A 28-year-old man is brought to the trauma bay following a stab wound to the left lower abdomen. On arrival, he is tachycardic (HR 118 bpm), hypotensive (BP 94/56 mmHg), and in severe pain. Abdominal examination reveals a stab wound with evisceration of small bowel. FAST examination shows free fluid in the pelvis and paracolic gutters. What is the most appropriate immediate management?

Explanation

## Clinical Context This patient has **clear indications for immediate operative intervention**: - **Haemodynamic instability** (hypotension, tachycardia) - **Peritoneal signs** (evisceration, severe pain) - **Positive FAST** (free fluid) - **Penetrating trauma** with visible bowel injury There is **no time for further imaging** in an unstable patient with obvious intra-abdominal injury. ## Indications for Immediate Laparotomy in Trauma | **Indication** | **Present in This Case?** | |---|---| | Haemodynamic instability (SBP < 100 mmHg, HR > 100) | ✓ Yes (BP 94/56, HR 118) | | Peritoneal signs (guarding, rigidity, rebound) | ✓ Yes (evisceration, severe pain) | | Positive FAST in unstable patient | ✓ Yes | | Penetrating trauma with evisceration | ✓ Yes | | Deteriorating clinical status | ✓ Yes | **Key Point:** In an **unstable patient with penetrating abdominal trauma and obvious intra-abdominal injury**, immediate laparotomy is **mandatory**. Delay for imaging is contraindicated and increases mortality. ## Why Immediate Laparotomy? **High-Yield:** The **MNEMONIC for immediate laparotomy indications is "STAB"**: - **S**hock / haemodynamic instability - **T**enderness with peritoneal signs - **A**bdominal distension - **B**lunt or penetrating trauma with positive FAST This patient meets **all criteria**. ## Penetrating vs. Blunt Trauma Management ```mermaid flowchart TD A[Abdominal trauma]:::outcome --> B{Penetrating or Blunt?}:::decision B -->|Penetrating| C{Haemodynamically stable?}:::decision B -->|Blunt| D{Haemodynamically stable?}:::decision C -->|No, unstable| E[Immediate laparotomy]:::urgent C -->|Yes, stable| F[CT or local wound exploration]:::action D -->|No, unstable| E D -->|Yes, stable| G[FAST + CT if indicated]:::action E --> H[Control bleeding, repair injury]:::action ``` **Clinical Pearl:** **Evisceration is an absolute indication for laparotomy**, regardless of haemodynamic status. Exposed bowel must be covered with sterile saline gauze, but operative intervention cannot be delayed. ## Why Not CT Imaging? CT imaging requires patient transport out of the operating theatre, delays definitive treatment, and is contraindicated in unstable patients. In penetrating trauma with haemodynamic instability and obvious intra-abdominal injury, the diagnosis is made clinically — imaging is unnecessary and dangerous. ## Why Not DPL? DPL is an obsolete procedure. It provides no additional diagnostic information beyond clinical examination and FAST in this case, and it delays operative intervention.