Surgical Management
A 60-year-old woman undergoes abdominal hysterectomy, and in the recovery room she is noted to be persistently anuric despite aggressive resuscitation. Her estimated blood loss during the case was approximately 1 L. Her catheter is flushed and found to be patent. An ultrasound reveals bilateral hydronephrosis. The best explanation for her condition is:
Bilateral ureteral obstruction - A high index of suspicion must be maintained in the setting of a hysterectomy, in which the ureter may be damaged during dissection of the broad ligament.
An 8-year-old boy presents to the trauma bay after being hit by a car while riding his bicycle. He was wearing a helmet, had no loss of consciousness, and hit his left side against the vehicle. He is reporting abdominal pain. His HR is 100 beats/min, RR is 16 breaths/min, and BP is 92/60 mm Hg. He has an abdominal wall contusion and bruising of his left arm and leg without deformities. CT reveals findings of a grade III splenic laceration and a small amount of perisplenic blood. How would you manage this patient?
Admission for observation with serial hematocrit measurements
You place a left subclavian central venous catheter and order a CXR to confirm proper placement. Before the CXR is completed, the patient reports chest pain and shortness of breath. His HR is now 155 beats/min, his BP is 82/48 mm Hg, and his O2 saturation is 74% on a 15-L nonrebreather mask. He has no breath sounds on the left, and his trachea is deviated to the right. He has new jugular venous distention. What should you do next?
Urgent thoracic decompression
A postoperative patient is found to be in atrial fibrillation with a rapid ventricular rate in the 150s (beats/min). After what time do you decide to initiate therapeutic anticoagulation in this patient?
Indications for therapeutic indication include a CHADS score of greater than 2 or a duration of atrial fibrillation of more than 48 hours, because this predisposes to atrial clot formation and thus stroke.
Someone coming in with a Grade II liver laceration; what should this patient's diet order be?
Grade I/II = Clears x12 hrs
Grade III/IV/V = NPO for first 12 hours
A 42-year-old man sustains blunt trauma to the abdomen. He is hemodynamically normal on arrival to the hospital, and CT of the abdomen and pelvis demonstrates a grade II liver laceration and a duodenal hematoma with dilation of the stomach. How would you manage this patient?
Place a decompressive nasogastric (NG) tube, initiate TPN, and obtain serial CBCs.
A 28-year-old man is brought into the emergency department after sustaining a gunshot wound to his right medial thigh. He has no other injuries. Examination reveals an expanding hematoma and an absent popliteal pulse. What is the next step in management for this patient after his trauma evaluation is complete?
Transfer directly to operating room - Patients with hard signs of vascular injury should be transferred to the operating room expeditiously. Further imaging, if required, may be performed on the operating table.
28-year-old man is taken to the operating room for exploratory laparotomy after presenting with a stab wound to the right anterior abdomen. Findings include a grade II diaphragmatic laceration and a small penetrating wound to the liver. There is no active hemorrhage from the liver. The diaphragm is repaired primarily. A drain is left over the liver, and a chest tube is placed. All drains are removed, and the patient is discharged on postoperative day 4. The patient returns several days later with shortness of breath. Chest x-ray shows a massive effusion. A chest tube is placed and bilious-appearing fluid is evacuated. What complication has occurred?
Biliary pleural fistula - diagnosis can be confirmed with scintigraphy. Initial treatment includes placement of a thoracostomy tube and decompression of the biliary tree by endoscopic retrograde cholangiopancreatography with sphincterotomy, or placement of a percutaneous biliary drain
A 65-year-old woman undergoes an open right thoracotomy for an empyema she developed after undergoing a right hepatectomy for intrahepatic cholangiocarcinoma 3 months ago. The case was difficult and took several hours to complete.
In the recovery room, she is noted to have low urine output. Chest tubes are placed to suction with a small air leak, and minimal output is noted. She remains persistently hypotensive despite a 1-L crystalloid bolus. She is subsequently transferred to the ICU and started on vasopressor support.
Initial laboratory values include a hemoglobin of 9.2 g/dL, platelets of 100,000/µL, creatinine of 0.9 mg/dL, AST of 40 U/L, ALT of 32 U/L, and a bilirubin of 1.2 mg/dL. Overnight, her platelet count falls to 65,000/µL, hemoglobin drops to 8.6 g/dL, and AST and ALT increase to 5300 U/L and 6500 U/L, respectively. Bilirubin is now 2.1 mg/dL, and creatinine is 1.8 mg/dL. INR is now 2.2, up from 1.0 preoperatively. Urine output has been 200 mL for the past 12 hours, and the woman continues to require vasopressor support to maintain BP. Her liver enzymes continue to increase along with her creatinine over the next 48 hours before stabilizing and then downtrending. What test should be performed to evaluate the underlying cause of acute liver failure in the patient?
Doppler Ultrasound of Liver - A Doppler ultrasound of the liver should be ordered if liver enzymes continue to rise within the first 24 hours of an insult to the liver to assess for hepatic and portal flow.
A 42-year-old woman presents after a motor vehicle crash and is found to have a Lefort II fracture. She is neurologically intact and otherwise asymptomatic except for some left neck pain and bruising from her seatbelt. What is the best next step?
Injuries requiring CTA neck for BCVI:
Lefort II or III fracture pattern • Complex mandibular fracture • Cervical spine subluxation or ligamentous injury at any level • Fractures extending to the transverse cervical foramen • Any fracture, subluxation or ligamentous injury of the cervical spine • Complex skull fracture, basilar skull fracture, temporal skull fracture, occipital condyle fracture • Diffuse axonal injury with GCS ≤ 6 • Combination of Traumatic Brain Injury and Thoracic Injury • Clothesline type injury or seatbelt abrasion with significant swelling, pain, or altered mental status • Scalp degloving • Blunt cardiac rupture • Near hanging with anoxic brain injury • Upper rib fracture
A 66-year-old man falls from a ladder and sustains multiple left-sided rib fractures involving ribs 6 to 10 in multiple areas. His pain is adequately controlled; however, his oxygen saturation progressively declines over the next 3 days, ultimately requiring intubation and mechanical ventilation. Despite the resolution of the underlying lung contusions, he is unable to be weaned from the ventilator. What is the indication in particular for this patient to have surgical repair of his rib fractures in this patient?
Inability to wean from ventilator - The inability to wean a patient from mechanical ventilation in the context of rib fractures with associated pulmonary contusion is an indication for operative rib fixation.
A 60-year-old woman is brought to the trauma bay after being involved in a high-speed motor vehicle crash. She reports abdominal pain. A digital rectal examination is positive for blood. Her abdomen is tender to palpation. CT imaging reveals free fluid along the left pericolic gutter and pelvis and mesenteric stranding in the left lower quadrant of the abdomen. What is the most likely diagnosis?
Intraperitoneal colon injury with possible rectal injury
A 45-year-old woman is undergoing laparotomy following a single gunshot wound to the epigastrium, with no exit wound. A 2-cm ballistic gastrotomy is identified on the anterior stomach at the level of the incisura halfway between the greater and lesser curves. A thorough exploration shows only a 1-cm defect in the midportion of the splenic flexure mesocolon with no active bleeding and no devascularized colon. There is no zone II hematoma, and the Foley catheter is draining yellow urine. What next step must you take to ensure there is no posterior gastrotomy?
Division of the gastrocolic ligament to enter the lesser sac and visualize the posterior stomach
A 19-year-old patient is brought to the ED by private vehicle after sustaining a GSW to the right chest. He is found to be diaphoretic, hypotensive, and tachycardic, with decreased lung sounds in the right chest. On exam, he is somnolent and groans in response to painful stimuli. A right-sided chest tube is placed, with an immediate return of 2000 mL of bright red blood. Point-of-care testing of his arterial blood shows pH 7.288, pCO2 36.2 mm Hg, pO2 60.7 mm Hg, HCO3 16.8 mEq/L, base excess –8.6, and lactic acid 5.3 mmol/L. Which value is most concerning for decreased O2 delivery?
Lactic acid - The pH can reflect overall acid-base status, but it does not discriminate between respiratory and metabolic causes. pCO2 is a marker of ventilation. pO2 levels contribute little to the O2 delivery equation.
What is the antibiotic management for non-operative open facial fractures?
Non-operative open facial fracture
1. Unasyn 3g IV q6 hours for no longer than 24 hours. 2. If penicillin allergy: Clindamycin 900 mg IV q8h
A 41-year-old man sustains a gunshot wound to zone I of the neck. CT angiography reveals that there is a pseudoaneurysm of the proximal left subclavian artery. His BP is 126/82 mm Hg, HR is 91 beats/min, RR is 18 breaths/min, and temperature is 98.2 °F, with an SpO2 of 97% on room air. GCS score is 15. What is the best treatment option for this patient?
Placement of endovascular stent graft over the lesion
A 24-year-old patient with obesity arrives in the trauma bay 20 minutes after sustaining 2 gunshot wounds: one to the left upper quadrant and one on the right flank. His airway is intact, his GCS score is 15, and he has bilateral breath sounds. His hemodynamics are normal. His abdomen is tender at the site of the bullet entry without diffuse tenderness, peritonitis, or distension. A CT scan reveals an elevated left hemidiaphragm but no solid organ injury, free fluid, or contrast extravasation. What is the appropriate next step?
Diagnostic laparoscopy -This patient has an injury to the diaphragm but is hemodynamically stable and without peritonitis. Current Eastern Association for the Surgery of Trauma guidelines recommend a laparoscopic approach to diaphragm repair at initial presentation
A 45-year-old man presents to the ED following a motor vehicle crash. A CT scan reveals a traumatic esophageal injury in the cervical region. The patient is taken to the OR for repair of the injury. A linear incision is made down the medial border of the left sternocleidomastoid muscle. What is the next step in this operative approach?
Raise platysmal flaps - Injuries to the cervical esophagus are repaired via the left neck. A linear incision is made down the medial border of the sternocleidomastoid muscle. After this, platysmal flaps are created to allow for greater visualization of the field.
An 18-year-old patient is brought to the ED after a gunshot wound to the head. He has a GCS of 3T and is hemodynamically stable on arrival. The diameter of his right pupil is 4 mm and that of his left pupil is 2 mm. Two wounds to his head are apparent. He is given a 3% saline bolus. CT imaging reveals a transtentorial gunshot wound with no surgically correctable lesion. He is admitted to the trauma ICU for close monitoring. Neurosurgery is consulted for evaluation. There is no improvement in his examination, and his injury is deemed nonsurvivable. On day 1 of hospitalization, the man begins to put out more than 400 mL/h of clear urine. His urine and serum sodium/Osm values reveal elevated serum sodium and osmolality with minimally concentrated urine. What condition is this presentation concerning for?
Central diabetes insipidus
Patient coming in with a Grade III Liver laceration; what activity order should be placed for this patient?
Bedrest until pain free
Grade I-III = bedrest until pain free
Grade IV/V = bedrest x24 hrs, out of bed to chair once H&H stable
A 42-year-old man presents to the trauma bay in extremis for a penetrating injury to the chest. You are concerned about a suspected cardiac injury. The chest is opened, and you see a cardiac laceration close to the left anterior descending artery. Which of the following techniques should you consider in the repair of the injury?
Horizontal mattress stitch using a nonabsorbable monofilament suture
A young man has a stab wound to hepatic segment V with modest hemorrhage and a 90% transection of the right hepatic artery with significant hemorrhage. What operative management is appropriate?
Ligation of R hepatic artery -
Because the right portal vein furnishes 50% of the oxygenated blood to the right lobe of the liver, ligation of this small artery is appropriate. If this is an injury to the proximal right hepatic artery, a cholecystectomy should be performed after arterial ligation.
A 47-year-old man is in the OR undergoing abdominal exploration following a high-speed motor vehicle crash. The pancreas is noted to have a parenchymal laceration to the left of the superior mesenteric vein, and a complete transection of the pancreatic duct is identified during exploration of the laceration. What is the next step in management?
Distal Pancreatectomy - For injuries to the right of the SMA/SMV, management consists of closed suction drainage, whereas management of injuries to the left of the SMA/SMV with ductal disruption, as in this patient, consists of a distal pancreatectomy to prevent pancreatic ascites or pancreatic fistula.
A 54-year-old man with a history of congestive heart failure is brought to the ED after sustaining stab wounds to the left posterior chest and right neck in zone 2. On arrival to the ED, he becomes pulseless, and resuscitative thoracotomy is performed. The patient is successfully resuscitated and taken for operative exploration and repair of his injuries. On postoperative day 8, a right pleural effusion is noted, and thoracentesis is performed, which yields milky-appearing fluid that is high in triglycerides. What is the diagnosis?
Chylothorax -
This patient has developed a chylothorax related to thoracic duct injury. Traumatic injury to the thoracic duct may be due to penetrating or nonpenetrating trauma to the neck, thorax, or upper abdomen. The thoracic duct enters at the junction of the left subclavian and jugular veins.
Sally Sue is drunk and normally drinks 3 pints of spiked egg nog daily. You start her on high dose phenobarbital and order a phenobarb level 72 hours after admission because youre a good resident. 3 days have passed, your phenobarb level returns at 25 mcg/ml. What do you do with this information
Lower dose to PO 97.2 mg BID until 7 days are finished or until end of hospital admission