In a high-speed motor vehicle crash, a restrained driver has a forehead laceration and a distended abdomen. Blood pressure 80/50, pulse 120, respirations 20. Which intra-abdominal injury is most likely?

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When a patient in a high-speed blunt trauma presents with abdominal distension and signs of shock (low blood pressure and rapid pulse), think about intra-abdominal hemorrhage from a solid-organ injury. The liver is the most commonly injured solid organ in adults after blunt, high-energy impacts because of its large size and rich blood supply. A hepatic laceration can bleed heavily into the peritoneal cavity, producing rapid blood loss that leads to hypotension and a distended abdomen from accumulating blood.

Pneumothorax would more typically cause chest findings and respiratory distress rather than abdominal distension. Kidney laceration can occur, but it often presents with flank pain and sometimes hematuria rather than immediate, dramatic distension and shock. Splenic rupture is also a common cause of hemorrhage after blunt trauma, but in the context of a high-speed impact with a distended abdomen and shock, hepatic injury remains the most likely source of significant intra-abdominal bleeding.