## Management of Haemodynamically Unstable Patient with Positive FAST **Key Point:** In a haemodynamically unstable patient with a positive FAST examination, immediate operative intervention is indicated. Imaging delays are contraindicated in unstable trauma patients. ### Decision Algorithm for FAST-Positive Patients ```mermaid flowchart TD A[Blunt abdominal trauma + Positive FAST]:::outcome --> B{Haemodynamically stable?}:::decision B -->|Yes| C[CT abdomen/pelvis with contrast]:::action B -->|No| D[Haemodynamically unstable]:::urgent D --> E[Proceed to OR for exploratory laparotomy]:::action E --> F[Definitive surgical management]:::outcome ``` ### Rationale for Immediate Laparotomy **High-Yield:** A positive FAST examination in an unstable patient indicates intra-abdominal bleeding requiring urgent surgical control. Imaging studies (CT, ultrasound) delay definitive treatment and are contraindicated. **Clinical Pearl:** The ATLS principle is: "A positive FAST in an unstable patient = OR." Stability is the key discriminator: - **Unstable + Positive FAST** → Immediate laparotomy - **Stable + Positive FAST** → CT imaging for further characterization ### Why Imaging Is Contraindicated Here | Reason | Explanation | |--------|-------------| | Time-sensitive bleeding | Intra-abdominal bleeding from solid organ or vascular injury requires urgent surgical control | | Continued haemorrhage | Every minute in the OR increases survival; CT delays definitive haemostasis | | ATLS guideline | Unstable patients with positive FAST do not require confirmatory imaging | | Risk of deterioration | Transport to CT suite risks further decompensation | **Warning:** Do NOT delay laparotomy for imaging in an unstable patient. CT is appropriate only in haemodynamically stable patients to guide selective management (e.g., non-operative management of solid organ injuries). 
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