A 28-year-old woman is brought to the trauma bay after a stab wound to the right lower abdomen. On arrival: BP 88/54 mmHg, HR 138/min, RR 26/min, GCS 14. Physical examination shows a single stab wound with minimal bleeding, mild abdominal distension, and diffuse tenderness. A FAST scan is performed and shows free fluid in the right paracolic gutter and pelvis. After 2 liters of rapid crystalloid infusion, her BP is 90/56 mmHg and HR remains 136/min. What is the most appropriate next step?

Explanation

## Clinical Context This patient has a **penetrating abdominal trauma (stab wound)** with **hemodynamic instability** (BP 88/54 → 90/56 despite 2 L crystalloid, HR 138/min) and a **positive FAST examination**. ## Penetrating vs. Blunt Trauma: Different Management Paradigms | Trauma Type | Hemodynamically Stable | Hemodynamically Unstable | |-------------|------------------------|-------------------------| | **Blunt** | CT imaging + SNOM | Emergency laparotomy | | **Penetrating** (anterior abdomen) | Local wound exploration ± CT | **Emergency laparotomy** | | **Penetrating** (flank/back) | CT imaging | Emergency laparotomy if unstable | **Key Point:** In **penetrating abdominal trauma with hemodynamic instability**, the management is **emergency laparotomy**—not imaging. Imaging delays definitive hemorrhage control and increases mortality. **High-Yield:** The **"Shock triad" of penetrating trauma**: 1. Hypotension (BP < 90 mmHg) 2. Tachycardia (HR > 120/min) 3. Positive FAST **→ Mandates immediate operative intervention.** **Clinical Pearl:** Penetrating anterior abdominal wounds with peritoneal penetration require laparotomy. This patient has: - Hemodynamic instability despite resuscitation ("non-responder") - Positive FAST (free fluid) - Abdominal tenderness and distension - No time for CT—risk of exsanguination during imaging ## Why Laparotomy Now - Ongoing hemorrhage from solid organ or vascular injury - Possible hollow viscus injury with peritonitis - Failure to respond to fluids = surgical emergency [cite:ATLS 10th Edition Ch 5; Sabiston Textbook of Surgery 21e Ch 19]