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General Surgery


Answer 4
  1. The patient requires an urgent laparotomy, with packing of the liver if further hemorrhaging occurs. The liver has low perfusion pressure; tight packing with laparotomy sponges will compress bleeding. In this hypothermic patient, a lengthy operation will further decrease the temperature. Laparotomy with packing, closing, and correction of coagulopathy is the safest course. Currently, diagnostic peritoneal lavage, abdominal ultrasonography, or computed tomography (CT) scan are used to assess intra-abdominal injury after blunt abdominal trauma. The CT scan showed the presence of free intra-abdominal air, indicating a perforated hollow viscus and requiring laparotomy. Serial laboratory or imaging studies are not indicated in this patient, because the presence of free air is a clear indication for surgery. In this patient, the hepatic injury is contained. Because the patient is hypothermic and thus coagulopathic, hepatic resection is not indicated. Results of a diagnostic peritoneal lavage would not alter this patient’s management, given the findings of the CT scan.

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