This is a discussion of the algorithms and tactical decisions when you have a trauma patient with a positive FAST. In the podcast, we had a quasistable patient with a positive FAST and a severe pelvic fracture, head injury, and pulmonary contusion. How do you decide what decisions the FAST triggers and what should your reasoning be?
First, remember trauma patients have blood in their belly all the time and the vast majority of them do not go to the OR. In my practice, we admit around 75 blunt spleen injuries, and 90 blunt liver injuries a year, and only around 10% go to the operating immediately for hypotension. The remainder are treated with a non-operative protocol of bedrest and re-evaluation. Of those, around 93% are successfully managed without surgery. So just having fluid in your abdomen, which is what a positive FAST says, does not mean you need to get a laparotomy.
So who does or does not get a laparotomy? Keep in mind we are only talking blunt trauma, penetrating has different algorithms.
An unstable, or recurrently unstable patient with a positive FAST gets a laparotomy, in my opinion. These are patients who present with a SBP<90 who does not increase their BP with fluids (at least 2 liters) and/or blood. If that patient has a positive FAST, then you go to the OR hyperurgently (meaning right now). If that patient has focal neurologic signs, then you need to do your best to rule out a intracranial mass lesion with CT, but that needs to be an attending decision, and the patient needs to be alive (you have more options with a living patient). I once took a patient during residency in this situation to get a head CT with a clamp on their aorta. My attending was not amused. Having a clamp on your aorta is pretty much the definition of unstable, and they cant stop for a head CT. A recurrently unstable patient (or more commonly known as a transient responder) needs surgery. However, in that case, a head CT may be possible with vigorous blood resuscitation, but again, the patient needs to be alive enough to transport.
In this case, we have a quaistable patient (I know many of you have not heard these terms, and we may be the only ones using them). This is a patient with a stable BP, who requires ongoing resuscitation, but whose BP continues to rise and their perfusion improves. To us, this means the patient has bled considerably, but may have stopped, or has a bleed that is worsening when the BP exceeds a certain level. Thus, their perfusion never gets back to normal, but is not worsening. These patients usually have time for CT, but need to be watched like a hawk. We also feel better having big central access and an arterial line. If the patient begins to get unstable, they get pulled off the CT table and go to the OR.
The pelvic fracture adds a big wrinkle. We feel laparotomies are not good for a patient bleeding from pelvic fractures (the Denver group obviously disagrees). This could be a long argument, but I’ll skip it. read the literature and form your own opinion. In this case, you are quasistable with a head injury so you go to CT. You find hemoperitoneum, a minor liver injury, and a major LC3 pelvic fracture with an arterial blush. Angio can kill two birds with one stone in these patients, if you have good access to IR, and good interventionalists (which we have). They can control the pelvic bleeding, squirt theliver and take care of any arterial injuries there, and even squirt the aorta if you didnt have time for a CTA.
Once, again the Chief resident and the Attending should be no more than 20 meters from these patients at any time, and should always keep a close eye on the monitor. If they begin to crash, you may need a new plan. Remember, never let someone bleed to death when you could stop the bleeding in the OR, but also remember, some bleeding can only realistically be controlled by IR.
Add your opinions, nicely.