The correct treatment for an intraperitoneal bladder rupture:
A. Foley catheter drainage
C. Suprapubic drainage with Foley catheter drainage
D. Bladder drainage, percutaneous paravesical drainage and antibiotics
E. Laparotomy with open bladder exploration and repair, paravesical drainage, and Foley catheter drainage
An intraperitoneal bladder rupture must be operatively repaired. Drainage of the paravesical space at laparotomy as well as Foley catheter drainage is essential. Any option that suggests drainage without exploration would be inadequate.
A passenger was involved in a high-speed head on motor vehicle collision and sustained severe hyperflexion injury of the lumbar region. She was wearing a seat belt. The most important abdominal injury to exclude would be:
A. Pancreatic neck transection
A missed pancreatic injury could have devastating consequences. Hyperflexion injuries while wearing a seat belt trap abdominal viscera and cause severe deceleration injuries that could result in pancreatic neck transection. Interestingly, falling over bicycle handlebars in pediatric trauma is associated with pancreatic injury.
All the other listed injuries are exceedingly rare with this mechanism; a duodenal hematoma is more commonly associated with a pancreatic injury.
A hypotensive patient had sustained multiple stab wounds to the abdomen. In the operating room, a through-and-through laceration to the stomach and a pancreatic and a low-grade splenic injury. How would you manage the gastric perforations?
A. Gastric resection with primary closure
B. Primary closure of both wounds
C. A posterior gastrojejunostomy with primary repair of the anterior injury
D. Resection with Roux-en-Y reconstruction
E. Subtotal gastrectomy with gastrojejunostomy
This patient is a candidate for rapid primary closure of both wounds. There is no need for pyloric exclusion, resection, or gastrojejunostomy.
Which of the following scenarios requires immediate operative intervention?
A. A stab wound to zone II of the that violates the platysma
B. A grade III splenic injury in a stable 7-year-old girl
C. A nonexpanding retroperitoneal zone II hematoma
D. A distal femur fracture with overlying palpable thrill
E. Extraperitoneal bladder rupture
This question covers a lot of ground: Distal femur fractures are frequently associated with vascular injury. A thrill is a hard sign of vascular injury, which mandates immediate surgery. Other hard signs of vascular injury are arterial bleeding, pulsatile hematoma, bruit, and obvious arterial occlusion (pulselessness). In cases where there are so-called soft signs (diminished pulses, proximity of wound to vessels, small nonpulsatile hematoma, an ankle brachial index of <0.9, neurologic deficit, or history of arterial bleeding at the scene), further evaluation with arteriography or serial examinations is warranted in respect to penetrating neck trauma; the paradigm has shifted from mandatory exploration of deep zone II injuries after literature showed that many explorations were unnecessary and did not demonstrate any clinically significant injury. If associated with hard signs of neck injury or hemodynamic instability, then exploration should be pursued. Hard signs include respiratory, digestive, or vascular findings: dyspnea, hoarseness, stridor, dysphagia, odynophagia, pulsatile hematoma, thrill/bruit, or neurologic deficit. Particularly in children, because of the slightly higher incidence of postsplenectomy sepsis, splenic preservation should be attempted. This is acceptable in a stable patient.
All zone I retroperitoneal hematomas should be explored. Retroperitoneal hematomas secondary to penetrating trauma should be explored; however, recent evidence has demonstrated that observation of nonexpanding zone II hematomas is safe.
Extraperitoneal bladder rupture does not lead to intra-abdominal urine extravasation and are managed with transurethral (Foley) catheter drainage for 7 to 10 days. No surgery is usually required.
Regarding cervical spine injury, which of the following statements are true?
A. Hangman fractures are very unstable and are best managed with operative spinal fusion
B. Type II dens (odontoid) fractures are stable
C. C1 fractures are usually caused by an axial load and involve a blowout of the ring
D. Radiographic assessment of the cervical spine is recommended in trauma patients who are awake, alert, and not intoxicated, who are without neck pain or tenderness, and who do not have significant associated injuries that detract from their general evaluation
Jefferson (C1 burst) fractures are considered stable and are treated with a rigid collar. Hangman fractures involve the posterior elements of C2 and are unstable. They are treated with traction for displacement and a halo for immobilization lasting 3 months. Odontoid fractures are subdivided into 3 types. Type I involve the odontoid above the base and are stable. Type II fractures occur at the base of C2 and are usually unstable. They are treated with a halo for 3 months if the displacement is less than 5 mm. If greater than 5 mm, then posterior fusion of C1 and C2 or screw fixation is generally required. Type III extend into the C2 body and are treated with a halo or rigid collar. Per nexus criteria, a patient with the above findings could have his cervical spine clinically cleared without imaging.
Which one of the following is an indication for immediate ventriculostomy in head trauma?
A. 1 mm subdural hematoma, GCS 14
B. 5 cm epidural hematoma, GCS 5
C. Multiple hemorrhagic contusions, GCS 13
D. Mild global cerebral edema, GCS 7
E. Normal CT scan, with serum alcohol of 250, GCS 9
If you can follow a neurologic examination and it is adequate, there is no need for ICP monitoring. If the alcohol level is high with a normal CT scan, then it is reasonable to allow the intoxicating drugs to metabolize. A patient with a large epidural hematoma should undergo emergent neurosurgical intervention with evacuation in the operating room.
A 20-year-old male involved in high-speed motor vehicle collision arrives to the emergency department. He was intubated at the scene, arrives with oxygen saturation of 80%, systolic blood pressure is 90 mm Hg with 1 L of crystalloid infusing, and he has near amputation of left leg. What is the first most appropriate step in treatment?
B. Reasses airway and listen to breath sounds
D. Place a large-bore central line
While these are likely all important in the care of this patient, one must always remember to reevaluate the ABCs, and always double check the ET whenever a patient arrives or is transferred. This patient may have a right mainstem intubation, malpositioned ET, tension hemo/pneumothorax, or massive lung contusions to account for the desaturation and the blood pressure may respond to securing the airway or decompressing the chest.
An obese 40-year-old female arrives to the ED after a motor vehicle collision awake but confused and complaining of abdominal pain with a systolic BP of 80 after 2 L of crystalloid infusion. She also has crepitus due to bilateral pneumothoraces s/p chest tube placement. FAST is positive in RUQ. What is the next step?
B. Aggressively resuscitate
C. CT scan of abdomen and pelvis
This patient is still in hypotensive despite initial resuscitation and chest tube placement. While further resuscitation is ongoing with likely colloid or blood product infusion, the patient’s abdomen should be explored. The FAST is positive in this case; however, if the FAST were negative or equivocal due to obesity/subcutaneous air, one should also obtain a pelvis x-ray and perform a DPL. Since the patient is unstable, a CT scan would not be appropriate as the next step.
A 30-year-old male patient complains of abdominal pain after a snowboarding accident. He is hemodynamically stable. A CT scan of the abdomen and pelvis shows a grade III spleen with moderate hemoperitoneum and an IV contrast blush. What is the appropriate treatment?
A. Observation and serial H/H
E. Laparoscopic exploration
While this is dependent on resources at your hospital, angioembolization is associated with high splenic salvage rates. Findings on CT associated with failure of pure observation and nonoperative management are high grade of injury, amount of hemoperitoneum, and presence of blush. If there is no interventional radiology capabilities available, this patient can be observed closely with an expected high failure rate or nonoperative management or alternatively taken for a laparotomy and either a splenectomy or splenorraphy. Laparoscopic splenectomy has no role in the acute setting.
A motorcyclist crashes and arrives to the emergency department intubated, hypotensive despite 2 L of crystalloid infusion, with a fixed and dilated pupil on the right. His chest and pelvic x-rays are unremarkable, and his FAST is positive. What is the first priority in management?
B. Right-sided craniotomy
This is a multitrauma patient with multiple life-threatening issues. Thus, it is important to prioritize and start with the primary survey. Airway must be secured and adequate ventilation ensured. Next, circulation is assessed—as this patient is hypotensive despite initial fluid resuscitation, a source of ongoing hemorrhage that needs to be identified or excluded controlled. Given a positive FAST, negative plain films, and the mechanism, the abdomen is the most likely source. While the presence of a lesion with mass effect on the brain is a true emergency, the most important way to prevent secondary brain injury is to prevent hypotension and hypoxia. If simultaneous craniotomy and laparotomy is feasible, this too could be considered.
An 18-year-old male arrives to the emergency department after sustaining a stab wound to left chest, just below the nipple and parasternal. His blood pressure is normal and his heart rate is 110. There are no other wounds on examination. A chest x-ray is normal, and a FAST examination shows fluid in the pericardium. A subxiphoid pericardial window is performed and is positive for blood in the pericardium. The patient remains hemodynamically stable. What is the next step in management?
A positive pericardial window in this setting mandates exploration to evaluate for a cardiac injury. While the method is dependent on comfort level of the surgeon, a median sternotomy is preferred over left anterolateral thoracotomy. However, if the patient arrives unstable or becomes hypotensive during initial assessment then more urgent exploration (left anterolateral thoracotomy or sternotomy) without confirmatory tests is appropriate.
If a pulseless penetrating chest trauma victim arrives with CPR in progress, within 15 minutes a left anterolateral thoracotomy is indicated. It is also appropriate to proceed with exploration with a positive ultrasound examination (FAST, TTE, TEE) without pericardial window in the hemodynamically stable patient. Remember, penetrating injuries to the mediastinal “box” have to be evaluated either with a pericardial window or with ECHO ultrasonography to exclude tamponade.