Injuries
More Injuries
Stop The Bleed(ing)
Next Steps
100
A 34-year-old female presents after a high-velocity MVC with right flank pain and frank bright red blood in her urine. Her primary survey is intact, and vital signs are HR 112 bpm, BP 86/59 mmHg, RR 20/min, and oxygen saturation is 98% on room air. CT scan demonstrates a Grade IV laceration to the right kidney. The best choice for management is:
A. Renorrhaphy
B. Packing of the renal fossa, temporary abdominal closure, and return to the ICU.
C. Total nephrectomy
D. Observation in the intensive care unit with blood transfusion as needed
E. Gelfoam angioembolization
A. Renorrhaphy
This patient is hemodynamically unstable, and therefore should be taken to the operating room for laparotomy and renal exploration. Principles of operative repair for a Grade IV, and for some Grade V kidney lacerations include renal preservation, when possible—debridement of non-viable tissue, hemostasis using absorbable sutures in a figure-of-eight fashion with care taken to preserve arterial supply to distal segments, closure of the collecting system with absorbable suture in a running fashion, and reapproximation of the capsule. An omental flap can be substituted for large defects if necessary. Damage control laparotomy is not indicated in this patient in the absence of coagulopathy, hypothermia, or acidosis.
100
A 54-year-old man was brought to the hospital after his leg was pinned in machinery at work. His left lower leg is swollen and tense. He reports a tingling sensation and has decreased sensation in the left foot. You perform a double-incision fasciotomy with the medial incision 2 cm posterior to the tibia. What compartments will you decompress through this incision?
A. Superficial and deep posterior
B. Lateral and superficial posterior
C. Superficial posterior only
D. Anterior and lateral
E. Anterior and deep posterior
A. Superficial and deep posterior
Treatment of extremity compartment syndrome is surgical decompression of the affected extremity via a fasciotomy. In the lower leg, a double-incision, four-compartment fasciotomy is performed (see
A lateral incision is made anterior to the fibula and the lateral and anterior compartments are decompressed. The medial incision is made 2 cm posterior to the tibia and the superficial and deep posterior compartments are decompressed.
100
A 60-year-old man was not wearing a seatbelt when his car collided with a traffic barrier and he was ejected. On arrival to the nearest hospital, his pulse is 120, blood pressure is 80/60, and respiratory rate is 28/min. Glasgow coma scale score is 8. He is intubated, venous access is obtained, and 2units of whole blood are rapidly infused. His pulse is 125 and blood pressure 80/60.
Primary survey reveals a non-bleeding scalp laceration, a distended, silent abdomen, and shortening and external rotation of the left leg. A chest x-ray is normal, and pelvic films show a femoral neck fracture.
The most important next step would be
A. Switch to colloid resuscitation
B. Obtain computed tomographic (CT) scans of head and abdomen
C. Apply a traction splint
D. Perform diagnostic peritoneal lavage
E. Perform laparotomy
Perform laparotomy
The patient has suffered high-energy trauma and is in hemorrhagic shock. He has failed to respond to a fluid challenge. Ongoing hemorrhage is the most likely cause of his tachycardia and hypotension. The scalp laceration is not sufficient to explain the physiologic findings. The normal chest x-ray rules out a thoracic source, and there is no evidence for a pelvic fracture. Physical findings and adjunctive studies indicate the abdomen is the most likely bleeding source. The femoral fracture should be properly splinted, but splinting will not correct the life-threatening problem.
Continued fluid therapy is appropriate but insufficient. Colloid offers no advantage over crystalloid in persistent hemorrhagic shock, is expensive, and recent analysis of its use in hypovolemic shock resuscitation demonstrates a mortality risk greater than that of crystalloid resuscitation. Transfusion of packed red cells should be initiated based on the response to crystalloid.
Scanning of the actively bleeding, hemodynamically abnormal trauma patient is contraindicated. All of the findings so far point to the abdomen as the source, and further defining the problem with imaging studies is unnecessary and potentially harmful. Diagnostic peritoneal lavage is also contraindicated in the face of obvious indications for laparotomy. Focused assessment with sonography for trauma (FAST) examination might be considered if it could be accomplished without delaying transfer to the operating room, but for similar reasons is unnecessary and unlikely to provide information that would alter the need for laparotomy.
This patient has failed to respond, and needs immediate laparotomy to identify and treat the bleeding source.
100
A 9-month-old infant was brought to the ED for evaluation of an upper respiratory infection. On chest x-ray, multiple posterior rib fractures estimated to be a few weeks old were identified. What should be included in this patient's workup?
A. Liver function tests
B. Chest CT for better delineation of the rib fractures
C. Outpatient referral for a social worker
D. A full skeletal survey should be obtained.
E. Vitamin D level
D. A full skeletal survey should be obtained.
Fractures highly specific for abuse include metaphyseal lesions ("corner fracture" or "bucket handle" pattern), posterior rib fractures, scapular process fractures, spinous process fractures and sternal fractures. Moderately specific fractures include multiple bilateral fractures, fractures of different ages, epiphyseal separations, vertebral body fractures and subluxations, digital fractures, complex skull fractures and pelvic fractures. Finally, low specificity fractures include clavicular, long bone shaft, linear skull fractures and subperiosteal new bone formation.
Elevated liver function tests can be a marker of blunt trauma, but is non-specific without evidence of acute injury.
Chest CT is not necessary, and it is important to limit unnecessary radiation in children.
The American Academy of Pediatrics recommends an ophthalmologic exam as part of the diagnostic evaluation for all previously well children under the age of 5 years who present with intracranial hemorrhage or an acute life-threatening event or any concern for non-accidental trauma (child abuse), as is strongly the case here. Even the suspicion for child abuse should prompt immediate inpatient referral to the appropriate state or local authority.
200
A 19-year-old male presents to the emergency room after a motorcycle crash. Digital rectal exam including the prostate is normal, and there is no blood at the urethral meatus. He has a lateral compression pelvis fracture and gross hematuria. The appropriate evaluation for this patient would include:
A. Retrograde cystogram
B. Retrograde cystogram and contrast CT scan of the abdomen and pelvis
C. Contrast CT scan of the abdomen and pelvis
D. Retrograde urethrogram
B. Retrograde cystogram and contrast CT scan of the abdomen and pelvis
The combination of a cystogram and a contrast CT scan of the abdomen and pelvis will diagnose potential bladder and renal injuries. No retrograde urethrogram (D) is needed as the patient did not have a high-riding prostate on digital rectal exam and did not have blood at the urethral meatus. A cystogram alone (A) would not evaluate for renal injuries which are possible with the given mechanism and hematuria. A CT scan alone (C) would not evaluate for a potential bladder injury which is possible with the given mechanism and hematuria.
200
A 23-year-old male sustains a gunshot wound to the mid upper abdomen. At exploratory laparotomy, he is found to have a <50% of the circumferential injury at the junction of the 2nd and 3rd portion of the duodenum. What is the best approach to management of this injury pattern?
A. Pyloric exclusion
B. Whipple procedure
C. Omental patch
D. Primary repair of the injury
E. Resection with single layer anastomosis
D. Primary repair of the injury
Primary repair is preferable unless the injury is greater than 50% of the circumference of the duodenum. None of the other choices are appropriate in this situation.
200
A 30-year-old man presents to the Emergency Department after being struck by a motor vehicle; he was found pinned under the vehicle and required 30 minutes of extrication. On arrival, his blood pressure is 76/50 mmHg, pulse 132 beats/min, and he is slow to respond to stimuli. A massive transfusion protocol is initiated. The FAST scan is positive. On exploration, he has a large zone I retroperitoneal hematoma, a large volume of free intraperitoneal blood, several small bowel lacerations, and a grade III liver laceration. After packing the four quadrants, exploration of the hematoma demonstrates complete transection of the vena cava below the renal veins. The patient remains hemodynamically unstable despite transfusion. What is your next step in management of the vena caval injury?
A. Perform a right medial visceral rotation, apply clamps proximally and distally on the cava, and repair the injury primarily.
B. Insert a balloon through the laceration, occlude proximally and transfuse intraoperatively until the patient becomes stable, and attempt repair.
C. Perform a left medial visceral rotation and attempt primary repair while auto-transfusing the intraperitoneal blood.
D. Perform a left medial visceral rotation, and pack the injury.
E. Perform a right medial visceral rotation and ligate the vena cava.
E. Perform a right medial visceral rotation and ligate the vena cava.
In the setting of an unstable patient with complete transection of the vena cava, the best option is ligation. Repair of the vena cava is usually the preferred option; however, this may not be feasible in the setting of damage control laparotomy in an unstable patient with multiple injuries where prolonging the operative time risks developing coagulopathy, acidosis, and hypothermia prior to control of all major bleeding sources. A left medial visceral rotation is performed for aortic exposure from the hiatus to the iliacs. A right medial visceral rotation is required for caval exposure.
200
A 23-year-old male presents to the ER four hours after sustaining a stab wound to the abdomen. He is intoxicated. His HR is 74 bpm, BP 140/70 mmHg, and RR 15 breaths/min. Physical examination demonstrates an obese abdomen with a 2-centimeter stab wound in the left upper quadrant, abdominal distension with tenderness around the stab wound with involuntary guarding and rebound tenderness throughout the abdomen. What is the next step in the management of this patient?
A. Bedside wound closure and discharge home
B. Triple contrast CT imaging of his chest, abdomen and pelvis
C. Inpatient admission with serial abdominal examinations
D. Exploratory laparoscopy
E. Exploratory laparotomy
E. Exploratory laparotomy
This patient is intoxicated which can make the abdominal examination difficult to assess; however, he has signs of peritonitis away from the wound site four hours after time of injury. The best next step in management would be exploratory laparotomy due to the peritonitis. The other major indication for an emergent laparotomy would be hemodynamic instability. Bedside wound closure is inappropriate since the patient has peritonitis and no evaluation for fascial penetration has yet been documented. CT imaging would be a reasonable option if frank peritonitis was not present. If a patient presents with no peritonitis, no hemodynamic instability and CT imaging that demonstrates no intra-abdominal injury after a stab wound that penetrates the fascia, inpatient admission with serial abdominal exams is appropriate. Serial exams have been shown to be reliable in detecting significant injuries after penetrating trauma to the abdomen if performed by experienced clinicians and preferably by the same team. If there is suspicion for an isolated diaphragmatic injury, diagnostic laparoscopy can be considered.
300
A 55-year-old man presents with hemodynamic instability and severe abdominal pain after being struck by a car. On exploratory laparotomy, he is found to have a grade 5 splenic injury and a 6-cm left-sided zone II retroperitoneal hematoma that is not expanding. Microscopic hematuria was also detected on urinalysis. After performing splenectomy, what is the next step in management?
A. Explore the zone II retroperitoneal hematoma.
B. Observe the zone II hematoma.
C. Perform a left nephrectomy.
D. Perform an on-table angiogram.
B. Observe the zone II hematoma.
Zone 2 hematomas caused by penetrating injuries are routinely explored if encountered in the operating room. Whether proximal control of the renal pedicle should be obtained before exploration of a perinephric hematoma is controversial. In cases of severe ongoing hemorrhage, time should not be taken to obtain proximal control, and the kidney should be mobilized directly. If time and the degree of hemorrhage permit, however, it is acceptable to obtain vascular control before mobilization of the kidney. Zone 2 hematomas caused by blunt trauma can be left alone if they are not expanding. Microscopic hematuria is not an indication for exploration of zone II hematomas as it is a common finding with such injuries. A nephrectomy or angiogram is not indicated in this setting.
300
A 41-year-old male who sustained multiple gunshot wounds to the upper abdomen is taken to the operating room for exploratory laparotomy. He has a through-and-through injury to the 3rd portion of the duodenum and laceration to the tail of the pancreas with evidence of main pancreatic ductal disruption. What is the best operative approach to manage the pancreatic injury?
A. Kocher maneuver to expose the body and tail of the pancreas
B. Splenectomy
C. Distal pancreatectomy and drainage
D. Drainage alone
E. Whipple operation
C. Distal pancreatectomy and drainage
An important factor in the operative management of pancreatic injury is whether or not a ductal injury has occurred. Injuries to the tail or body of the pancreas with obvious ductal disruption should be managed with resection of the distal pancreas and oversewing of the proximal pancreatic duct. Wide drainage should also be accomplished.
300
A 17-year-old male is involved in a motor vehicle accident. He is hemodynamically stable and a CT scan shows the left kidney with poor contrast enhancement, integrity of the vascular pedicle, and no evidence of intra-peritoneal injury. What is the best management?
A. Diagnostic laparoscopy
B. Arteriogram of the left kidney
C. Resuscitation and observation
D. Emergent nephrectomy
E. Percutaneous nephrostomy
C. Resuscitation and observation
The absolute indications for renal exploration include hemodynamic instability secondary to renal hemorrhage, expanding or pulsatile retroperitoneal hematoma at laparotomy, and pedicle avulsion. If renal exploration is contemplated, necessary demonstration of contralateral renal function is important in the event of ipsilateral nephrectomy. Laparoscopy is not the test of choice for diagnosing injury to a retroperitoneal structure.
Poor contrast enhancement may improve after resuscitation. There is no indication for a renal arteriogram or interventional procedure or nephrostomy.
300
A 25-year-old male presents to the emergency room after suffering a stab wound to the left 11th rib interspace. His vitals indicate a HR of 70 bpm, blood pressure of 120/80 mmHg, and a respiratory rate of 11 breaths/min. Abdominal exam is normal. A chest x-ray demonstrates a left pneumothorax. Triple contrast CT imaging demonstrates the pneumothorax with no solid or hollow viscus injury. What is the best next step in management?
A. Exploratory laparotomy
B. Exploratory laparoscopy
C. Gastrografin upper GI series
D. Bedside closure of wound and admission for observation
E. Bedside closure of wound and discharge home
A. Exploratory laparoscopy
The patient has an isolated stab wound with normal hemodynamics and no peritoneal signs. In light of these findings and imaging that has already been performed, a laparotomy is likely to demonstrate no solid or hollow organ injuries. A thoracoabdominal stab wound, however, can result in a diaphragm injury that is usually not seen on CT imaging. Missing a diaphragm injury on the left side has the potential to result in significant morbidity to this patient in the future. Diagnostic or exploratory laparoscopy is a relatively benign intervention that can be very sensitive and specific in diagnosing diaphragmatic injuries. In skilled hands, it may also be therapeutic. An upper GI series is unlikely to add information.
400
A 55-year-old man sustains a stab wound to the left flank, and is taken to the operating room for peritonitis. He has a laceration to the splenic flexure of the colon which is primarily repaired. There is no retroperitoneal hematoma. The most appropriate step to assess possible left ureteral injury is:
A. Methylene blue intravenously
B. Retrograde pyelogram
C. Manual palpation of the entire course of the ureter
D. Direct inspection of the entire course of the ureter
E. Placement of retroperitoneal drain and closure of the incision
D. Direct inspection of the entire course of the ureter
Direct inspection of the entire course of the ureter is the most definitive method to assess for ureteral injury. Retrograde pyelogram would be an acceptable option; however, the patient needs to be in lithotomy position for a retrograde pyelogram. The open abdomen is also a hindrance to this option. Manual palpation of the ureter does not substitute for direct inspection.
400
A 24-year-old man sustains a gunshot wound to the left lower quadrant of the abdomen. At laparotomy he has significant hemoperitoneum and an injury to the left iliac artery, which is repaired primarily. During this repair he loses 1.5 L of blood and is hypotensive (60/P) for 5 minutes. He also has an injury to the sigmoid colon with significant devascularization and > 50% circumferential tissue loss over 6 cm. The patient is now hemodynamically normal, not acidotic or hypothermic. There is moderate peritoneal contamination. The most appropriate procedure for treatment of the colon injury would be
A. Primary repair
B. Primary repair with diverting colostomy
C. Resection with primary anastomosis
D. Resection with primary anastomosis and diverting colostomy
E. Resection with oversew of the distal colon and proximal colostomy
C. Resection with primary anastomosis
Fecal diversion was credited with decreasing mortality from penetrating colon injuries in World War II. Since that time, evidence has been steadily accumulating that primary repair of the colon after penetrating injury is safe. In a recent meta-analysis from the Cochrane Database of Systematic Reviews, pooled data from 5 prospective randomized trials noted fewer total complications, intra-abdominal infections, total infections, and wound complications after primary repair versus fecal diversion with a stoma. There was no difference in overall mortality between the groups. All studies but 1 included patients traditionally considered to be "high risk," i.e., patients with delay to operation, shock, significant hemorrhage or transfusion requirement, fecal contamination, and significant tissue loss. None of the studies' data included complications or hospital length of stay due to colostomy takedown. Colostomy takedown has a reported complication rate of 5% to 25%, can require postoperative hospital stays of over 15 days, and can add significantly to overall healthcare costs.
400
A 27-year-old oilfield worker presents after falling from a 30-ft platform at his drilling site. A pelvic binder was placed on scene by paramedics for pelvic instability, bruising and scrotal hematoma. Attempted removal of the binder in the trauma bay results in hypotension despite blood transfusion. The binder is reapplied and a CT scan performed which demonstrates a 4-cm left zone III hematoma with blush on the arterial phase along with bilateral inferior and superior pubic ramus fractures and left sacro-iliac widening. A cystogram shows no evidence of bladder injury. He is hemodynamically stable after resuscitation. The most appropriate next step would be:
A. Immediate surgical exploration of the hematoma
B. Observation in the ICU and removal of the binder as soon as feasible to prevent decubitus ulceration
C. Perform angioembolization of bleeding pelvic arteries followed by external fixation of the pelvis.
D. Immediate operative repair of the pelvic fractures
E. Apply external fixation to the pelvis.
C. Perform angioembolization of bleeding pelvic arteries followed by external fixation of the pelvis.
Pelvic arterial injury may be managed by open intraperitoneal exploration and ligation of vessels, endovascular embolization or pre-peritoneal packing. In recent years, endovascular control has become the preferred option for control of pelvic hemorrhage in most patients, especially if they are relatively hemodynamically stable. In some facilities, hybrid operating rooms may allow this modality to be extended even to the unstable patient. Control of hemorrhage should be accompanied or immediately followed by temporary stabilization of the bony pelvis with external fixation devices.
400
A 23 year-old male presents after being a pedestrian struck as a level 1 trauma activation. On arrival he is hemodynamically normal, with an intact primary exam. Secondary reveales a tibial plateu fracture of the left lower extremity with posterior dislocation of the knee. A distal open tibial fracture is also present with exposed bone. A tourniquet is in place above the left knee, placed prehospital. Early rescucitation is hampered by the inability of the team to obtain intravenous access. An FAST exam is Negative. Appropriate management of this patient include.
A. Traction splint application to the effected injury
B. Insertion of Tibial IO in contralateral leg
C. Radial afterial line placement
D. Angioram of the left lower extremity
E. Removal of the Tourniquet
D. CT. angio with runoff of the left lower extremity
This patient is hemodynamically stable and may require IO placement if intravenous line is not able to be obtained, however this should avoid the lower extremities in this patient who may have bilateraly tibial fractures. Dislocation injuries of the knee should prompt a thorough vascular exam of the affected extremity with interrogation for popliteal artery injury.
500
A 27-year-old male arrives in the trauma bay after a motorcycle accident. On exam he has a noticeable straddle injury with a laceration and hematoma in the perineum, and pelvic radiograph identifies bilateral pubic rami fractures. There does not appear to be any blood at the urethral meatus. What is the next step in management with an otherwise stable patient?
A. CT scan of the abdomen and pelvis
B. Proceed to the OR for exploration.
C. Place a Foley urinary catheter.
D. Retrograde urethrogram
E. Explore the wound in the trauma bay.
D. Retrograde urethrogram
Although blood at the urethral meatus is a classic sign of urethral injury, it is not present in all cases. While less common, a pelvic hematoma and a perineal laceration are also associated with urethral injury. If the mechanism of injury is suspicious, a retrograde urethrogram (RUG) should be performed.
500
A 28-year-old male is brought to the emergency room after suffering a stab wound to the epigastrium. Exploration reveals a gastric laceration with spillage of gastric contents. After closing the laceration, you notice a small wound in the adjacent diaphragm. Prevention of empyema in this patient is most appropriately accomplished by:
A. Early postoperative ambulation
B. Prolonged course of postoperative antibiotics
C. Placement of a subdiaphragmatic intraabdominal drain
D. Transdiaphragmatic thoracic lavage
E. Conversion to formal thoracotomy
D. Transdiaphragmatic thoracic lavage
Concomitant gastric and diaphragmatic injuries can lead to contamination of the pleural cavity due to the negative pressure gradient caused by spontaneous ventilation. The degree of contamination may not be appreciated during surgery. Adequate thoracic lavage is necessary to reduce the risk of empyema. If adequate lavage cannot be performed transdiaphragmatically, "prophylactic" VATS (rather than formal thoracotomy) should be considered.
500
A 28-year-old male is brought to the hospital after an abdominal gunshot wound. During laparotomy, you note 3 L hemoperitoneum, a bleeding spleen, and a 65% circumferential small bowel laceration. After removing the spleen, the patient's vital signs are temperature 35°F, BP 80/40 mmHg, HR 130 bpm, and the splenic bed is diffusely oozy. At this point, the best treatment of the small bowel injury is?
A. Primary repair of the injury.
B. Resect the injury and leave the stapled ends in discontinuity.
C. Resect the injury and perform stapled anastomosis.
D. Resect the injury and perform hand-sewn anastomosis.
E. Resect the injury and perform a small bowel ostomy.
B. Resect the injury and leave the stapled ends in discontinuity.
The patient is hemodynamically unstable, hypothermic, and coagulopathic. A damage control approach is indicated, and the operation should be terminated as soon as possible. The small bowel injury should be resected with a stapler to prevent ongoing contamination and the ends left in discontinuity until the physiologic abnormalities have been corrected.
500
A 26-year-old male was involved in a motor vehicle collision. He was intubated in the field and transported to the ER with BP 90/64 mmHg and HR 112 bpm and was taken to the operating room after positive FAST. He was found to have a grade V splenic injury requiring splenectomy, a grade III right hepatic lobe injury with persistent venous bleeding, and an injury to the base of the terminal ileum mesentery which was resected and stapled. Packing with laparotomy pads was able to achieve hemostasis and temporary abdominal closure was done. In ER and OR he received 24 U PRBC, 22 U FFP, and 4 six-packs of platelets. Three hours later, peak inspiratory pressures have increased from 21 to 35, urine output has decreased from 25 ml/hr to anuria, and vasoactive medications have to be started to maintain BP. Hemoglobin is 12 g/dL with no transfusion of PRBC since surgery. What is the next best step in management?
A. Volume resuscitation with blood products
B. Remove abdominal dressing at bedside with reapplication to allow for worsening bowel edema
C. Diuresis with furosemide
D. Give IV paralytics
E. Initiate extracorporeal membrane oxygenation (ECMO)
B. Remove abdominal dressing at bedside with reapplication to allow for worsening bowel edema
This patient has developed abdominal compartment syndrome (ACS) despite having an open abdomen. One must keep in mind that the temporary abdominal closure can be restrictive and may require modification over time. Volume resuscitation will exacerbate this patient's primary problem without significantly improving preload. Diuresis is inappropriate in light of this patient's recent major blood loss and ongoing hemodynamic instability. Paralysis is sometimes necessary if the diagnosis of ACS is in doubt, or the patient has ongoing ventilator dyssynchrony, neither of which is present here. ECMO may yet be necessary for this patient's pulmonary and/or hemodynamic support but does not address the current primary issue.