PreTest Surgery: Trauma and Shock

Question 1

A patient s/p MVC gets an NG tube that seems to go into the left chest on CXR. What should you do?

Answer 1

Immediate laparotomy for suspected diaphragmatic rupture

Question 2

Explain the management of abdominal injuries with prominent ecchymoses but otherwise negative workup.

Answer 2

Abdominal injuries with prominent ecchymoses are worrisome for small bowel injury. This can present later (hours), so you ought to observe the patient for several hours before discharging home.

Question 3

Rib fractures should be managed with ______________.

Answer 3

analgesia

The main problem of rib fractures is inadequate ventilation, which can lead to atelectasis or pneumonia. For those with respiratory compromise, you should ensure proper pain control with either a hospital stay or an epidural. Those without comorbidities can usually be treated with oral analgesics as an outpatient.

Question 4

A patient is hemodynamically unstable after a transection of the popliteal vein. What is the right immediate treatment?

Answer 4

Ligation

If a person is hemodynamically unstable you need to save their life before their limb.

Question 5

What is the appropriate management of a stable person with a penetrating abdominal wound?

Answer 5

Diagnostic laparoscopy

CT has a poor sensitivity for penetrating wounds to the abdominal organs.

Question 6

Insulin ____________ with traumatic injury.

Answer 6

increases

There is an initial drop (as a result of the catecholamine surge), but then it rises.

Question 7

Why is the bile duct connected to the jejunum in a Roux-en-Y bypass (choledochojejunostomy)?

Answer 7

The duodenum has a tendency to form fistulas with leaks whereas the jejunum doesn’t.

Question 8

Describe the two management strategies for severed common bile duct.

Answer 8

• Stable patient, no loss of tissue: T-tube with staged repair
• Unstable patient, loss of tissue: Roux-en-Y

Question 9

An upper GI series showing the corkscrew pattern around the 2nd/3rd portions of the duodenum is diagnostic of _______________.

Answer 9

duodenal hematoma

Question 10

Give the two tiers of carotid dissection management.

Answer 10

• Asymptomatic patient: antiplatelet therapy

* Patient with FNDs: surgical bypass or stenting

Question 11

Describe the immediate management of intracranial hypertension.

Answer 11

• Hyperventilate
• Elevate the head of the bed (do not do this in those with hypotension)
• Mannitol (again, do not do this in those with hypotension)

Question 12

How is flail chest managed?

Answer 12

• Analgesia
• Chest PT
• Observation
• Respiratory support (i.e., intubation) if distressed

AKA just like any other rib fracture.

Question 13

CO poisoning can be treated with 100% O2 by mask or hyperbaric oxygen. When would you use each?

Answer 13

• 100%: awake patient

* Hyperbaric: obtunded patient

Question 14

A patient has a knee dislocation but maintains adequate pedal pulses. What is the next best evaluation?

Answer 14

ABI

If the ABI is less than 0.9, angiography is indicated.

Question 15

Give the chest tube output that indicates exploratory thoracotomy.

Answer 15

•≥1500 mL initially
or
•≥ 200 mL/hr

Question 16

What is a celiotomy?

Answer 16

Abdominal laparotomy

Question 17

A patient is shot in the abdomen and ex-lap reveals a through-and-through puncture wound of the transverse colon. What should you do?

Answer 17

Repair it (primary) in the absence of hemodynamic instability

Question 18

What is the protocol for managing renal lacerations based on presentation?

Answer 18

• Stable: bed rest with serial hemoglobins

* Unstable: surgical exploration

Question 19

You suspect a urethral injury in a patient with a pelvic fracture. What is the best initial diagnostic (after the x-ray showing pelvic fracture)?

Answer 19

Retrograde urethrogram

This can show you whether a Foley can be placed or if you need to do a suprapubic.

Question 20

Review the three surgical treatments of pancreatic injury.

Answer 20

• Proximal pancreas (to the right of the mesenteric vessels): Roux-en-Y
• Distal pancreas (to the left of the mesenteric vessels: distal pancreatectomy
• Pancreas and duodenal injury: pancreaticoduodenectomy (Whipple)

Question 21

Describe the management of small bowel fistulas after surgery.

Answer 21

• For low-output fistulas (generally more distal and not caused by obstruction), treat with TPN, bowel rest, and observation. Generally, the anastomosis will close on its own.
• For high-output fistulas (generally more proximal and caused by obstruction), treat with surgical closure.

Question 22

Describe extraperitoneal bladder injury.

Answer 22

• Occurring almost exclusively with pelvic traumatic fracture, extraperitoneal bladder injury is a perforation of the bladder.
• Treated with catheter drainage for two weeks and repeat imaging (it usually self-heals).
• Surgical correction can be done if there is already going to be an open pelvic surgery (such as for fracture fixation).

Question 23

True or false: a grade V splenic injury needs to be managed operatively.

Answer 23

False

Based on hemodynamic stability and reassuring physical exam, a nonoperative treatment can be tried in any grade of splenic injury.

Question 24

List the three criteria that make a diagnostic peritoneal lavage positive.

Answer 24

• Greater than 10 mL of gross blood
• Greater than 100,000 RBCs/uL
• Greater than 500 WBCs/uL

Question 25

Normal CVP is ___________.

Answer 25

2 to 6 mm Hg

Question 26

A patient with significant abdominal trauma develops increased peak airflow pressures a few hours after exploratory laparotomy. What is this syndrome?

Answer 26

Abdominal compartment syndrome

Increased pressures in the peritoneum cause decreased blood flow to the heart (from compression of the IVC), increased SVR (compression of the vessels), and decreased perfusion of the kidneys (same).

Treat with decompressive laparotomy.

Question 27

What is the initial fluid replacement protocol for kids?

Answer 27

• First: 20 mL/kg x 2

* Second: transfusion

Question 28

According to PreTest, the best treatment for cardiac tamponade is ________________.

Answer 28

pericardiocentesis or subxiphoid drainage under local anesthetic in the OR

I’ve heard pericardiocentesis in the ER in other places… The patient in this question was only mildly hypotensive, so maybe that played into their suggestion.

Question 29

How does a pulmonary contusion appear on CXR?

Answer 29

Well-defined infiltrate with possible effusion

Question 30

Pneumothorax and air in the mediastinum suggest ______________.

Answer 30

tracheobronchial perforation