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?
AIn accordance with the husband's wishes, do not transfuse any blood products
BObserve and reassess mental status in an hour to see if patient can consent for herself
CAttempt to contact the patient’s parents for additional collateral information
DConsult the hospital ethics committee
EAdminister blood products
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?
AEmergency laparoscopy
BAbdominal ultrasound
CDiagnostic peritoneal lavage (DPL)
DEmergency laparotomy
ECT scan
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?
AExploratory laparotomy
BDiagnostic peritoneal lavage
CCT scan of the abdomen and pelvis
DExploratory laparoscopy
EFAST exam
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