A 35-year-old woman with no significant past medical history is brought in by ambulance after a major motor vehicle collision. Temperature is 97.8 deg F (36.5 deg C), blood pressure is 76/40, pulse is 110/min, and respirations are 12/min. She arouses to painful stimuli and makes incomprehensible sounds, but is unable to answer questions. Her abdomen is distended and diffusely tender to palpation. Bedside ultrasound shows blood in the peritoneal cavity. Her husband rushes to the bedside and states she is a Jehovah’s Witness and will refuse blood products. No documentation of blood refusal is available for the patient. What is the most appropriate next step in management?

In accordance with the husband's wishes, do not transfuse any blood products

Observe and reassess mental status in an hour to see if patient can consent for herself

Attempt to contact the patient’s parents for additional collateral information

Consult the hospital ethics committee

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 27-year-old man presents to the emergency department after being stabbed. The patient was robbed at a local pizza parlor and was stabbed over 10 times with a large kitchen knife with an estimated 7 inch blade in the ventral abdomen. His temperature is 97.6°F (36.4°C), blood pressure is 74/54 mmHg, pulse is 180/min, respirations are 19/min, and oxygen saturation is 98% on room air. The patient is intubated and given blood products and vasopressors. Physical exam is notable for multiple stab wounds over the patient's abdomen inferior to the nipple line. Which of the following is the best next step in management?

CT scan of the abdomen and pelvis

A trauma 'huddle' is called. Morphine is administered for pain. Low-flow oxygen is begun. A traumatic diaphragmatic rupture is suspected. Infusion of 0.9% saline is begun. Which of the following is the most appropriate next step in management?

CT of the chest, abdomen, and pelvis

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 32-year-old man is brought to the emergency department after a skiing accident. The patient had been skiing down the mountain when he collided with another skier who had stopped suddenly in front of him. He is alert but complaining of pain in his chest and abdomen. He has a past medical history of intravenous drug use and peptic ulcer disease. He is a current smoker. His temperature is 97.4°F (36.3°C), blood pressure is 77/53 mmHg, pulse is 127/min, and respirations are 13/min. He has a GCS of 15 and bilateral shallow breath sounds. His abdomen is soft and distended with bruising over the epigastrium. He is moving all four extremities and has scattered lacerations on his face. His skin is cool and delayed capillary refill is present. Two large-bore IVs are placed in his antecubital fossa, and he is given 2L of normal saline. His FAST exam reveals fluid in Morison's pouch. Following the 2L normal saline, his temperature is 97.5°F (36.4°C), blood pressure is 97/62 mmHg, pulse is 115/min, and respirations are 12/min. Which of the following is the best next step in management?

Upper gastrointestinal endoscopy

A 17-year-old adolescent male is brought to the emergency department by fire and rescue after being struck by a moving vehicle. The patient reports that he was running through his neighborhood when a car struck him while turning right on a red light. He denies any loss of consciousness. His temperature is 99.0°F (37.2°C), blood pressure is 88/56 mmHg, pulse is 121/min, respirations are 12/min, and SpO2 is 95% on room air. The patient is alert and oriented to person, place and time and is complaining of pain in his abdomen. He has lacerations on his face and extremities. On cardiac exam, he is tachycardic with normal S1 and S2. His lungs are clear to auscultation bilaterally, and his abdomen is soft but diffusely tender to palpation. The patient tenses his abdomen when an abdominal exam is performed. Bowel sounds are present, and he is moving all 4 extremities spontaneously. His skin is cool with delayed capillary refill. After the primary survey, 2 large-bore IVs are placed, and the patient is given a bolus of 2 liters of normal saline. Which of the following is the best next step in management?

Focused Abdominal Sonography for Trauma (FAST) exam

A 35-year-old male is brought into the emergency department for a trauma emergency. The emergency medical services states that the patient was wounded with a knife on his upper left thigh near the inguinal ligament. Upon examination in the trauma bay, the patient is awake and alert. His physical exam and FAST exam is normal other than the knife wound. Large bore intravenous lines are inserted into the patient for access and fluids are being administered. Pressure on the knife wound is being held by one of the physicians with adequate control of the bleeding, but the physician notices the blood was previously extravasating in a pulsatile manner. His vitals are BP 100/50, HR 110, T 97.8, RR 22. What is the next best step for this patient?

Coagulation studies and blood typing/crossmatch

Tourniquet of proximal lower extremity

Penetrating abdominal trauma — USMLE Lesson

Initial Stab - Triage & Vitals

Primary Survey (ABCDEs): Airway, Breathing, Circulation, Disability, Exposure.
Assess Hemodynamic Status: The critical first decision point.
- Unstable: SBP < 90 mmHg, HR > 120 bpm, or altered mental status.
- Stable: Vitals within normal limits.

⭐ Any signs of peritonitis (rigidity, guarding), evisceration, or impalement mandate immediate surgical exploration, even in a hemodynamically stable patient.

The Scan Plan - Imaging & Workup

Initial Assessment: Unstable vitals, peritonitis, or evisceration? → Immediate Exploratory Laparotomy.
Stable Patient: Proceed with imaging.
- FAST Exam: Focused Assessment with Sonography for Trauma. Rapidly identifies free fluid (hemoperitoneum).
- CT Scan (IV Contrast): The gold standard in stable patients. Defines organ injury, trajectory, and retroperitoneal status.

⭐ A negative FAST exam does not rule out significant injury, especially to the retroperitoneum or hollow viscera. CT is superior for these cases.

Belly of the Beast - Management Decisions

Core Principle: Is the patient stable or unstable? This dictates the immediate next step.
Absolute Indications for Exploratory Laparotomy (Ex-Lap):
- Hemodynamic instability (SBP < 90 mmHg)
- Peritonitis (guarding, rebound tenderness)
- Evisceration of omentum or organs
- Positive FAST exam in an unstable patient
- Gunshot wound (most cases)

⭐ A negative FAST exam does not rule out retroperitoneal bleeding or hollow viscus injury. Consider a triple-contrast CT scan if suspicion remains high in a stable patient.

High‑Yield Points - ⚡ Biggest Takeaways

Hemodynamically unstable patients with penetrating abdominal trauma require immediate exploratory laparotomy.

Gunshot wounds to the abdomen are presumed to violate the peritoneum and mandate surgical exploration.

For stab wounds, management depends on stability. Unstable patients, or those with peritonitis or evisceration, need surgery.

The FAST exam is critical for rapidly identifying intraperitoneal hemorrhage.

Local wound exploration (LWE) can assess for fascial penetration in stable anterior stab wound patients.

Always suspect diaphragmatic injury in thoraco-abdominal penetrating trauma.

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