Hg. Abdominal examination shows ecchymosis over the upper abdomen, with tenderness to palpation over the left upper quadrant. There is no guarding or rigidity. Rectal examination is unremarkable. A CT scan of the abdomen with intravenous contrast shows a subcapsular splenic hematoma comprising 8% of the surface area, with no contrast extravasation and minimal blood in the peritoneal cavity. Which of the following is the next best step in management?

Hospitalization and frequent ultrasounds

Discharge home and follow up closely

Coil embolization of short gastric vessels

Exploratory laparotomy and splenectomy

A 33-year-old man is brought to the emergency department because of trauma from a motor vehicle accident. His pulse is 122/min and rapid and thready, the blood pressure is 78/37 mm Hg, the respirations are 26/min, and the oxygen saturation is 90% on room air. On physical examination, the patient is drowsy, with cold and clammy skin. Abdominal examination shows ecchymoses in the right flank. The external genitalia are normal. No obvious external wounds are noted, and the rest of the systemic examination values are within normal limits. Blood is sent for laboratory testing and urinalysis shows 6 RBC/HPF. Hematocrit is 22% and serum creatinine is 1.1 mg/dL. Oxygen supplementation and IV fluid resuscitation are started immediately, but the hypotension persists. The focused assessment with sonography in trauma (FAST) examination shows a retroperitoneal fluid collection. What is the most appropriate next step in management?

Take the patient to the OR for an exploratory laparotomy

Perform an MRI scan of the abdomen and pelvis

CT of the abdomen and pelvis with contrast

Obtain a retrograde urethrogram

Perform a diagnostic peritoneal lavage

A 33-year-old man is brought to the emergency department 20 minutes after losing control over his bicycle and colliding with a parked car. The handlebar of the bicycle hit his lower abdomen. On arrival, he is alert and oriented. His pulse is 90/min, respirations are 17/min and blood pressure is 110/70 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 97%. The pupils are equal and reactive to light. There are multiple bruises over his chest and lower extremities. The lungs are clear to auscultation. Cardiac examination shows no abnormalities. The abdomen is soft and nontender. There is no pelvic instability. Rectal examination is unremarkable. A complete blood count, prothrombin time, and serum concentrations of glucose, creatinine, and electrolytes are within the reference range. Urine dipstick is mildly positive for blood. Microscopic examination of the urine shows 20 RBCs/hpf. Which of the following is the most appropriate next step in management?

CT scan of the abdomen and pelvis

Blunt abdominal trauma for USMLE Step 3: High-Yield Surgery Lessons

Initial Assessment - Gut Check Time

The primary survey (ABCDEs) is the mandatory first step. Before any imaging, the clinician must determine if immediate surgical intervention is required based on "hard signs." This assessment is a rapid, hands-on evaluation to catch critical injuries that cannot wait.

A: Airway, B: Breathing, C: Circulation: Is the patient hemodynamically stable? A systolic blood pressure of < 90 mmHg is a critical threshold indicating severe hemorrhage and the need for immediate action.
D: Disability & E: Exposure: A full-body examination is crucial. Look for signs of peritonitis (involuntary guarding, rebound tenderness) or evisceration, which are absolute indications for surgery.

⭐ Peritonitis in a patient with blunt abdominal trauma is a hard sign that mandates immediate exploratory laparotomy.

Diagnostic Workup - Picture This Trauma

FAST Exam (Focused Assessment with Sonography for Trauma): Initial test for unstable patients to rapidly detect hemoperitoneum (free fluid).
- Indications: Blunt or penetrating abdominal trauma, hypotension.
- 📌 Views: 'RUQ (Morison's pouch), LUQ (splenorenal), Pelvic (pouch of Douglas), Subxiphoid (pericardial)'.

LUQ FAST exam view with free fluid (spleen and kidney)

CT Scan with IV Contrast: Gold standard for hemodynamically stable patients. Accurately identifies specific organ injury, retroperitoneal hemorrhage, and quantifies bleeding.
Diagnostic Peritoneal Lavage (DPL): Invasive and largely historical. Considered only if FAST/CT are unavailable in an unstable patient.

⭐ The FAST exam is excellent for detecting hemoperitoneum but poor for retroperitoneal, diaphragmatic, or hollow viscus injuries.

Organ-Specific Injuries - The Damage Report

Spleen: Most commonly injured organ in blunt abdominal trauma.
Liver: Second most common.
Injury Grading: Standardized scales (AAST Grade I-V for spleen, I-VI for liver) assess severity and guide management.

Management Approach

Non-Operative Management (NOM): Preferred for many solid organ injuries. Key criteria include:
- Hemodynamic stability.
- No signs of peritonitis.
- Absence of other injuries requiring surgery.
Angioembolization: A key adjunct to NOM for patients with active arterial extravasation on CT scan but who are otherwise stable.
Surgery (Exploratory Laparotomy): Indicated for:
- Hemodynamic instability.
- Peritonitis.
- Failure of NOM/angioembolization.

⭐ Kehr's sign: Referred pain to the left shoulder due to phrenic nerve irritation from a splenic rupture. A classic exam finding.

CT: Splenic Laceration with Active Extravasation

High‑Yield Points - ⚡ Biggest Takeaways

The spleen is the most commonly injured organ in blunt abdominal trauma, followed by the liver.

In unstable patients, the eFAST exam is the primary diagnostic tool to assess for hemoperitoneum.

Hemodynamically stable patients should undergo a CT scan with IV contrast for accurate injury grading.

Non-operative management is the standard for most solid organ injuries in stable patients.

A "seatbelt sign" strongly suggests underlying hollow viscus or mesenteric injury.

Retroperitoneal injuries (e.g., pancreas, duodenum) can be occult on initial FAST scan.

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