A 28-year-old woman is brought to the trauma bay after a fall from a 15-foot height. During the primary survey, she has a patent airway, adequate breathing, and a radial pulse. Blood pressure is 110/70 mmHg, heart rate 92/min. Abdominal examination reveals mild tenderness in the left upper quadrant with no guarding or rebound. There is no visible external bleeding. What is the most appropriate next step in the secondary survey?

Explanation

## Secondary Survey: FAST Examination in Trauma **Key Point:** In a hemodynamically stable patient with abdominal tenderness following significant blunt trauma, FAST (Focused Assessment with Sonography for Trauma) is the most appropriate **next step** during the secondary survey to rapidly evaluate for intra-abdominal free fluid (hemoperitoneum). **High-Yield:** Per ATLS 10th Edition, FAST is an adjunct to the primary and secondary survey. It is a rapid, bedside, non-invasive tool that can be performed concurrently with or immediately after the primary survey in any trauma patient — stable or unstable. In a stable patient with LUQ tenderness after a fall from height (high suspicion for splenic injury), FAST is the most appropriate immediate next step to guide further management. **FAST Windows:** - **Perihepatic (Morrison's pouch):** Right upper quadrant — hepatorenal space - **Perisplenic:** Left upper quadrant — splenorenal space - **Pelvic (pouch of Douglas / rectovesical):** Suprapubic view - **Pericardial:** Subxiphoid view for hemopericardium ### Decision Algorithm in Stable Blunt Abdominal Trauma ```mermaid flowchart TD A[Primary Survey Complete — Stable Patient]:::outcome A --> B[Secondary Survey begins]:::action B --> C[FAST examination]:::action C --> D{Free fluid detected?}:::decision D -->|Yes| E[CT Abdomen/Pelvis for characterization]:::action D -->|No| F[Continue systematic head-to-toe exam]:::action F --> G{High clinical suspicion persists?}:::decision G -->|Yes| H[CT Abdomen/Pelvis]:::action G -->|No| I[Observation and reassessment]:::action ``` **Why NOT the other options?** - **Option B (CT scan immediately):** CT is the gold standard for characterizing injuries in stable patients, but FAST is faster, bedside, and is performed first to guide the decision for CT. CT is not the immediate next step before FAST. - **Option C (Systematic head-to-toe examination):** While the full secondary survey is important, the clinical finding of LUQ tenderness in a patient who fell 15 feet mandates targeted evaluation of the abdomen (FAST) as the most appropriate *next* step, not deferral to a generic head-to-toe sequence. - **Option D (Diagnostic peritoneal lavage):** DPL is invasive and largely replaced by FAST and CT in modern trauma care. It is reserved for situations where FAST is unavailable or non-diagnostic. **Clinical Pearl:** FAST is an adjunct to — not a replacement for — the physical examination. A negative FAST does not exclude injury; if clinical suspicion remains high (as with LUQ tenderness after a significant fall), CT abdomen/pelvis should follow. The key distinction: FAST is the *immediate* bedside tool; CT is the definitive characterization tool. [cite: ATLS 10th Edition, Chapter 2: Patient Assessment; Chapter 5: Abdominal and Pelvic Trauma]