Management of Hypotensive Patients with Severe Abdominal Pain

Diagnostic Approach

The American College of Surgeons recommends performing FAST (Focused Assessment with Sonography for Trauma) immediately in hypotensive patients with severe abdominal pain, as it takes 8-10 minutes and has near 100% sensitivity and specificity in detecting intra-abdominal bleeding 1, 2, 3
FAST is the preferred diagnostic tool over CT scan in unstable patients, as it is faster and more sensitive, and CT scan may delay definitive treatment by up to 90 minutes and increase mortality up to 70% 3, 4

The European and American guidelines recommend immediate laparotomy in patients with positive FAST results and hypotension, as this indicates a high likelihood of intra-abdominal catastrophe requiring urgent surgical intervention 1, 3, 6
Every 3-minute delay from FAST to laparotomy increases mortality by 1%, and every 10-minute delay from admission to laparotomy increases 24-hour mortality by a factor of 1.5 and in-hospital mortality by 1.4 3, 5, 7

The American College of Surgeons recommends maintaining large-bore IV access with rapid crystalloid administration targeting mean arterial pressure ≥ 65 mmHg, and initiating vasopressor support with norepinephrine if fluid resuscitation is inadequate 8, 9
Activation of massive transfusion protocol is recommended if hemorrhagic shock is suspected, and broad-spectrum antibiotics should be administered immediately if peritonitis is suspected 1, 10, 8