A 30-year-old motorcyclist is brought to the emergency department after a road traffic accident. He is haemodynamically unstable with a distended abdomen. FAST ultrasound shows free fluid in Morrison's pouch and the pelvis. Despite two large-bore IV lines and 1 L of crystalloid, his blood pressure remains 80/50 mmHg. What is the most appropriate next step?
- A CT abdomen and pelvis with contrast
- B Immediate exploratory laparotomy ✓
- C Diagnostic peritoneal lavage (DPL)
- D Further resuscitation with 2 more litres of crystalloid
Correct answer: B. Immediate exploratory laparotomy
Explanation
In haemodynamically unstable patients with a positive FAST (free intraperitoneal fluid indicating haemorrhage), the ATLS principle mandates immediate surgical intervention — exploratory laparotomy — without delay for CT scanning. CT is reserved for haemodynamically STABLE patients with suspected abdominal injury. Prolonged crystalloid resuscitation in haemorrhagic shock is harmful (dilutional coagulopathy, hypothermia). Damage control resuscitation principles (permissive hypotension, 1:1:1 blood product ratio) are applied en route to theatre.
Reference: Bailey & Love's Short Practice of Surgery, 27th ed.
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