A 34-Year-Old Man Is Brought to the Emergency Department After

question 434

Multiple Choice

A 34-year-old man is brought to the emergency department after a head-on motor vehicle collision.  On arrival, blood pressure is 78/40 mm Hg and pulse is 134/min.  On physical examination, the patient is alert but intoxicated.  Pupils are equal and reactive to light.  Ecchymosis in the distribution of a seat belt is present over the chest and abdominal wall.  The left chest wall is tender to palpation.  Breath sounds are equal bilaterally.  Heart sounds are normal.  The abdomen is distended and diffusely tender.  Portable chest x-ray reveals multiple left rib fractures without pneumothorax or effusion.  Cervical spine and pelvic radiographs are negative for fractures and dislocations.  Focused Assessment with Sonography for Trauma is negative for pericardial effusion but positive for free intraperitoneal fluid.  After rapid infusion of 2 L of intravenous crystalloid, blood pressure is 80/50 mm Hg and pulse is 118/min.  Transfusion of uncrossmatched blood is pending.  Which of the following is the best next step in management of this patient?

• A)Abdominal CT scan
• B)Contrast angiography
• C)Diagnostic peritoneal lavage
• D)Emergent laparotomy
• E)Vasopressor therapy

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