A 28-year-old woman is brought to the trauma bay after a stab wound to the right lower abdomen. She is restless, pale, and diaphoretic. Vital signs: BP 88/56 mmHg, HR 128/min, RR 24/min, SpO₂ 96% on supplemental oxygen. Abdominal examination reveals a single stab wound with minimal external bleeding, rigid abdomen, and severe tenderness. FAST examination shows free fluid in the right paracolic gutter and pelvis. What is the most appropriate immediate management?

Explanation

## Clinical Presentation Analysis This patient has **penetrating abdominal trauma (stab wound) with haemodynamic instability and peritoneal signs** — a surgical emergency requiring immediate operative intervention. ## Key Diagnostic Findings | Finding | Significance | |---------|-------------| | **Stab wound to lower abdomen** | Penetrating trauma; high risk of visceral injury | | **BP 88/56 mmHg** | Shock (Class III–IV haemorrhage) | | **HR 128/min** | Severe compensation; ongoing blood loss | | **Rigid abdomen** | Peritonitis; visceral perforation or bleeding | | **Positive FAST** | Confirms intra-abdominal bleeding | | **Restlessness, pallor, diaphoresis** | Signs of hypovolaemic shock | ## Penetrating Abdominal Trauma: Decision Algorithm ```mermaid flowchart TD A[Penetrating abdominal wound]:::outcome --> B{Haemodynamically stable?}:::decision B -->|No - Shock/unstable| C[Immediate laparotomy]:::urgent B -->|Yes - Stable vitals| D{Peritoneal signs?}:::decision D -->|Yes - Rigidity/tenderness| E[Exploratory laparotomy]:::urgent D -->|No - Soft abdomen| F[CT or local wound exploration]:::action C --> G[Resuscitate during transport]:::action E --> G G --> H[Operating theatre]:::urgent ``` ## Why Immediate Laparotomy Is Mandatory **High-Yield:** In penetrating abdominal trauma with **haemodynamic instability** OR **peritoneal signs**, laparotomy is indicated WITHOUT delay for imaging. Rationale: 1. **Shock indicates active bleeding** — CT delays life-saving surgery 2. **Rigid abdomen indicates visceral perforation** — requires urgent exploration 3. **Penetrating wounds have high injury rates** — 80–90% of stab wounds to the lower abdomen involve viscera 4. **Time is tissue** — every minute of delay increases mortality **Key Point:** Do NOT obtain CT in an unstable, peritonitic patient with penetrating trauma. This is a **Class I indication for immediate laparotomy** [cite:ATLS 10th Edition]. ## Resuscitation During Transport **Clinical Pearl:** Initiate **damage control resuscitation (DCR)**: - **Activate massive transfusion protocol** (2 units O-negative blood immediately) - **Permissive hypotension** — target SBP 80–90 mmHg until haemorrhage control in OR - **Avoid over-resuscitation** — increases bleeding and coagulopathy - **Notify OR and blood bank** — prepare for emergency surgery **Mnemonic: ABC + D** — **A**irway, **B**reathing, **C**irculation, **D**amage control (laparotomy). ## Why Other Options Are Incorrect ### Option B: CT Imaging **Warning:** CT is **contraindicated** in unstable patients. This patient: - Has SBP < 90 mmHg (shock) - Has peritoneal signs (rigid abdomen) - Requires immediate operative intervention CT delays definitive haemorrhage control and increases mortality. CT may be considered only in **stable patients** with penetrating wounds and equivocal findings. ### Option C: Diagnostic Peritoneal Lavage (DPL) **High-Yield:** DPL is **obsolete** in modern trauma: - Invasive and time-consuming - Positive in this patient (obvious from FAST + clinical signs) - Does NOT change management — laparotomy is already indicated - Delays operative intervention ### Option D: Observation and Serial Examination **Urgent:** This approach is **dangerous** and **contraindicated** in: - Haemodynamically unstable patients (shock) - Patients with peritoneal signs (rigid abdomen) - Penetrating abdominal trauma Observation is only appropriate for **stable patients with equivocal findings** (e.g., stab wound to flank with soft abdomen). This patient requires immediate surgery. ## Indications for Laparotomy in Penetrating Abdominal Trauma **Key Point:** Laparotomy is indicated if ANY of the following are present: 1. **Haemodynamic instability** (SBP < 90 mmHg despite resuscitation) 2. **Peritoneal signs** (rigidity, guarding, rebound tenderness, distension) 3. **Evisceration** (bowel or omentum protruding) 4. **Positive FAST** + unstable or peritonitic 5. **Penetrating wound** with trajectory suggesting peritoneal violation This patient meets criteria 1, 2, and 4 — laparotomy is non-negotiable. [cite:ATLS 10th Edition Chapter 5; Sabiston Textbook of Surgery 21e Chapter 19]