Blunt Abdominal Trauma With a Blush and a Positive FAST: Cutting or Scanning?

The decision turns on physiology, not anatomy. This patient has a base deficit of −11 mmol/L, lactate 7.4 mmol/L, hypothermia, a coagulopathy (INR 1.6) and persistent hypotension after 2 units of red cells - the lethal triad is already established, and he is a non-responder to resuscitation. In that state, CT adds time and removes monitoring and resuscitation capability from a patient who is minutes from arrest; the only acceptable destination is the operating theatre for a damage-control laparotomy. The local constraints reinforce the principle: no rapid infuser and a suite 40 metres away make a CT round-trip physiologically expensive.

Priorities, in order:

• Activate the massive transfusion protocol, and give balanced components rather than more crystalloid; use the remaining O-negative units now.
• Give tranexamic acid 1 g within the 3-hour window, warm the patient actively, and correct ionised calcium with the first units of blood.
• Permit systolic pressures around 80–90 mmHg until haemorrhage is controlled, accepting that this is inappropriate if there is a concomitant brain injury.
• Re-check the pelvic binder, document a rapid secondary survey (chest, pelvis, long bones, back), and notify theatre and anaesthesia.
• Consent is by emergency necessity; document the discussion with any available relative and the reasoning.

CT is reserved for patients who are haemodynamically stable or who respond transiently and can be monitored during transfer.

Sequence:

1. Rapid midline incision, evisceration, and four-quadrant packing to slow bleeding; suction to improve visibility.
2. Systematic clot removal: liver first (perihepatic packing, Pringle manoeuvre if bleeding seems hepatic), then spleen, then retroperitoneum/pelvis. A pelvic haematoma that is not expanding and not pulsatile is packed and left alone; exploring it in the acute phase releases the tamponade.
3. Control named bleeding with ligation, repair or splenectomy; do not attempt complex vascular reconstruction if a shunt or ligation will save the patient.
4. Contamination control: staple or clamp bowel injuries, no anastomoses, no stomas, no time-consuming small-bowel resection unless a segment is clearly dead.
5. Temporary abdominal closure with a negative-pressure dressing.

Stopping rules: the endpoint is physiological, not anatomical. Stop when temperature is below about 35 °C, pH below 7.2, INR above 1.5 or fibrinogen below 1.5 g/L, or when the patient becomes vasopressor-dependent or shows diffuse non-surgical bleeding. Pack, close temporarily and move to ICU; the abdomen is a planned relook at 24–48 hours once the patient is warm, coagulopathy has been corrected and acidosis has cleared.

This is intra-abdominal hypertension progressing towards abdominal compartment syndrome: high airway pressures, oliguria despite adequate filling, and a rising lactate in the absence of new bleeding. Primary fascial closure now would be dangerous, regardless of how tidy the abdomen looks at relook.

Plan:

• Keep the abdomen open with a negative-pressure dressing, and perform only the surgery the patient needs at relook - re-packing, bowel viability review, definitive haemostasis - without attempting bowel anastomosis.
• Optimise before any closure attempt: adequate sedation and neuromuscular blockade, nasogastric decompression, drainage of any free fluid, cautious fluid removal if the patient is net positive, and avoidance of further over-resuscitation.
• Measure intra-abdominal pressure if a bladder catheter is available; define failure of medical management and a return to theatre for decompression.
• Reassess daily and attempt sequential fascial closure when the airway pressures, urine output and lactate normalise and the patient is no longer fluid-overloaded.
• Protect against enteroatmospheric fistula: keep the bowel covered, avoid exposing it to the dressing, start enteral nutrition early to maintain gut integrity, and anticipate a planned ventral hernia if closure is late.