A 32-year-old man is brought to the emergency department following a motor vehicle collision. On arrival, his blood pressure is 88/56 mmHg, heart rate 128 bpm, respiratory rate 24/min, and GCS 14. Focused assessment with sonography for trauma (FAST) shows free fluid in the pelvis. After two large-bore IV lines are established and initial fluid resuscitation begun, what is the most appropriate next step in management?

Explanation

## Clinical Scenario Analysis This patient presents with **hemorrhagic shock (Class III)** secondary to blunt abdominal trauma with a **positive FAST scan** (free pelvic fluid). His hemodynamics — BP 88/56 mmHg, HR 128 bpm — indicate ongoing significant hemorrhage that has **not responded adequately to initial fluid resuscitation**. GCS 14 reflects mild neurological compromise consistent with shock. ## Rationale for Correct Answer **Key Point (ATLS 10th Edition):** A hemodynamically **unstable** trauma patient with a **positive FAST** is a candidate for **immediate operative intervention (exploratory laparotomy)**. CT scanning is contraindicated in the truly unstable patient because it delays definitive hemorrhage control and risks deterioration in the scanner. **High-Yield:** The ATLS algorithm is explicit: - **Hemodynamically stable + positive FAST → CT scan** for further characterization. - **Hemodynamically unstable + positive FAST → Operating room immediately** for exploratory laparotomy. A rapid **pelvic X-ray** (portable, done in the trauma bay) is appropriate to identify pelvic fractures — a major occult source of hemorrhage — and can be obtained without delaying OR transfer. ## Why the Other Options Are Incorrect - **Option B (O-negative blood + CT scan):** While early blood transfusion is correct, sending an unstable patient to CT is dangerous and contradicts ATLS guidelines. CT is reserved for hemodynamically stable patients. - **Option C (Crystalloid resuscitation alone):** Crystalloid-only resuscitation is outdated and harmful in hemorrhagic shock; it worsens the "lethal triad" (hypothermia, acidosis, coagulopathy). Blood products are required. - **Option D (DPL):** Diagnostic peritoneal lavage has been largely replaced by FAST in modern trauma care. It is rarely indicated when FAST is already positive and the patient is unstable. ## Summary | Hemodynamic Status | FAST Result | Next Step | |---|---|---| | Stable | Positive | CT Abdomen/Pelvis | | **Unstable** | **Positive** | **OR (Exploratory Laparotomy)** | | Unstable | Negative | Search for extra-abdominal source | **Clinical Pearl:** Blood products (O-negative PRBCs, FFP, platelets in 1:1:1 ratio per damage control resuscitation) should be initiated en route to the OR — this does not delay surgery and corrects coagulopathy simultaneously. [cite: ATLS 10th Edition, Chapter 3: Shock; Chapter 5: Abdominal and Pelvic Trauma]