Question

A 33-year-old man presents to the emergency department after he is found passed out next to his car. The patient's car was found rammed into a telephone pole. The patient was found napping outside of his car on a bench nearby. Upon arrival, the patient is too intoxicated to offer a useful history. His past medical history is notable for alcohol and IV drug abuse. His temperature is 97.6°F (36.4°C), blood pressure is 124/94 mmHg, pulse is 105/min, respirations are 12/min, and oxygen saturation is 98% on room air. The patient has a Glasgow coma scale of 12 and is not intubated. He is observed in the emergency department with a plan for discharge when clinically sober. The patient is evaluated 7 hours later, and his heart rate is 130/min and blood pressure is 95/60 mmHg. The finding in Figure A is present. He appears obtunded and only arouses to sternal rub. Which of the following is the most appropriate next step in management?

a. CBC
b. CT abdomen/pelvis
c. Exploratory laparotomy
d. Focused assessment with sonography in trauma (FAST) exam
e. Observation and serial abdominal exams

Answer 1

Given the patient's decreasing blood pressure, increased heart rate, and obtunded mental state, immediate medical intervention, including resuscitative measures and potentially exploratory laparotomy, must be considered over simple observation and serial exams.

Step-by-step explanation:

The scenario describes a man who has suffered a traumatic event and is showing signs of deteriorating health in the emergency department. Initially, he was found to be intoxicated and passed out after an accident involving his car. Over time, despite planning for discharge on clinical sobriety, his condition worsens with an increased heart rate and a decrease in blood pressure, coupled with obtundation. This change may suggest an underlying condition not initially apparent.

A blood pressure of 70/45 mmHg and symptoms of confusion and thirst are often indicative of hypovolemia, which could be due to internal bleeding. The emergency department aims to quickly assess and treat such emergent conditions. For example, when a patient presents with a suspected stroke, a rapid neurological examination is imperative to guide further diagnostic steps and management, as with the use of aspirin therapy to prevent clot formation.

Given the patient's worsening vital signs and mental status, observation and serial abdominal exams may no longer be sufficient. Immediate resuscitative measures and a diagnostic workup, including imaging and laboratory tests, are warranted. If these suggest intra-abdominal hemorrhage or other surgical pathology, an exploratory laparotomy might be essential to identify and treat the source of bleeding or injury.

Controlled hypothermia in the emergency department is employed following cardiac arrest to reduce heart damage. This practice reflects the critical, time-sensitive interventions that emergency medicine physicians have at their disposal to manage life-threatening conditions.