A 35-year-old woman is brought to the trauma centre 45 minutes after a stab wound to the right upper quadrant. She is haemodynamically unstable with blood pressure 88/54 mmHg, heart rate 128 bpm, and respiratory rate 24/min. Physical examination reveals right upper quadrant tenderness with guarding and rebound. FAST scan shows free fluid in the right paracolic gutter and Morrison's pouch. The patient has received 2 units of O-negative blood and 1 litre of crystalloid, but remains hypotensive. What is the most appropriate next step in management?

Explanation

## Management of Penetrating Abdominal Trauma with Haemodynamic Instability ### Clinical Context: Indications for Immediate Laparotomy This patient meets multiple criteria for emergent surgical intervention: | Finding | Significance | |---------|-------------| | **Penetrating injury (stab)** | High risk of intra-abdominal organ injury | | **Haemodynamic instability** | SBP 88 mmHg despite 2 units PRBC + 1 L crystalloid | | **Peritoneal signs** | Guarding and rebound tenderness | | **FAST positive** | Free fluid in right paracolic gutter and Morrison's pouch | | **Persistent hypotension** | Failure to respond to initial resuscitation | **Key Point:** In penetrating abdominal trauma with haemodynamic instability and peritoneal signs, immediate exploratory laparotomy is the standard of care. Diagnostic imaging delays definitive haemorrhage control and increases mortality [cite:ATLS 10th Edition, Chapter 6]. ### Why Laparotomy Is Indicated NOW **High-Yield:** The "Unstable Penetrating Trauma" algorithm: ```mermaid flowchart TD A[Penetrating abdominal trauma]:::outcome --> B{Haemodynamically stable?}:::decision B -->|Yes| C{Peritoneal signs?}:::decision B -->|No| D[Immediate laparotomy]:::urgent C -->|Yes| E[Laparotomy]:::action C -->|No| F[Observe or selective imaging]:::action D --> G[Haemorrhage control + repair]:::action E --> G ``` This patient is **unstable** (SBP 88 despite resuscitation) → **Immediate laparotomy** is mandatory. ### Operative Goals 1. Identify and control bleeding (most common cause of preventable death) 2. Assess all four quadrants and retroperitoneum 3. Repair or resect injured organs 4. Prevent infection and secondary complications **Clinical Pearl:** In penetrating trauma, do NOT delay surgery for imaging. Imaging is appropriate only in haemodynamically stable patients with equivocal peritoneal signs (e.g., isolated flank wound, no free fluid on FAST). ### Why Other Options Are Wrong **Repeat FAST (Option A):** - FAST has already been performed and is positive - Repeating it wastes critical time - The patient is unstable and requires surgical intervention, not further diagnostic confirmation **Diagnostic Peritoneal Lavage (Option B):** - DPL is rarely used in modern trauma (FAST and CT have replaced it) - Even if performed, a positive result (blood, bile, bacteria) would mandate laparotomy — so it only delays surgery - This patient already has clinical and imaging evidence of peritoneal penetration **CT Angiography (Option D):** - CT is contraindicated in haemodynamically unstable patients - The patient cannot be transported safely to the CT scanner - Time spent on imaging delays haemorrhage control and increases mortality - Selective imaging is reserved for stable patients with isolated wounds and no peritoneal signs **Warning:** The "damage control" mindset applies here: in an unstable patient, the goal is rapid surgical haemorrhage control, not anatomical perfection. Definitive repair can occur after resuscitation and stabilization in the ICU.