Trauma and Critical Care Flashcards
Cricothyroidotomy
A. Should not be performed in children younger than 12 years
B. Should only be performed in patients who are not good
candidates for a tracheostomy
C. Requires the use of an endotracheal tube smaller than 4 mm in diameter
D. Is preferable to the use of percutaneous transtracheal ventilation
Answer: A
Patients in whom attempts at intubation have failed or are precluded from intubation due to extensive facial injuries require a surgical airway.
Cricothyroidotomy (Fig. 7-1) and percutaneous transtracheal ventilation arc preferred over tracheostomy in most emergency situations because of their simplicity and safety.
One disadvantage of cricothyroidotomy is the inability to place a tube greater than 6 mm in diameter due to the limited aperture of the cricothyroid space.
Cricothyroidotomy is also relatively contraindicated in patients younger than 12 years because of the
risk of damage to the cricoid cartilage and the subsequent risk of
subglottic stenosis.
Which of the following is NOT a sign of tension
pneumothorax?
A. Tracheal deviation
B. Decreased breath sounds
C. Respiratory distress with hypertension
D. Distended neck veins
Answer: C
The diagnosis of tension pneumothorax is presumed in any patient manifesting respiratory distress and hypotension in combination with any of the following physical signs: tracheal deviation away from the affected side, lack of or decreased breath sounds on the affected side, and subcutaneous emphysema on the affected side.
Patients may have distended neck veins due to impedance of venous return, but the neck veins may be flat due to concurrent systemic hypovolemia.
Tension pneumothorax and simple pneumothorax have similar signs, symptoms, and examination findings, but hypotension qualifies the pneumothorax as a tension pneumothorax.
Which of the following is a cause of cardiogenic shock in a trauma patient?
A. Hemothorax
B. Penetrating injury to the aorta
C. Air embolism
D. Iatrogenic increased afterload due to pressors
Answer: C
In trauma patients the differential diagnosis of cardiogenic shock consists of a short list:
(1) tension pneumothorax,
(2) pericardial tamponade,
(3) myocardial contusion or infarction, and
(4) air embolism.
Tension pneumothorax is the most frequent cause of cardiac failure.
Traumatic pericardial tamponade is most often
associated with penetrating injury to the heart.
As blood leaks out of the injured heart, it accumulates in the pericardial sac.
Because the pericardium is not acutely distensible,
the pressure in the pericardial sac rises to match that of the injured chamber.
Since this pressure is usually greater than that of the right atrium, right atrial filling is impaired and right ventricular preload is reduced.
This leads to decreased right ventricular output and increased central venous pressure (CVP).
Increased intrapericardial pressure also impedes
myocardial blood flow, which leads to subendocardial ischemia and a further reduction in cardiac output.
This vicious cycle may progress insidiously with injury of the vena cava or atria, or precipitously with injury of either ventricle.
With acute tamponade, as little as 100 mL of blood within the pericardial sac can produce life-threatening hemodynamic compromise.
Patients usually present with a penetrating injury in
proximity to the heart, and they are hypotensive and have distended neck veins or an elevated CVP.
The classic findings of Becks triad (hypotension, distended neck, and muffled heart sounds) and pulsus paradoxus are not reliable indicators of acute tamponade.
Ultrasonography (US) in the emergency department (ED) using a subxiphoid or parasternal view is extremely helpful if the findings are clearly positive (Fig. 7-2);
however, equivocal findings are common.
Early in the course of tamponade, blood pressure (BP) and cardiac output will transiently improve with fluid administration.
This may lead the surgeon to question the diagnosis or be lulled into a false sense of security.
A trauma patient arrives following a stab wound to the left chest with systolic blood pressure (SBP) 85 mmHg, which improves slightly with intravenous (IV) fluid resuscitation.
Chest X-ray demonstrates clear lung fields. What is the most appropriate next step?
A. Computed tomography (CT) scan of the chest
B. Pelvic X-ray
C. Focused abdominal sonography for trauma (FAST) examination
D. Tube thoracostomy of the left chest
Answer: C
During the circulation section of the primary survey, four life-threatening injuries must be identified promptly:
(1) massive hemothorax,
(2) cardiac tamponade,
(3) massive hemoperitoneum, and
(4) mechanically unstable pelvic fractures with bleeding.
In this patient hemothorax is unlikely given normal chest X-ray; thus, hemoperitoneum and cardiac tamponade should be suspected.
Cardiac tamponade occurs most commonly
after penetrating thoracic wounds, although occasionally blunt rupture of the heart, particularly the atrial appendage, is seen.
Acutely, <100 mL of pericardial blood may cause pericardial tamponade. The classic Beck’s triad—dilated neck veins, muffled heart tones, and a decline in arterial pressure—is usually not appreciated in the trauma bay because of the noisy environment and associated hypovolemia.
Diagnosis is best achieved by bedside ultrasound of the pericardium, which is one of the four views of the FAST examination.
(See Schwartz 10th cd.,p. 166.)
Primary repair of the trachea should be carried out with
A. Wire suture
B. Absorbable monofilament suture
C. Nonabsorbable monofilament suture
D. Absorbable braided suture
Answer: B
Injuries of the trachea are repaired with a running 3-0 absorbable monofilament suture.
Tracheostomy is not required in most patients.
Esophageal injuries are repaired in a similar fashion. If an esophageal wound is large or if tissue is missing, a sternocleidomastoid muscle pedicle flap is warranted, and a closed suction drain is a reasonable precaution.
The drain should be near but not in contact with the esophageal or any other suture line. It can be removed in 7 to 10 days if the suture line remains secure. Care must be taken when exploring the trachea and esophagus to avoid iatrogenic injury to the recurrent laryngeal nerve.
In which patient is emergency department thoracotomy
contraindicated?
A. Motor vehicle accident victim, cardiac tamponade seen on ultrasound, SBP decreasing to 50 mm Hg.
B. Motor vehicle accident victim, became asystolic during transport with 5 minutes of cardiopulmonary resuscitation (CPR) with no signs of life.
C. Patient with chest stab wound, SBP decreasing to 50 mm Hg.
D. Patient with chest stab wound, became asystolic during transport with 20 minutes of CPR with no signs of life.
Answer: D
The utility of resuscitative thoracotomy (RT) has been debated for decades.
Current indications arc based on 30 years of prospective data, supported by a recent multicenter prospective
study.
RT is associated with the highest survival rate after isolated cardiac injury; 35% of patients presenting in shock and 20% without vital signs (ie, no pulse or obtainable BP) are salvaged after isolated penetrating injury to the heart.
For all penetrating wounds, survival rate is 15%.
Conversely, patient outcome is poor when RT is done for blunt trauma, with 2% survival among patients in shock and <1% survival among those with no vital signs.
Thus, patients undergoing cardiopulmonary resuscitation (CPR) upon arrival to the ED should undergo RT selectively based on injury and transport time.
A patient with spontaneous eye opening, who is confused and localizes pain has a Glasgow Coma Score (GCS) of
A. 9
B. 11
C. 13
D. 15
Answer: C
The Glasgow Coma Score (GCS) should be determined for all injured patients.
It is calculated by adding the scores of the best motor response, best verbal response, and eye opening. Scores range from 3 (the lowest) to 15 (normal). Scores of 13 to 15 indicate mild head injury, 9 to 12 moderate injury, and less than 9 severe injury.
The GCS is useful for both triage and prognosis.
Neck injuries
A. Less than 15% penetrating injuries require neck exploration, a majority can be managed conservatively.
B. Divided into three zones, with zone I above the angle of the mandible, zone II between the thoracic outlet and angle of mandible, and zone III inferior to the clavicles.
C. All patients with neck injury should receive computed tomography angiogram (CTA) of the neck.
D. Patients with dysphagia, hoarseness, hematoma,
venous bleeding, hemoptysis, or subcutaneous emphy¬
sema should undergo neck exploration.
Answer: A
Zone I is inferior to the clavicles encompassing the thoracic outlet structures, zone II is between the thoracic outlet and the angle of the mandible, and zone III is above the angle of the mandible. Patients with symptomatic zone I and III injuries should ideally undergo diagnostic imaging before operation if they remain hemodynamically stable.
Specific symptoms which indicate further imaging include dysphagia, hoarseness, hematoma, venous bleeding, minor hemoptysis, and subcutaneous emphysema.
Symptomatic patients should undergo CTA with further evaluation or operation based upon the imaging findings; less than 15%of penetrating cervical trauma requires neck exploration.
Asymptomatic patients are typically observed for 6 to 12 hours. The one caveat is asymptomatic patients with a transcervical gunshot wound; these patients should undergo CTA to determine the track of the bullet.
CTA of the neck and chest determines trajectory of the injury tract; further studies are performed based on proximity to major structures.
Angiographic diagnosis, particularly of zone III injuries, can then be managed by selective angioembolization.
Appropriate surgical management of a through-and-through gunshot wound to the lung with minimal bleeding and some air leak is
A. Chest tube only
B. Oversewing entrance and exit wounds to decrease the air leak
C. Pulmonary tractotomy with a stapler and oversewing of vessels or bronchi
D. Wedge resection of the injured lung
Answer: C
Pulmonary injuries requiring operative intervention usually result from penetrating injury.
Formerly the entrance and exit wounds were oversewn to control hemorrhage.
This set the stage for air embolism, which occasionally caused sudden death in the operating room or in the immediate postoperative period.
A recent development, pulmonary tractotomy, has been employed to reduce this problem as well as the need for pulmonary resection.
Linear stapling devices arc inserted directly into the injury tract and positioned to cause the least degree of devascularization.
Two staple lines are created and the lung is divided between. This allows direct access to the bleeding vessels and leaking bronchi. No effort is made to close the defect. Lobectomy or pneumonectomy is rarely necessary.
Lobectomy is only indicated for a completely devascularized or destroyed lobe.
Parenchymal injuries severe enough to require pneumonectomy are rarely survivable, and major pulmonary hilar injuries necessitating pneumonectomy are usually lethal in the field.
What is true regarding the evaluation of blunt abdominal trauma?
A. Patients with abdominal wall rigidity and negative abdominal CT should undergo diagnostic peritoneal
lavage (DPL) to rule out small bowel injury.
B. If FAST examination is negative in a hemodynamically unstable patient then DPL is indicated to rule out abdominal bleeding.
C. FAST examination cannot detect intraperitoneal fluid if the total volume is <1000 mL
D. Bowel injury can be ruled out in hemodynamically
stable patients with abdominal CT scanning.
Answer: B
The presence of abdominal rigidity and hemodynamic compromise is an undisputed indication for prompt surgical exploration.
Blunt abdominal trauma is evaluated initially by
FAST examination in most major trauma centers, and this has largely supplanted diagnostic peritoneal lavage (DPL).
FAST is not 100% sensitive, however, so diagnostic peritoneal aspiration is warranted in hemodynamically unstable patients without a defined source of blood loss to rule out abdominal hemorrhage. This method is exquisitely sensitive for detecting intraperitoneal fluid of >250 mL Patients with fluid on FAST examination, considered a ‘’positive FAST” who do not have immediate indications for laparotomy and are hemodynamically stable undergo CT scanning to quantify their injuries.
CT also is indicated for hemodynamically stable patients for whom the physical examination is unreliable. Despite the increasing diagnostic accuracy of multidetector CT scanners, identification of intestinal injuries remains a limitation.
Patients with free intraabdominal fluid without solid organ injury are closely monitored for evolving signs of peritonitis; if patients have a significant closed head injury or cannot be serially examined, DPL should be performed to exclude bowel injury.
After placement of the catheter, a 10-mL syringe is connected and the abdominal contents aspirated (termed a diagnostic peritoneal aspiration). The aspirate is considered to show positive findings if >10 mL of blood is aspirated.
If <10 mL is withdrawn, a liter of normal saline is instilled, the effluent is withdrawn via siphoning and sent to the laboratory for red blood cell (RBC) count, white blood cell (WBC) count, and determination of amylase, bilirubin, and alkaline phosphatase levels.
TABLE 7-2
Criteria for “positive” finding on diagnostic peritoneal lavage
Abdominal Trauma Red blood cell count >100,000.'mL White blood cell count >500/mL Amylase level >19 OL Alkaline phosphatase level >2 IU-'L Bilirubin level >0.01 mg/dL
Thoracoabdominal Stab Wounds Red blood cell count >10,000'mL White blood cell count >500'mL Amylase level >19IU'L Alkaline phosphatase level >2WL Bilirubin level >0.01 mg/dL
After an automobile accident, a 30-year-old woman is discovered to have a posterior pelvic fracture. Hypotension and tachycardia respond marginally to volume replacement. Once it is evident that her major problem is free intraperitoneal bleeding and a pelvic hematoma in association with the fracture, appropriate management
would be
A. Application of medical antishock trousers with inflation of the extremity and abdominal sections.
B. Arterial embolization of the pelvic vessels.
C. Celiotomy and ligation of the internal iliac arteries
bilaterally.
D. Celiotomy and pelvic packing.
E. External fixation application to stabilize the pelvis.
Answer: D
Severe pelvic bleeding is a major problem in the trauma patient. Neither external fixation nor the use of medical anti-shock trousers control free intra-abdominal hemorrhage regardless of its source.
In the unstable patient, celiotomy is mandatory. If there is a ruptured retroperitoneal hematoma bleeding into the peritoneal cavity, control is a major problem.
Internal iliac artery ligation has been abandoned as it is
rarely effective.
Angiography and arterial embolization may be effective with an arterial bleeding problem, but most severe pelvic hemorrhage is venous in origin.
If the hematoma is stable, it is best to leave it undisturbed. However, if the hematoma has ruptured into the peritoneal cavity, pelvic packing offers the best hope of control.
Which is true of vascular injuries of the extremities?
A. In the absence of hard signs of vascular injury, if the difference between SBP in an injured limb is within
15% of the uninjured limb, no further evaluation is needed.
B. Occult profunda femoris injuries can result in compartment syndrome and limb loss.
C. All patients with significant hematoma should be surgically explored.
D. Vascular injury repair should be performed prior to
realignment of bony fractures or dislocations.
Answer: B
Physical examination often identifies arterial injuries, and findings are classified as cither hard signs or soft signs of vascular injury (Table 7-3).
In general, hard signs constitute indications for operative exploration, whereas soft signs are
indications for further testing or observation.
Bony fractures or knee dislocations should be realigned before definitive vascular examination.
In management of vascular trauma, controversy exists regarding the treatment of patients with soft signs of injury, particularly those with injuries in proximity
to major vessels. It is known that some of these patients will have arterial injuries that require repair.
The most common approach has been to measure SBP using Doppler ultrasonography and compare the value for the injured side with that for the uninjured side, termed the A-A index. If the pressures are within 10% of each other, a significant injury is unlikely and no further evaluation is performed.
If the difference is >10%, CTA or arteriography is indicated.
Others argue that there are occult injuries, such as pseudoaneurysms or injuries of the profunda femoris or peroneal arteries, which may not be detected with this technique.
If hemorrhage occurs from these injuries, compartment syndrome and limb loss may occur.
Although busy trauma centers continue to debate this issue, the surgeon who is obliged to treat the occasional injured patient may be better served by performing CTA in selected patients with soft signs.
Hard Signs (Operation Mandatory):
Pulsatile hemorrhage
Absent pulses
Acute ischemia
Soft Signs (Further Evaluation Indicated):
Proximity to vasculature
Significant hematoma
Associated nerve injury
A-A index (systolic blood pressure on the injured side compared with that on the uninjured side) of <0.9
Thrill or bruit
Which of the following statements about blunt carotid injuries is true?
A. Magnetic resonance imaging is the diagnostic modality of choice in patients at risk.
B. Approximately 50% of patients have a delayed
diagnosis.
C. The mechanism of injury is usually cervical flexion
and rotation.
D. Such injuries are always treated operatively when
identified.
Answer: B
Blunt injury to the carotid or vertebral arteries may cause dissection, thrombosis, or pseudoaneurysm.
More than one half of patients have a delayed diagnosis.
Facial contact resulting in hypertension and rotation appears to be the mechanism.
To reduce delayed recognition, the authors employ CTA in patients at risk, to identify these injuries before neurologic symptoms develop. The injuries frequently occur at or extend into the base of the skull and are usually not surgically accessible.
Currently accepted treatment for thrombosis and dissection is anticoagulation with heparin followed by warfarin for 3 months.
Pseudoaneurysms also occur near the base of
the skull. If they are small, they can be followed with repeat angiography.
If enlargement occurs, consideration should be
given to the placement by an interventional radiologist of a stent across the aneurysm.
Another possibility is to approach the intracranial portion of the carotid by removing the overlying bone and performing a direct repair. This method has only recently been described and has been performed in a limited
number of patients.
Massive transfusion protocols
A. Should include transfusion of plasma and platelets in addition to packed RBCs
B. Should only be initiated after blood typing, but cross match is not needed
C. Should be initiated in patients with tachycardia despite administration of 3.5 Lof crystalloid fluids
D. Should include testing for coagulopathies, present in 5% of patients requiring massive transfusion
Answer: A
In the critically injured patient requiring large amounts of blood component therapy, a massive transfusion protocol should be followed.
This approach calls for administration of various components in a specific ratio during transfusion
to achieve restoration of blood volume and correction of coagulopathy.
Although the optimal ratio is yet to be determined, current scientific evidence indicates a presumptive 1:2 RBC: plasma ratio in patients at risk for massive transfusion.
Because complete typing and cross-matching takes up to 45 minutes, patients requiring emergent transfusions are given type O, type-specific, or biologically compatible RBCs.
Blood typing, and to a lesser extent cross-matching, is essential to
avoid life-threatening intravascular hemolytic transfusion reactions.
Injured patients with life-threatening hemorrhage develop an acute coagulopathy of trauma (ACOT). Activated protein C is a key element, although the complete mechanism remains
to be elucidated.
Fibrinolysis is an important component of the ACOT; present in only 5% of injured patients requiring
hospitalization, but 20% in those requiring massive transfusion.
T e most appropriate treatment for a duodenal hematoma that occurs from blunt trauma is
A. Exploratory laparotomy and bypass of the duodenum.
B. Exploratory laparotomy and evacuation of the
hematoma.
C. Exploratory laparotomy to rule out associated
injuries.
D. Observation.
Answer: D
Duodenal hematomas are caused by a direct blow to the abdomen and occur more often in children than adults.
Blood accumulates between the seromuscular and submucosal layers, eventually causing obstruction.
The diagnosis is suspected by the onset of vomiting following blunt abdominal trauma; barium examination of the duodenum reveals either the coiled spring sign or obstruction.
Most duodenal hematomas in children can be managed nonopcratively with nasogastric suction and parenteral nutrition.
Resolution of the obstruction occurs in the majority of patients if this therapy is continued for 7 to 14 days.
If surgical intervention becomes necessary, evacuation of the hematoma is associated with equal success but fewer complications than bypass procedures.
Despite few existing data on adults, there is no reason to believe that their hematomas should be treated differently from those of children.
A new approach is laparoscopic evacuation if the obstruction persists more than 7 days.
Damage control surgery (DCS)
A. Limits enteric spillage by rapid repair of partial small bowel injuries with whipstitch, and complete transection with a GIA stapling device.
B. Aims to control surgical bleeding and identify injuries that can be managed conservatively or with interventional radiology.
C. Is indicated when patients develop intraoperative refractory hypothermia, scrum pH >7.6, or refractory coagulopathy.
D. Abdominal wall should be closed with penetrating towel clips.
Answer: A
The goal of damage control surgery (DCS) is to control surgical bleeding and limit gastrointestinal (GI) spillage. The operative techniques used are temporary measures, with definitive repair of injuries delayed until the patient is physiologically replete.
Small GI injuries (stomach, duodenum, small intestine, and colon) may be controlled using a rapid whipstitch of 2-0 polypropylene.
Complete transection of the bowel or segmental damage is controlled using a GIA stapler, often with resection of the injured segment.
Before the patient is returned to the surgical intensive care unit (SICU), the abdomen must be temporarily closed.
Originally, penetrating towel clips were used to approximate the skin; however, the ensuing bowel edema often produces a delayed abdominal compartment syndrome.
Instead, the bowel is covered with a fenestrated subfascial sterile drapes (45 x 60 cm Steri-Drape 3M
Health Care), and two Jackson-Pratt drains are placed along the fascial edges; this is then covered using an Ioban drape, which allows closed suction to control reperfusion-related ascitic fluid egress while providing adequate space for bowel expansion to prevent abdominal compartment syndrome.
Therapy for increased intracranial pressure (ICP) in a patient with a closed head injury is instituted when the
ICP is greater than
A. 10
B. 20
C. 30
D. 40
Answer: B
In patients with abnormal findings on CT scans and GCS scores of <8, intracranial pressure (ICP) should be monitored using fiberoptic intraparenchymal devices or intraventricular catheters.
Although an ICP of 10 mm Hg is believed to be the
upper limit of normal, therapy generally is not initiated until ICP is >20 mm Hg.
Indications for operative intervention to remove space-occupying hematomas are based on the clot volume, amount of midline shift, location of the clot, GCS score, and ICP.
A shift or>5 mm typically is considered an indication for evacuation, but this is not an absolute rule.
Cerebral perfusion pressure (CPP)
A. Equals the SBP minus ICP
B. Should be targeted to be greater than 100 mmHg
C. Is lowered with sedation, osmotic diuresis, paralysis,
ventricular drainage, and barbiturate coma
D. Can be increased by lowering ICP and avoiding
hypotension
Answer: D
The goal of resuscitation and management in patients with head injuries is to avoid hypotension (SBP of <100 mm Hg) and hypoxia (partial pressure of arterial oxygen of <60 or arterial oxygen saturation of <90).
Attention, therefore, is focused on maintaining cerebral perfusion rather than merely lowering ICP.
Resuscitation efforts aim for a euvolemic state and
an SBP of >100 mm Hg.
Cerebral perfusion pressure (CPP) is equal to the mean arterial pressure minus the ICP, with a target range of >50 mm Hg.
CPP can be increased by either lowering ICP or raising mean arterial pressure.
Sedation, osmotic diuresis, paralysis, ventricular drainage, and barbiturate coma are used in sequence, with coma induction being the last resort.
An 18-year-old man is admitted to the ED shortly after being involved in an automobile accident. He is in a coma (GCS = 7). His pulse is barely palpable at a rate of 140 beats per minute, and BP is 60/0. Breathing is rapid and shallow, aerating both lung fields. His abdomen is moderately distended with no audible peristalsis. There are closed fractures of the right forearm and the left lower leg.
After rapid IV administration of 2 L of lactated Ringer solution in the upper extremities, his pulse is 130 and BP
70/0. The next immediate step should be to
A. Obtain cross-table lateral X-rays of the cervical spine.
B. Obtain head and abdominal CT scans.
C. Obtain supine and lateral decubitus X-rays of the abdomen.
D. Obtain an arch aortogram.
E. Explore the abdomen.
Answer: E
Ideally, a patient seriously injured in an automobile accident should undergo X-rays of the cervical spine, the chest, and the abdomen.
When he has a GCS of 7, CT scans of the head are
certainly desirable. If the chest X-ray shows a widened mediastinum, arch aortograms are indicated. However, this patient has had no response to a rapid fluid challenge, and if he is to survive, bleeding must be controlled immediately.
The head injury, although severe, is not responsible for his hypotension and tachycardia.
The most likely problem is uncontrolled abdominal hemorrhage. Immediate abdominal exploration offers the best chance for survival.
A 36-year-old patient arrives in the trauma bay with a stab wound to the left chest. After placement of a left thoracostomy tube and fluid resuscitation, his breathing is stable with BP 160/74 mm Hg and heart rate of 110 beats per minute. CT scanning reveals a descending thoracic pscudoaneurysm and no intracranial or intra-abdominal injury. What is the most appropriate next step?
A. Open repair with partial left heart bypass
B. Endovascular repair with stent
C. Esmolol drip
D. Admission to SICU with repeat CT in 24 hours
Answer: C
Descending thoracic aortic injuries may require urgent if not emergent intervention.
However, operative intervention for intracranial or intra-abdominal hemorrhage or unstable pelvic fractures takes precedence.
To prevent aortic rupture, pharmacologic therapy with a selective ß-antagonist, esmolol, should be instituted in the trauma bay, with a target SBP of <100 mm Hg and heart rate of <100 beats per minute.
Endovascular stenting is now the mainstay of treatment, but open operative reconstruction is warranted, or necessary, in select patients.
Endovascular techniques are particularly appropriate in patients who cannot tolerate single lung ventilation,
patients older than 60 years who are at risk for cardiac decompensation with aortic clamping, or patients with uncontrolled intracranial hypertension.
A patient with penetrating injury to the chest should
undergo thoracotomy if
A. There is more than 500 mL of blood which drains from the chest tube when placed.
B. There is more than 200 mL/h of blood for 3 hours
from the chest tube.
C. There is an air leak that persists for >48 hours.
D. There is documented lung injury on CT scan.
Answer: B
The most common injuries from both blunt and penetrating thoracic trauma are hemothorax and pneumothorax.
More than 85% of patients can be definitively treated with a chest tube. The indications for thoracotomy include significant initial or ongoing hemorrhage from the tube thoracostomy and specific imaging-identified diagnoses.
One caveat concerns the patient who presents after a delay. Even when the initial chest tube output is 1.6 L, if the output ceases and the lung is re-expanded, the patient may be managed non operatively, if hemodynamically stable.
Indications for operative treatment of thoracic injuries:
- Initial tube thoracostomy drainage of >1000 mL (penetrating injury) or >1500 mL (blunt injury)
- Ongoing tube thoracostomy drainage of >200 mL/h or 3 consecutive hours in noncoagulopathic patients
- Caked hemothorax despite placement of two chest tubes
- Selected descending torn aortas
- Great vessel injury (endovascular techniques may be used in selected patients)
- Pericardial tamponade
- Cardiac herniation
- Massive air leak rom the chest tube with inadequate ventilation
- Tracheal or mainstem bronchial injury diagnosed by endoscopy or imaging
- Open pneumothorax
- Esophageal per oration
- Air embolism
After sustaining a gunshot wound to the right upper quadrant of the abdomen, the patient has no signs of peritonitis.
Her vital signs are stable, and CT scan shows a grade III
liver injury. What is the next step in management?
A. Exploratory laparotomy with control of hepatic
parenchymal hemorrhage.
B. Admission to SICU with serial complete blood count.
C. Admission to SICU with repeat CT in 24 hours.
D. Hepatic angiography.
Answer: B
The liver’s large size makes it the organ most susceptible to blunt trauma, and it is frequently involved in upper torso penetrating wounds.
Nonoperative management of solid organ injuries is pursued in hemodynamically stable patients who do not have overt peritonitis or other indications for laparotomy.
Patients with more than grade II injuries should be admitted to the SICU with frequent hemodynamic monitoring, determination of hemoglobin, and abdominal examination.
The only absolute contraindication to nonoperative management is hemodynamic instability.
Factors such as high injury grade, large hemoperitoneum, contrast extravasation, or pseudoaneurysms may predict complications or failure of nonoperative management.
Angioembolization and endoscopic retrograde
cholangiopancreatography (ERCP) are useful adjuncts that can improve the success rate of nonoperative management.
The indication for angiography to control hepatic hemorrhage is transfusion of 4 units of RBCs in 6 hours or 6 units of RBCs in 24 hours without hemodynamic instability.
A 25-year-old man has multiple intra-abdominal injuries after a gunshot wound. Celiotomy reveals multiple injuries to small and large bowel and major bleeding from the liver. After repair of the bowel injuries, the abdomen is closed with towel clips, leaving a large pack in the injured liver. Within 12 hours, there is massive abdominal swelling with edema fluid, and intra-abdominal pressure exceeds 35 mm Hg. The immediate step in managing this problem is to
A. Administer albumin intravenously
B. Give an IV diuretic
C. Limit IV fluid administration
D. Open the incision to decompress the abdomen
Answer: D
Cardiac, pulmonary, and renal problems develop when invasive ascites compresses the diaphragm and the inferior vena cava. Dialysis, diuresis, and increasing scrum oncotic pressure will not correct this problem rapidly enough to save the patient’s life.
Opening the incision relieves the intra-abdominal
pressure. There are few reports of sudden hypotension after this maneuver, but volume loading has largely eliminated this problem.
Which of the following statements is correct regarding traumatic spleen injury?
A. An elevation in WBC to 20,000/mm3 and platelets to 300,000/mm3 on postoperative day 7 is a common benign finding in postsplenectomy patients.
B. Delayed rebleeding or rupture will typically occur within 48 hours of injury.
C. Common complications after splenectomy include
subdiaphragmatic abscess, pancreatic tail injury, and gastric perforation.
D. Postsplcncctomy vaccines against encapsulated bacteria is optimally administered preoperatively or
immediately postoperative.
Answer: C
Unlike hepatic injuries, which usually rebleed within 48 hours, delayed hemorrhage or rupture of the spleen can occur up to weeks after injury.
Indications for early intervention include
initiation of blood transfusion within the first 12 hours and
hemodynamic instability.
After splenectomy or splenorrhaphy, postoperative hemorrhage may be due to loosening of a tie
around the splenic vessels, an improperly ligated or unrecognized short gastric artery, or recurrent bleeding from the spleen if splenic repair was used.
An immediate postsplenectomy increase in platelets and WBCs is normal; however, beyond postoperative day 5, a WBC count above 15,000/mm3 and a platelet/WBC ratio of <20 arc strongly associated with sepsis and should prompt a thorough search for underlying infection.
A common infectious complication after splenectomy is a subphrenic abscess, which should be managed with percutaneous drainage.
Additional sources of morbidity include a concurrent but unrecognized iatrogenic injury to the pancreatic tail during rapid splenectomy resulting in pancreatic ascites or fistula, and a gastric perforation during short gastric ligation.
Enthusiasm for splenic salvage was driven by the rare, but often fatal, complication of overwhelming postsplenectomy sepsis.
Overwhelming postsplenectomy sepsis is caused by encapsulated bacteria, Streptococcus pneumoniae, Haemophilus influenzae, and Neisseria meningitidis, which are resistant to antimicrobial
treatment.
In patients undergoing splenectomy, prophylaxis
against these bacteria is provided via vaccines administered optimally at 14 days.
The most appropriate treatment for a duodenal hematoma that occurs from blunt trauma is
A. Exploratory laparotomy and bypass of the duodenum
B. Exploratory laparotomy and evacuation of the
hematoma
C. Exploratory laparotomy to rule out associated injuries
D. Observation
Answer: D
Duodenal hematomas arc caused by a direct blow to the abdomen and occur more often in children than adults. Blood accumulates between the seromuscular and submucosal layers, eventually causing obstruction.
The diagnosis is suspected by the onset of vomiting following blunt abdominal trauma; barium examination of the duodenum reveals either the coiled spring sign or obstruction.
Most duodenal hematomas in children can be managed nonoperatively with nasogastric suction and parenteral nutrition.
Resolution of the obstruction occurs in the majority of patients if this therapy is continued for 7 to 14 days.
If surgical intervention becomes necessary, evacuation of the hematoma is associated with equal success but fewer complications than bypass procedures.
Despite few existing data on adults, there is no reason to believe that their hematomas should be treated differently from those of children.
A new approach is laparoscopic evacuation if the obstruction persists more than 7 days.
A 19-year-old man fell of his skateboard, reporting blunt injury to his upper abdomen.
Abdominal CT and magnetic resonance cholangiopancreatography (MRCP) confirmed he suffered transection of the main pancreatic duct at the middle of the pancreatic body.
Which of the following would be the most appropriate next step in management?
A. Nonoperative treatment
B. Endoscopic retrograde cholangiopancreatography
(ERCP) with stenting of pancreatic duct
C. Distal pancreatectomy with splenic preservation
D. Primary repair of pancreatic duct with closed suction drainage
Answer: C
Optimal management of pancreatic trauma is determined by where the parenchymal damage is located and whether the intrapancreatic common bile duct and main pancreatic duct remain intact.
Patients with pancreatic contusions (defined as injuries that leave the ductal system intact) can be treated nonoperatively or with closed suction drainage if undergoing laparotomy for other indications.
Patients with proximal pancreatic injuries, defined as those that lie to the right of the superior mesenteric vessels, are also managed with closed suction drainage.
In contrast, distal pancreatic injuries are managed based upon ductal integrity.
Pancreatic duct disruption can be identified through direct exploration of the parenchymal laceration, operative pancreatography, endoscopic retrograde pancreatography (ERCP), or magnetic resonance
cholangiopancreatography (MRCP).
Patients with distal ductal disruption undergo distal pancreatectomy, preferably with splenic preservation.
An alternative, which preserves both the spleen and distal transected end of the pancreas, is either
a Roux-en-Y pancreaticojejunostomy or pancreaticogastrostomy.
If the patient is physiologically compromised, distal
pancreatectomy with splenectomy is the preferred approach.
The most appropriate treatment for a gunshot wound to the hepatic flexure of the colon that cannot be repaired
primarily is
A. End colostomy and mucous fistula.
B. Loop colostomy.
C. Exteriorized repair.
D. Resection of the right colon with ilcocolostomy.
Answer: D
Numerous large retrospective and several prospective studies have now clearly demonstrated that primary repair is safe and effective in the majority of patients with penetrating injuries.
Colostomy is still appropriate in a few patients, but the current dilemma is how to select them.
Exteriorized repair is probably no longer indicated since most patients who were once candidates for this treatment are now successfully managed by primary repair.
Two methods have been advocated that result in 75 to 90% of penetrating colonic injuries being safely treated by primary repair.
The first is to repair all perforations not requiring resection. If resection is required due to the local extent of the injury, and it is proximal to the middle colic artery, the proximal portion of the right colon up to and including the injury is resected and an ileocolostomy performed.
If resection is required distal to the middle colic
artery, an end colostomy is created and the distal colon oversewn and left within the abdomen.
The theory behind this approach is that an ileocolostomy heals more reliably than colocolostomy, because in the trauma patient who has suffered shock and may be hypovolemic, assessing the adequacy of the blood supply of the colon is much less reliable than in elective procedures.
The blood supply of the terminal ileum is never a problem. The other approach is to repair all injuries regardless of the extent and location (including colocolostomy), and reserve colostomy for patients with protracted shock and extensive contamination.
The theory used to support this approach is that systemic factors are more important than local factors in determining whether a suture line will heal.
Both of these approaches are reasonable and result in the majority of patients being treated by primary repairs.
When a colostomy is required, regardless of the theory used to reach that conclusion, performing a loop colostomy proximal to a distal repair should be avoided because a proximal colostomy does not protect a distal suture line.
All suture lines and anastomoses are performed with the running single-layer technique.
Which of the following statements is FALSE regarding traumatic genitourinary injury?
A. If exploratory laparotomy is performed for trauma, all blunt and penetrating wounds to the kidneys should be explored.
B. Renal vascular injuries are common after penetrating trauma, and can be deceptively tamponaded by surrounding fascia.
C. Success of renal artery repair after blunt trauma is slim, but can be attempted if injury occurred within 5 hours or patient does not have any reserve renal function (solitary kidney or bilateral injury).
D. Suspected ureteral injuries in patients with penetrating trauma or pelvic fractures can be evaluated intraoperatively with methylene blue or indigo carmine administered intravenously.
E. Bladder injuries with extraperitoneal extravasation can be managed with Foley decompression for 2 weeks.
Answer: A
When undergoing laparotomy for trauma, the best policy is to explore all penetrating wounds to the kidneys.
However, over 90% of blunt injuries are treated nonoperatively; the indications for surgery include parenchymal injuries leading to hypotension and evidence of renovascular injury.
If laparotomy is performed in the setting of blunt kidney injury for other reasons, expanding or pulsatile perinephric hematomas should be explored.
Injuries to the ureters are uncommon but may occur in patients with pelvic fractures and penetrating trauma.
An injury may not be identified until a complication (ie, a urinoma) becomes apparent.
If an injury is suspected during operative exploration but is not clearly identified, methylene blue or indIgo carmine is administered IV with observation for extravasation.
Bladder injuries are subdivided into those with intraperitoneal extravasation and those with extraperitoneal extravasation.
Extraperitoneal ruptures are treated nonoperatively with bladder decompression for 2 weeks, whereas injuries with intraperitoneal extravasation can be closed primarily.
Urethral injuries are managed by bridging the defect with a Foley catheter, with or without direct suture repair.
Strictures are not uncommon but can be managed electively.
At what pressure is operative decompression of a compartment mandatory?
A. 15 mmHg
B. 25mmHg
C. 35mmHg
D. 45mmHg
Answer: D
In comatose or obtundcd patients, the diagnosis is more difficult to secure.
A compatible history, firmness of the compartment to palpation, and diminished mobility of the joint are suggestive.
The presence or absence of a pulse distal to the affected compartment is notoriously unreliable in the diagnosis of a compartment syndrome.
A frozen joint and myoglobinuria are late signs and suggest a poor prognosis.
As in the abdomen, compartment pressure can be measured. The small, hand-held Stryker device is a convenient tool for this purpose.
Pressures greater than 45 mm Hg usually require operative intervention.
Patients with pressures between 30 and 45 mm
Hg should be carefully evaluated and closely watched.
(See Schwartz 10th ed.,p. 215.)
Which is true regarding trauma in geriatric patients?
A. Admission GCS score after severe head injury is a good predictor of outcome.
B. Rib fractures are associated with pulmonary contusion in 35% of patients, and complicated by pneumonia in 10 to 30% of patients.
C. Approximately 10% of patients older than 65 years
will sustain a rib fracture from a fall <6 ft.
D. Chronologic age older than 65 years is associated with higher morbidity and mortality after trauma.
Answer: B
Mortality in patients with severe head injury more than doubles after the age of 55 years.
Moreover, 25% of patients with a normal GCS score of 15 had intracranial bleeding, with an associated mortality of 50%.
Just as there is no absolute age that predicts outcome, admission GCS score is a poor predictor of individual outcome.
Therefore, the majority of trauma centers advocate an initial aggressive approach with re-evaluation at the 72-hour mark to determine subsequent care.
Secondly, one of the most common sequelae of blunt thoracic trauma is rib fractures. In fact, in one study, 50% of patients older than 65 years sustained rib fractures from a fall of <6 ft, compared with only 1% of patients younger than 65 years.
Concurrent pulmonary contusion is noted in up to 35% of patients, and pneumonia complicates the injuries in 10 to 30% of patients with rib fractures.
A 76-year-old man with hypertension, chronic renal insufficiency, and Child class A cirrhosis is admitted to the intensive care unit (ICU) after emergency exploratory laparotomy for ruptured appendicitis. His vital signs are a temperature of 97.3°F, heart rate (HR) of 129 beats/min, blood pressure (BP) of 220/90 mmHg, respiratory rate (RR) of 30 breaths/min, and oxygen saturation (Sao2) of 90%. The patient is agitated and trying to pull his drains and nasogastric tube. He does not appear to respond to commands. Select the best choice to sedate this patient.
A. Lorazepam, 5 mg intravenously (IV)
B. Four-point restraints while trying to reason with the patient
C. Morphine delivered by patient-controlled anesthesia (PCA) with settings of 1 mg every 6 min and a 30-mg 4-h lockout
D. Diprivan and fentanyl drip
E. Placement of an epidural catheter for analgesia
ANSWER: D
COMMENTS: In the ICU, management of pain can be difficult and is often complicated by an inability to communicate with the patient and by the patient’s physiologic instability, comorbid conditions, or delirium.
Several methods have been developed to help assess sedation, including the Riker Sedation-Agitation Scale and the Ramsay Scale.
This patient has both renal and hepatic dysfunction, which makes lorazepam an incorrect choice. It has a slow onset and intermediate half-life.
In this situation, a faster-acting drug is preferable because the patient is obviously agitated.
A Diprivan and fentanyl drip is the best answer because Diprivan is a general anesthetic agent with a rapid onset and ultrashort duration of action.
Side effects of this medication include a risk for hypotension, high cost, pain on injection, and potential for hypertriglyceridemia.
It has no analgesic effect and therefore additional medication is required to control the pain.
Fentanyl is a better choice for analgesia because of the patient’s renal failure and its rapid onset of action relative to morphine, which can take 5 to 10 min.
The use of four-point restraints without additionally sedating the patient is not a good option.
Again, PCA is not a good option for a patient intubated and needing further sedation because of agitation.
Moreover, morphine and its active metabolites (morphine-3-glucuro- nide and morphine-6-glucuronide) can accumulate in patients with renal insufficiency.
Finally, placing an epidural catheter in an agitated patient would be difficult and dangerous to the patient and staff.
A 53-year-old man with coronary artery disease, Child class B alcoholic cirrhosis, and chronic renal insufficiency is admitted to the ICU after undergoing exploratory laparotomy and resection of necrotic small bowel from an incarcerated ventral hernia. He is septic and continues to require mechanical ventilation. Arterial blood gas analysis revealed a pH of 7.59, Pco2 of 20 mmHg, Po2 of 59 mmHg, HCO3 of 21 mEq/L, base deficit of −2, and Sao2 of 88%. The nurse calls because the ventilator alarms continue to go off. The patient is actually breathing at a rate of 43 breaths/min. After adequately sedating him, he is still dyssynchronous with the ventilator. Which paralytic agent is the most appropriate for this patient?
A. Pancuronium
B. Cisatracurium
C. Vecuronium
D. Succinylcholine
E. Rocuronium
ANSWER: B
COMMENTS: The best choice is cisatracurium, a nondepolarizing neuromuscular blocker and one of the most commonly used paralytics in the ICU.
It, along with atracurium, is metabolized by plasma ester hydrolysis and Hofmann elimination and is therefore the best choice in this patient with both hepatic and renal dysfunction.
Pancuronium is long acting but contraindicated in patients with coronary artery disease because it has a vagolytic effect and induces tachycardia.
Vecuronium is intermediate acting (30 min) but is cleared by the kidney and liver.
Succinylcholine is a short- acting depolarizing neuromuscular blocker, usually for facilitation of endotracheal intubation.
Rocuronium has a rapid onset and intermediate duration thus making it a better choice for short procedures, as opposed to the needs of this patient, who must be sedated for a longer period.
Which of the following statements concerning radial artery cannulation is true?
A. Aortic systolic pressure is higher than radial systolic pressure.
B. The Allen test is an outdated mode of assessing the collateral flow of the ulnar and radial arteries.
C. The incidence of infection is higher with catheters placed by surgical cutdown.
D. The catheter should be replaced every 3 days.
E. Intermittent flushing to keep the catheter free of clots is desirable.
ANSWER: C
COMMENTS: The incidence of complications after arterial catheterization seems to be operator independent, unlike the case with pulmonary artery (PA) catheterization.
Known risk factors include intermittent punctures, age younger than 10 years, prolonged catheterization (>4 days), anticoagulant therapy, and use of a catheter larger than 20 gauge or made of polypropylene rather than Teflon.
The radial artery is the site most frequently used for catheterization, provided that the ulnar artery and palmar arterial arch are patent.
Therefore the Allen test should be performed before attempting radial artery catheterization.
A normal test result consists of a palmar blush within 7s after the ulnar artery is released.
Most patients with arterial thrombosis remain asymptomatic. Symptoms can be minimized by placing lines in arteries with good collateral circulation.
Most thrombi (43%) are present at the time of catheter removal and another 30% develop within 24 h.
A higher incidence of thrombosis occurs within the first 24h when surgical cutdown is performed (48% vs. 23% with percutaneous placement), but the incidence of thrombosis at 1 week is the same for both methods of placement.
Brachial artery cannulation has a high incidence of embolic occlusion of the distal arteries (5%–41%) and should therefore be avoided.
Infection remains the most common complication.
Predisposing factors are prolonged catheterization, surgical cutdown, local inflammation, pre- existing bacteremia, and failure to change the saline flush fluid, transducer, and flush tubing every 48 h.
The need for intermittent arterial catheter replacement is not established and indeed is controversial.
The aortic mean arterial pressure (MAP) and diastolic arterial pressure are slightly higher than the radial MAP and diastolic arterial pressure.
However, systolic pressure is consistently higher in the radial artery than in the aorta. This discrepancy increases with distal progression, smaller arterial caliber, and age and is explained by the reflection of pressure waves from capillary beds, which results in augmentation of the systolic and reduction of the diastolic values measured.
A 70-kg, 72-year-old man known to suffer from congestive heart failure (CHF), arthritis, diabetes mellitus, and a first-degree heart block is intubated in the ICU on postoperative day 2 after exploratory laparotomy for perforated sigmoid diverticulitis. His urine output has dropped to 10 mL/h for the last shift, and he is hypotensive despite several fluid boluses. A PA catheter is placed through the right internal jugular vein with some difficulty. As the line is advanced to 50 cm, the patient has a 14-beat run of ventricular tachycardia, which resolves when the catheter is pulled back. It is finally advanced to 62 cm, and the balloon is inflated with 3cc of air. As the line is being secured, a large amount of blood is noted in the endotracheal tube and the patient becomes hypotensive. Select the best intervention for this patient:
A. Place external pacing wires and administer lidocaine to treat the ventricular tachycardia.
B. Place a double-lumen endotracheal tube and occlude the appropriate bronchus with a Fogarty catheter.
C. Pull the PA catheter back 2 cm with the balloon inflated.
D. Suction the endotracheal tube while deflating the balloon by 2 cc of air.
E. Obtain a chest radiograph to confirm the correct placement of the line.
ANSWER: B
COMMENTS: The indications for PA catheters and their value in patients with sepsis or hemodynamic instability are uncertain, but they may be useful in the management of patients unresponsive to the use of fluids and vasoactive agents.
Dysrhythmias occur in 12%–67% of patients undergoing catheterization but are usually self-limited, premature ventricular contractions.
Complete heart block can develop in patients with preexisting left bundle branch block.
A prophylactic pacing wire should be used in these patients.
Prophylactic lidocaine and full inflation of the balloon may prevent ventricular ectopy.
Hemoptysis in patients with a PA catheter sug- gests the diagnosis of perforation or rupture.
Mechanisms involved in PA rupture include
(1) overinflation of the balloon,
(2) incomplete balloon inflation (<75%) with the exposed tip being forced through the wall, and
(3) pulmonary hypertension
An “overwedge” pattern suggests eccentric balloon inflation, overdistention, or both. If hemoptysis develops, the catheter should be pulled back, with the balloon deflated.
Massive hemoptysis necessitates placement of a double-lumen endotracheal tube and occlusion of the bronchus on the side of the rupture with a Fogarty catheter.
Emergency thoracotomy is needed. Looping or knotting of the catheter may occur in the right ventricle during insertion and can be avoided if no more than 10 cm of the catheter are inserted after a ventricular tracing is identified and before a PA tracing appears.
Although catheter-related sepsis occurs in only up to 2% of insertions, bacterial colonization takes place in 5%–35% of catheterizations.
Infections are more common when the catheter is left in place for more than 72 h or when it is inserted via an antecubital vein.
A 51-year-old morbidly obese female who has a known history of symptomatic cholelithiasis is admitted to the ICU after presenting to the emergency department (ED) with severe epigastric pain. Her temperature is 100.5°F; HR, 115 beats/min; and BP, 123/84 mmHg. Her laboratory values are significant for a white blood cell (WBC) count of 15,000/ mm3 and a lipase of 1547. A computed tomography (CT) scan shows peripancreatic inflammation with a small fluid collection.
What is the next best step in the management of this patient?
A. Central line placement for monitoring of central venous pressure (CVP)
B. Broad-spectrum antibiotics
C. Placement of an enteral feeding tube and initiation of tube feeding
D. Percutaneous drain placement
E. Cholecystectomy
ANSWER: C
COMMENTS: Acute pancreatitis may have a variable presentation dependent on both etiology and severity.
If the patient is presenting with signs of shock and organ hypoperfusion, initial interventions must be targeted toward the improvement of oxygen delivery.
Additionally, CT is helpful in determining if pancreatic necrosis with or without infection is present.
Typically, infected pancreatic necrosis will present with air within the peripancreatic fluid collection, necessitating drainage or debridement.
The role of prophylactic antibiotics in severe pancreatitis has been debated without consensus.
A small number of randomized trials found benefit with fewer infectious complications when antibiotics are given prophylactically. However, this has not been widely repro- ducible.
Cholecystectomy should be performed prior to the patient’s discharge from the hospital, but not in the acute setting.
Early enteral feeding, typically beyond the second portion of the duodenum, is preferable over parenteral nutrition and is associated with fewer infectious complications.
Of the following parameters, which is the best predictor of
successful extubation?
A. Increase in Paco2 of less than 10 mmHg during a spontaneous breathing trial (SBT)
B. Spontaneous tidal volume (Vt)
C. 10-s head raise
D. Rapid shallow breathing index (RSBI)
E. Minute ventilation
ANSWER: D
COMMENTS: Many measures are utilized in order to determine the appropriateness for a trial of extubation.
The RSBI is RR divided by Vt.
A value of more than 105 predicts failure of extuba- tion in over 95% of patients, while an RSBI less than 105 predicts success in over 80% of patients.
Other factors can be useful in the decision to extubate; however, they are individually not as reliable as the RSBI.
The importance of reliable and objective indicators for successful liberation from the ventilator is tied to the avoidance of complications such as ventilator-associated pneumonia (VAP), along with a decreased requirement for sedative medications.
A 44-year-old male heroin user is intubated in the surgical intensive care unit (SICU) after undergoing debridement of a lower extremity wound. His vital signs are a temperature of 102.3°F, HR of 134 beats/min, and BP of 80/40 mmHg with a MAP of 55 mmHg. A triple lumen catheter is placed, and CVP reads 12 mmHg. Norepinephrine is started, and despite being at the upper limit of the recommended dose, the MAP increases to 62 mmHg. What is the next best step?
A. Fluid bolus
B. Echocardiography
C. Dobutamine
D. Epinephrine
E. Vasopressin
ANSWER: D
COMMENTS: This patient remains in septic shock postoperatively from debridement of an infected wound.
We can presume the source to be the wound and therefore source control has been obtained.
He should remain on broad-spectrum antibiotics and achieve certain parameters as directed by goal-directed therapy.
He is intubated, which mandates a goal CVP of 10 to 12 mmHg.
If he were extubated, a lower CVP of 8 to 10 mmHg would be appropriate, given the absence of positive pressure ventilation.
This indicates he is volume resuscitated or has an adequate preload.
If you are concerned about cardiac function, or need an indicator other than CVP to determine the volume status, echocardiography is indicated.
However, this patient remains hypotensive despite norepinephrine, and something must be done in the interim.
The first vasopressor used in septic shock should be norepinephrine. If a second vasopressor is required, it is now recommended that epi- nephrine be added to norepinephrine to achieve a MAP greater than 65 mmHg.
Vasopressin may be added subsequently, but the dose should not exceed 0.03 units/min.
Which of the following is an indication to give calcium gluconate in a patient with hyperkalemia?
A. Serum potassium of 6.2
B. Electrocardiogram (ECG) changes consistent with hyperkalemia
C. The patient does not have preexisting renal disease
D. Both A and B
E. All of the above
ANSWER: B
COMMENTS: While mild hyperkalemia is well tolerated, severe hyperkalemia results in a predictable progression of cardiac effects.
Classically, peaked T waves are the first to appear on ECG, fol- lowed by a widened QRS complex, loss of P wave, appearance of “sine” waves, and eventually ventricular fibrillation. Emergent treatment of hyperkalemia focuses first on the antagonization of the depolarizing effect that a high level of potassium has on the cardiac membranes.
Calcium should be administered
(1) to any patient with a serum potassium level of 6.5 or greater or
(2) to any patient with ECG changes consistent with hyperkalemia regardless of the potas- sium level.
Other treatment of acute hyperkalemia includes redistribution of potassium to the intracellular space with insulin or β-agonists (albuterol).
Ultimately, the elimination of excess potassium from the body is achieved by administering loop diuretics, sodium bicarbonate, Kayexalate, or hemodialysis.
You are asked to see a 24-year-old male with no medical problems who sustained a gunshot wound to the right thigh 1 h prior to arrival. He is afebrile with an HR of 136 beats/min and a BP of 90/60 mmHg. He is initially alert and asking for water but becomes confused during your brief interview. He is in which class of hemorrhagic shock?
A. I
B. II
C. III
D. IV
E. More information is needed
ANSWER: C
COMMENTS: This patient presents with hemorrhagic shock with altered mental status, tachycardia, and hypotension.
Driven to maintain adequate oxygen delivery, early changes in vital signs are representative of the body’s attempt to preserve homeostasis after the rapid loss of a significant amount of its circulating volume.
Early care is directed toward eliminating ongoing sources of exsanguination, along with restoration of intravascular volume.
The degree of derangement is reliably linked to the volume of blood loss and classified according to the following table.
This patient’s constellation of findings places him within class III shock, and he has an estimated blood loss of 1.5 to 2 L.
This estimate may help in guiding volume resuscitation to give an understanding of how much volume has been lost.
The choice of fluid replacement has been the subject of much debate and investigation. Generally, for moderate-to-severe shock, resuscitation is carried out with a com- bination of both crystalloid and colloid solutions. In the acute setting, hemoglobin is an unreliable indicator; rather, therapy should be aimed at restoring adequate intravascular volume and normalized hemodynamics.
(See ATLS, Chapter on Shock)
A 33-year-old unhelmeted male is brought to the ED after a motorcycle crash. His temperature is 99.4°F, HR is 95 beats/ min, BP is 110/65 mmHg, and RR is 10 breaths/min with an Sao2 of 94% on room air. He makes incomprehensible sounds, withdraws extremities, and opens eyes to painful stimuli. He is intubated in the ED and placed on the ventilator for transfer to the ICU. On head CT, he is found to have small subarachnoid hemorrhage and a nondepressed skull fracture. The remainder of his trauma workup is negative. In addition to head-of-bed elevation and frequent monitoring of neurologic status, which of the following is indicated?
A. IV mannitol bolus
B. Hypertonic saline infusion
C. Craniotomy
D. Hypothermia
E. Insertion of intracranial pressure (ICP) monitor at bedside
ANSWER: E
COMMENTS: Normal ICP ranges from 5 to 15 mmHg. Because of the bony calvarium, any increase in ICP results in an equivalent decrease in cerebral perfusion pressure (CPP), which is the difference between MAP and ICP.
Goals for treatment of closed head injuries are to maintain adequate CPP through the use of various maneuvers to lower ICP.
This patient has suffered a severe head injury, as evidenced by his Glasgow coma score (GCS) of 8.
He has an abnormal head CT with intracranial hemorrhage and has a significant risk (50%–60%) of elevations of ICP.
For all patients with head injury, abnormal CT scan, and GCS less than 9, and ICP monitoring should be considered.
One should also consider the placement of a monitor if the patient will be unable to be examined for a prolonged period [i.e., in the operating room (OR)].
There are conflicting data regarding the potential mortality benefit of ICP monitors; however, numerous data published since 2012 indicate improved outcomes when they are placed in these patients.
Mannitol and hypertonic saline are indicated for the treatment of elevated ICP, indicated by invasive monitoring or a change in physical examination (unilateral blown pupil).
Hypothermia was found in a recent study to have no benefit in patients with traumatic brain injury and elevated ICP.
When comparing early tracheostomy (<10 days after endotracheal intubation) versus late tracheostomy (>10 days after endotracheal intubation), which of the following is true?
A. Incidence of VAP is the same
B. Decreased mortality in those undergoing early tracheostomy at 28 days
C. Shorter ICU length of stay
D. No difference in sedation requirements
E. Improved patient satisfaction
ANSWER: C
COMMENTS: The timing of tracheostomy continues to be a debated topic in both the critical care and trauma literature.
The general division between early and late tracheostomy creation is at 10 days after endotracheal intubation.
For patients predicted to have prolonged ventilator requirements, the optimal timing of tracheostomy remains uncertain.
Early trials suggested a mortality benefit; however, this result has not been reproduced in more recently published data.
There does however seem to be a decrease in the incidence of VAP, along with decreased sedation requirements, more ventilator-free days, and shorter ICU length of stay.
Trials with longer follow-up are still ongoing; however, there is some evidence that there may be a long-term mortality benefit for early tracheostomy, though more data are needed to establish this conclusion.
While pulmonary hygiene and ease of care are improved with tracheostomy, there are no definitive data suggesting improved patient satisfaction with early versus late tracheostomy creation.
A 53-year-old woman with a history of metastatic lung cancer is admitted to the ICU after video-assisted resection of the right middle lobe. Initial vitals are an HR of 104 beats/ min, BP of 64/43 mmHg, and RR of 34 breaths/min. After multiple fluid boluses, the patient remains hypotensive, so a PA catheter is placed and secured at 43 cm. The following values were determined: PA pressure, 38/27 mmHg; CVP, 26 mmHg; PA occlusion pressure (PAOP), 27 mmHg; and cardiac index, 2.0 L/min/m2.
Which of the following explains the clinical scenario?
A. CHF from sepsis
B. Malignant pleural effusion
C. Cardiac tamponade
D. Hypovolemia
E. Pneumothorax
ANSWER: C
COMMENTS: There are many potential causes of pericardial tamponade, with lung cancer, renal failure, tuberculosis, breast carcinoma, and lymphoma and leukemia being among the most common.
Hemodynamic monitoring with a PA catheter can help determine the diagnosis by showing equalization of right ventricular diastolic pressure, a PA diastolic pressure, and a PAOP within 2 to 3 mmHg of each other, along with the elevated mean right atrial pressure.
With small effusions most patients are asymptomatic, but with fluid in excess of 500 mL, patients can experience the onset of dyspnea, cough, chest pain, tachycardia, and jugular venous distention.
Pulsus paradoxus, hypotension, cardiogenic shock, and paradoxical movement of the jugular venous pulse are also signs to be noted.
This patient has pericardial tamponade and is unlikely to improve with medical management.
Pericardial drainage is recommended in all patients with large effusions because of recurrence rates in the 40%–70% range.
Administration of a fluid bolus is an appropriate measure but likely to be temporary.
For immediate decompression, one can perform bedside pericardiocentesis.
Definitive treatment of persistent symptomatic pericardial effusions is surgical pericardiectomy.
Which of the following treatments of a hypotensive patient is correct?
A. Pericardiocentesis in a 54-year-old man after myocardial infarction (MI) with adequate volume status and hypotension refractory to inotropic agents
B. Cardiac pacing in a 73-year-old woman taking digitalis with atrial fibrillation on the ECG, a ventricular response rate of 40, and an adequate volume status
C. Intraaortic balloon pump (IABP) in a 47-year-old woman with sepsis from pyelonephritis, good volume, and an echocardiogram showing no mechanical defects
D. Inotropic agents in a 68-year-old woman with metastatic breast cancer, distended neck veins, and PA catheter readings showing normalization of right and left heart pressure
E. Clamping of the infrarenal aorta in a patient with a gunshot wound to the chest and low right and left atrial pressure
ANSWER: B
COMMENTS: Cardiogenic shock most commonly occurs as a consequence of acute left ventricular infarction.
However, it may also be due to right ventricular infarction, ruptured papillary muscle, ruptured ventricular wall, acute aortic valvular insufficiency, mitral regurgitation, and a ventricular septal defect.
However, before assuming that the hypotension is caused by a cardiogenic mechanism, one must be sure that there is adequate blood volume.
Therefore a patient who is hypotensive with low right and left atrial pressure should undergo fluid administration as the initial management.
If cardiac performance improves with fluid administration alone, cardiogenic shock is probably not present.
If adequate filling pressures are attained and the hypotension persists in the absence of mechanical defects, arrhythmia, and sepsis, a primary pump problem probably exists and should be managed with inotropic agents.
One form of cardiogenic shock is cardiac tamponade, which is seen in traumatized patients, postoperative cardiac patients, and those suffering from uremia and certain malignancies.
Pericardial tamponade has a trend toward equalization of pressures in the right and left sides of the heart.
In a patient who is overdigitalized or hypokalemic, a very low ventricular rate in response to atrial fibrillation or flutter may result in hypotension and should be managed with cardiac pacing.
If a patient remains in cardiogenic shock despite adequate blood volume, appropriate HR, absence of a mechanical or valvular defect, appropriate administration of inotropic agents, and restoration of pressure and coronary blood flow, support via IABP counterpulsation may be needed.
IABP counterpulsation is most beneficial in patients with severe left ventricular dysfunction.
It assists in left ventricular systolic unloading by directly reducing stroke work, which in turn reduces myocardial oxygen consumption during the cardiac cycle, and in diastolic augmentation, which raises arterial BP and provides better coronary arterial perfusion during diastole and improved delivery of oxygen to the myocardium.
Patients with hemodynamic compromise secondary to right ventricular MI require fluid resuscitation and inotropic support.
Any preload reducers must be avoided.
Afterload reducers in the presence of hypotension are not warranted.
The alarm on the cardiac monitor continues to go off on a 73-year-old man with CHF and diabetes mellitus who was recently transferred to the ICU. He appears calm and is sitting up in bed watching a baseball game. His vital signs are an HR of 155 beats/min, BP of 125/84 mmHg, RR of 18 breaths/min, and Sao2 of 96%. An ECG taken 7 days ago is normal. The most recent one, taken 24 h previously, shows that his previously distinct P waves have been replaced with rapid, polymorphic, irregular P waves that are irregular and occurring at a rate greater than 300/min. The ECG is repeated and confirms the presence of an arrhythmia. At this point, which is the best initial intervention for this patient?
A. Anticoagulation with a
heparin drip
B. Cardioversion with paddles and settings at 260 J up to three times
C. Repeat ECG in 48 h
D. Restoration of sinus rhythm by pharmacologic means such as amiodarone or diltiazem
E. Morphine, 4 mg by IV push, to alleviate the pain
ANSWER: D
COMMENTS: The most common sustained dysrhythmia is atrial fibrillation, which has a prevalence of 5% in persons older than 65 years.
There are numerous causes that may trigger new-onset atrial fibrillation, including ischemia, MI, hypertension, electrolyte imbalance, pulmonary embolism (PE), and digoxin toxicity.
Initially, an ECG should be obtained, and if the arrhythmia is symptomatic, it should be treated aggressively.
New-onset atrial fibrillation with a duration of less than 48 h is a clear indication to restore sinus rhythm by either electrical or pharmacologic means.
This can be performed with IV calcium channel blockers, amioda- rone, or β-blockers, which are usually effective in rapid conversion.
Cardioversion should be performed in patients who are hemodynamically instable.
Cardioversion in patients with atrial fibrillation for longer than 48 h is contraindicated until they are fully anticoagulated.
Acute intervention may not be necessary in patients with a history of well-tolerated arrhythmia.
A 58-year-old woman is found to have meningococcemia and sepsis. On examination, she is confused, agitated, and in respiratory distress. She is intubated and placed on assist- control (AC) ventilation. A central line is placed and several fluid boluses are given but she is still hemodynamically unstable. A continuous drip of a vasoactive drug is started. After administration, her HR remains at 105 beats/min, MAP rises to 70 from 45 mmHg, cardiac output (CO) drops to 2.8 from 3.3 L/min, and systemic vascular resistance increases to 1150 from 500 dynes⋅s/cm5. Based on the changes observed, which drug was most likely administered?
A. Dobutamine
B. Dopamine
C. Phenylephrine
D. Epinephrine
E. Milrinone
ANSWER: C
COMMENTS: Inotropic agents increase cardiac contractility by increasing the concentration and availability of intracellular calcium.
Catecholamines act by binding to adrenergic receptors. Each type of receptor controls a particular cardiovascular function (Table 10.1).
Epinephrine, norepinephrine, dopamine, and dobutamine are all catecholamines.
The α1-receptor mediates arterial vasoconstriction by causing contraction of the vascular smooth muscle, and the α2-receptor induces constriction of venous capacitance vessels.
The β1-receptor stimulates myocardial contractility, and the β2-receptor causes relaxation of bronchial smooth muscle and relaxation of vascular smooth muscle in skeletal muscle beds.
The dopamine receptors cause relaxation of the vascular smooth muscle. The dopamine-1 receptor induces relaxation of renal and splanchnic vascular smooth muscle, and the dopamine-2 receptor inhibits the uptake of norepinephrine at the sympathetic nerve terminal, which results in a prolonged action of norepinephrine at the motor end plate.
The effects of dopamine are unpredictable, and the side effects might be significant. Thus its use in the ICU has been ebbing.
The response to catecholamines in normal individuals is different from that in critically ill patients. Receptor populations change over short periods, and upregulation and downregulation can occur depending on the disease state.
It is important that catecholamines be administered for a predetermined effect. If the effect is not attained with the particular catecholamine chosen, the dose should be adjusted or another agent used.
You are consulted for a long-term enteral feeding access in a patient with a recent stroke. Despite speech therapy, he is unable to maintain adequate nutrition with by-mouth (PO) intake alone. Which of the following is an absolute contraindication to percutaneous endoscopic gastrostomy (PEG) placement?
A. Active infection
B. Hepatitis with large ascites
C. History of abdominal surgery
D. Peptic ulcer disease
E. Expected survival of less
than 6 months
ANSWER: B
COMMENTS: Placement of a PEG tube is a viable and safe option for many critically ill patients or those who are unable to maintain adequate PO intake.
There are few contraindications and complications when performed on a properly selected patient population.
The technique of PEG placement relies on the principles of transillumination of the entry site with a lighted gastroscope and 1:1 palpation.
These steps are critical to ensure the stomach and anterior abdominal wall are sufficiently opposed, and there are no other organs (i.e., transverse colon) that may be injured during tube insertion.
Contraindications to PEG include irreversible coagulopathy, hemodynamic instability, oropharyngeal or esophageal mass unable to be passed by a gastroscope, a history of total gastrectomy, massive ascites, or portal hypertension with varices.
There are reports of successful PEG placement with small-to-moderate ascites and the concurrent use of paracentesis; however, the complication rate in this population is much higher suggesting the risks of the procedure outweigh the benefits.
Which of the following conditions is not usually associated with elevated dead space ventilation?
A. 42-year-old female after MI with CHF and a CO of 1.5 L/min
B. 28-year-old woman on post partum [?] day 1 with
shortness of breath, a Pao of 60 mmHg, and segmental 2 clots bilaterally in the pulmonary arteries
C. 52-year-old Hispanic immigrant with a long-standing ventricular septal defect and PA pressure of 80/52 mmHg
D. 22-year-old man after multiple gunshot wounds, massive transfusions, and a mean arterial to inspired oxygen ratio (Pao2/FiO2) of 180
E. 62-year-old woman smoker with the following ventilator settings: controlled mandatory ventilation at a rate of 12 breaths/min, FiO2 of 60%, Vt of 600 mL, and positive end-expiratory pressure (PEEP) of 5 cm H2O
ANSWER: E
COMMENTS: The most common causes of increased dead space in critically ill patients are decreased CO, PE, pulmonary hypertension, acute respiratory distress syndrome (ARDS), and excessive PEEP, all of which directly cause decreased blood flow to the pulmonary vasculature.
In dead space ventilation with a high ventilation/perfusion (V/Q) ratio, there is decreased blood flow to ventilated areas, which primarily affects the elimination of carbon dioxide.
In ARDS, some areas of the lung are perfused but not ventilated. Alveoli may be filled with secretions, exudate, blood, or edema, thereby increasing the shunt fraction. Other areas of the lung may be ventilated but not perfused, which accounts for the dead space ventilation.
PEEP can cause dead space ventilation by decreasing CO and stenting alveoli open, which causes the surrounding capillaries to collapse and thereby decreases alveolar perfusion.
Carbon dioxide production and the dead space–tidal volume ratio (Vds/Vt) determine minute ventilation.
The anatomic dead space includes the volume of the airways to the level of the bronchiole (150 mL).
Dead space can also include alveoli that are well ventilated but poorly perfused.
When combined, the anatomic and alveolar dead space constitutes the physiologic dead space, which is essentially the volume of gas moved during each tidal breath that does not participate in gas exchange.
A 17-year-old female with asthma is brought to the OR for ruptured ectopic pregnancy. Postoperatively, she is dyspneic and in acute respiratory failure. She is intubated and transferred to the surgical ICU where her ventilator is set to AC mode, RR of 18 breaths/min, FiO2 of 0.80, Vt of 600 mL, and PEEP of 0 mmHg. She was sedated and paralyzed for the intubation and is not breathing over the ventilator settings. After examining the patient and the flow pattern on the ventilator, changes in the settings are made. A change in which ventilator setting would best limit the intrinsic PEEP?
A. Increase in Vt
B. Decrease in the inspiratory flow rate
C. Increase in PEEP
D. Decrease in RR
E. Change from AC mode to synchronized intermittent mandatory ventilation (SIMV)
ANSWER: D
COMMENTS: Intrinsic PEEP (commonly known as auto-PEEP) is a state at end exhalation in which there is incomplete gas emptying, which can elevate alveolar volume and pressure.
It is the threshold pressure needed to be overcome to initiate inspiratory flow.
Severe bronchospasm increases the expiratory time needed, and patients in status asthmaticus or severe chronic obstructive pulmonary disease (COPD) are at risk for intrinsic PEEP.
If combined with narrowed airways, such as in asthma, and parenchymal noncompliance, the inspiratory work of breathing is increased.
Therefore there is an imbalance of respiratory muscle strength and work of breathing leading to respiratory failure.
During mechanical ventilation, when the expiratory time is insufficient to allow full exhalation of a ventilator breath, expiratory flow is still occurring when the next ventilator breath is delivered.
To best limit intrinsic PEEP, one can decrease the RR, thereby giving the patient more time to exhale between breaths. In addition, decreasing Vt will allow minimal improvement.
One should also limit the inspiratory time to leave more time in the respiratory cycle for exhalation.
Avoidance of hyperinflation and overdistention at the expense of minute ventilation, otherwise known as permissive hypercapnia, is an important method of ventilatory management in asthmatics.
A 65-year-old male who is 7 days out from a three-vessel coronary artery bypass remains intubated for respiratory failure despite normal hemodynamics. He is sedated with propofol and failed an SBT earlier this morning. The nurse asks if you would like to hold his sedation. Which of the following is true with regard to daily sedation awakening trials (SATs)?
A. The risk of self-extubation is too high to justify SAT after failed SBT.
B. SAT performed daily decreases overall sedation requirements for ventilated patients.
C. SAT alone is associated with lower rates of delirium.
D. Daily paired SAT and SBT are associated with fewer ventilator days and decreased ICU length of stay.
E. When part of an ICU protocol, daily SAT is associated with decreased overall mortality.
ANSWER: D
COMMENTS: The concept of daily interruption in sedation has been widely adopted by ICUs despite little convincing evidence of its independent efficacy.
A number of studies have demonstrated improved time-to-extubation with combined SAT and SBT versus SBT alone.
However, SAT has been shown to be equivalent to no SAT in many more recent trials.
In these studies, there was no decrease in time-to-extubation, sedation requirement, and ICU stay or mortality.
In line with no change in sedation requirements, there also has been no proven improvement in the incidence of ICU delirium with routine SAT.
SAT can be associated with adverse events such as patient removal of the endotracheal tube or other lines; however, when performed in an appropriate setting, there was also no significant increase in these adverse events.
With regard to ventilatory mechanics, which of the following statements is true?
A. The work of breathing at rest consumes 10% of total-body oxygen consumption (Vo2).
B. COPD is associated with an increase in the work of breathing as a result of increased expiratory work.
C. The work of breathing may increase to 75% of the total-body Vo2 in postoperative patients.
D. Airway pressure reflects the compliance of only the lungs.
E. Compliance is measured as the change in pressure divided by the change in volume.
ANSWER: B
COMMENTS: For patients with COPD, the work of breathing is increased because of increased expiratory work, not inspiratory work.
It can be assessed by preoperative pulmonary function testing and optimized by preoperative chest physical therapy, bronchodilators, and antibiotics if infection is present.
The work of breathing at rest consumes 2% of the total-body Vo2 and can be markedly increased, up to 50% of total Vo2, in postoperative patients because of increased airway resistance and decreased compliance of the lung, chest wall, and diaphragm.
The proper use of volume-cycled ventilators and pressure support (PS) ventilation can take over most of the work of breathing during the postoperative period.
Compliance is defined as the change in pressure associated with each milliliter increase in the lung volume.
Measuring airway pressure reflects the compliance of the chest wall and diaphragm, as well as that of the lungs.
In relaxed patients this is of little importance, but in restless patients, intraesophageal or intrapleural pressure pro- vides a more accurate measure of compliance.
In acute respiratory failure, decreased compliance is usually associated with decreased functional residual capacity.
Less compliant lungs need ventilatory management that maintains inflation of alveoli by the use of PEEP and recruits closed alveoli by elevating peak inspiratory pressure.
However, because positive airway pressure may overdistend already-ventilated alveoli, the peak inspiratory pressure should be kept below 40 cm H2O.
A 53-year-old man with chronic kidney disease, severe COPD, and systolic heart failure after MI is in your ICU. He is unable to tolerate the Trendelenburg position during the placement of a central line in the right internal jugular vein. Immediately after placement, he becomes diaphoretic and complains of difficulty in breathing.
He then becomes obtunded, tachycardic, and progressively tachypneic. His BP is 80/50 mmHg, and he has bilateral breath sounds by auscultation. Which of the following should be performed immediately?
A. Left lateral decubitus and Trendelenburg position, then aspiration from the central line
B. Heparinization
C. Removal of the central line
D. Fluid bolus
E. Dobutamine
ANSWER: A
COMMENTS: Though uncommon, air embolism is a potentially lethal complication of the central line placement.
Providers must be familiar with its presentation and immediate, lifesaving treatment maneuvers.
Presentation depends upon the exact volume of air that enters the venous system.
The lethal dose for humans has been estimated at 3 to 5 mL/kg/min; however, cardiovascular compromise can be seen with rates less than 1.5 mL/kg per min.
The incidence of air embolism with central line placement is reported as between 0.2% and 1%.
Physical examination for a significant air embolism will demonstrate hemodynamic instability and, often, hypoxia, along with a “mill-wheel” murmur in the precordium.
Immediate intervention is Durant’s maneuver—left lateral decubitus and Trendelenburg position in order to entrap air in the apex of the ventricle.
Aspiration via central venous catheter may then allow removal of some amount of the air in the system.
A family meeting is called for a 69-year-old man who was intubated 6 days earlier for pneumonia and respiratory distress. He is now awake, alert, and asking for removal of the tube. His family wants to know when and whether he will be extubated. Which of the following characteristics of this patient DOES NOT meet conventional weaning criteria?
A. Negative inspiratory force of −10 cm H2O
B. A respiratory frequency/tidal volume (RF/Vt) ratio of 105 or less
C. Correction of underlying pulmonary and nonpulmonary complications
D. Pulse oximetry reading of 92%
E. Vital capacity of 12 to 15 mL/kg and peak inspiratory pressure of less than 25 cm H2O
ANSWER: A
COMMENTS: Many indices have been proposed to predict weaning outcome and success or failure of extubation.
Most surgical patients (90%) are weaned from mechanical ventilation in less than 1 week.
Conventional weaning criteria include:
(1) measurements of oxygenation with a pulse oximeter (best determined by arterial blood gas analysis, with an Sao2 > 90% and any FiO2 usually being adequate for weaning) and
(2) measurements of ventilation, such as an RR less than 24 breaths/min, Paco2 less than 50 mmHg, peak inspiratory pressure below 30 cm H2O, Vt of at least 5 to 8 mL/kg, and a vital capacity double the Vt value.
Failure to satisfy these conventional criteria is associated with unsuccessful weaning in as many as 63% of patients.
The rapid, shallow breathing test (RF/Vt) is performed by having the patient breathe room air for 1 min.
When RF/Vt is 105 or less, successful weaning occurs in 78% of patients, and when RF/ Vt is less than 80, the success rate is 95%.
Conversely, an RF/Vt value of 105 or higher is accompanied by a failure rate of 95%.
Another method often described is the Simple Object Access Protocol (SOAP) assessment:
(1) ability to clear secretions,
(2) adequate oxygenation (Pao2/FiO2 ratio > 200 mmHg, which requires an FiO2 of 0.4 to 0.5 and PEEP < 8 cm H2O),
(3) ability to protect the airway, and
(4) adequate pulmonary function.
Clinical judgment and correction of underlying pulmonary and nonpulmonary complications continue to be the best guide to successful weaning.
In addition, helpful ventilation scores include an FiO2 of less than 40%, continuous positive airway pressure (CPAP) of 3 cm H2O, effective static compliance greater than 50 mL/cm H O, dynamic compliance greater than 40 mL/cm H2O, ventilator minute ventilation of less than 10 L/min, and a triggered ventilatory rate of less than 20 breaths/min.
The duration of ventilatory support is not correlated with survival rates at discharge. Forty-one percent of long-term ventilated patients survive.
Because muscle atrophy is often present, a progressive ventilatory withdrawal plan designed to restore muscle function should be used.
Intermittent mandatory ventilation, PS ventilation, and weaning by T-piece have been used effectively.
A 29-year-old firefighter is intubated in the ICU after being exposed to smoke. She has thick yellow secretions that require frequent suctioning along with the administration of bronchodilators. On hospital day 5, she has a percutaneous central venous catheter placed through the right internal jugular vein. Several hours later, she undergoes respiratory arrest. Her peak inspiratory pressure has risen from 24 to 41 cm H2O, and her plateau pressure has stayed at 16 cm H2O. Choose which of the following is the most likely reason for the respiratory arrest:
A. Tension pneumothorax
B. Flash pulmonary edema
C. Pulmonary embolism (PE)
D. Endotracheal tube obstruction
E. Auto-PEEP with breath stacking
ANSWER: D
COMMENTS: This patient has an obstruction of the endotracheal tube.
The key to identifying this problem is recognizing the components of the patient’s respiratory pressure as shown in Table 10.2, most importantly the peak inspiratory and plateau pressures.
The peak inspiratory pressure is the pressure required to overcome the resistance in the endotracheal tube and airways, as well as the compliance of the airways.
The inspiratory plateau pressure is the pres- sure generated to overcome the elastance of the lung parenchyma, pleural space, and chest wall.
This patient had increasing peak inspiratory pressure, so her problem was related to the tube, not the lung itself.
Tension pneumothorax and flash pulmonary edema are associated with increases in both peak inspiratory pressure and inspiratory plateau pressure.
PE also does not change the inspiratory pressure.
A 73-year-old woman weighing 60 kg is admitted to the hospital with acute pancreatitis.
She is aggressively resuscitated with fluid but becomes hypotensive and has increasing work of breathing and O2 requirements within the next 12 h.
The patient is transferred to the ICU and intubated. A PA catheter is placed, and the wedge pressure is 8 cm H2O. Arterial blood gas analysis shows values of a pH of 7.36, a Pao2 of 62, a Pco2 of 42, a serum bicarbonate of 21, and a base deficit of −2 with Sao2 of 90%.
Which of the following ventilation strategies is most appropriate for this patient?
A. Pressure-control ventilation (PCV) with a pressure of 40 cm H2O and an inverse ratio ventilation of 3:1
B. SIMV with a Vt of 720mL and an RR set to keep the pH at 7.4
C. AC ventilation with a Vt of 600 mL and prone positioning
D. AC ventilation with a Vt of 360 mL and an RR to keep the pH above 7.2
E. SIMV with a Vt of 600 and an FiO2 of 100%
D
Which one of the following criteria is included in the
definition of ARDS?
A. Onset within 1 week of a clinical insult
B. Chest radiograph showing pulmonary infiltrate (unilateral or bilateral)
C. Hypoxemia with Pao2 to FiO2 ratio < 200 mmHg
D. Normal PA wedge pressure
E. Infectious origin
ANSWER: A
COMMENTS: Because the principal physiologic problem in ARDS is hypoxemia refractory to increasing FiO2, therapy is centered on the provision of mechanical ventilation to maximize oxygen delivery while minimizing lung injury.
PEEP is used to improve oxygenation and lung compliance and should be optimized with the help of pressure–volume curves to facilitate the maintenance of open alveoli and diffusion of oxygen into the pulmonary capillaries.
For a given FiO2, Pao2 usually increases on the administration of PEEP in patients with ARDS.
However, excessive PEEP (>15 cm H2O) can be hazardous and lead to pneumothorax from barotrauma and decreased venous return to the heart.
Overdistention of alveoli can be prevented by keeping the peak inspiratory pressure below 35 cm H2O.
Newer ventilatory methods attempt to enhance alveolar recruitment, maintain alveolar patency throughout the respiratory cycle, maintain an Sao2 of greater than 90%, avoid dynamic hyperinflation (volu-trauma), and reduce the risk for oxygen toxicity.
Spontaneous, augmented low-volume ventilation, with PS ventilation being used as a primary ventilatory support mode, directs flow to regions of low ventilation/perfusion.
Diuretics in cases of obvious fluid overload and cardiac decompensation and broad-spectrum antibiotics in cases of established pulmonary infection or other sources of sepsis may be useful for patients with ARDS.
The consensus conference on ARDS (ARDSnet.org) showed that a volume-restricted ventilation strategy reduced mortality.
In this well-accepted study, 861 patients were randomly assigned to either a traditional-volume ventilation strategy (12 mL/kg of ideal body weight with plateau pressures < 50 cm H2O) or low-Vt ventilation (6 mL/kg with plateau pressures < 30 cm H2O).
The study was halted early because of significantly reduced overall mortality (31.0% vs. 39.1%, P < .0007).
Permissive hypercapnia was allowed, and sodium bicarbonate was given to maintain pH higher than 7.2.
The patient developed ARDS, probably because of acute pancreatitis and systemic inflammatory response syndrome (SIRS).
Criteria used to define ARDS have been recently revised. The Berlin definition developed in 2013 now stratifies ARDS based upon the degree of hypoxemia.
All types of ARDS include an acute onset within 1 week of clinical insult, bilateral pulmonary infiltrates on chest radiographs, and some degree of hypoxemia not fully explained by cardiac failure.
There does not have to be an infectious process for a patient to have ARDS, and no longer are patients with cardiac failure excluded from having coexisting ARDS.
ARDS and acute lung injury have now been combined and categorized based on the severity of the Pao2/FiO2 ratio: mild (200 to 300), moderate (100 to 200), and severe (<100).
The lung response can be divided into an exudative phase (24 to 96 h), with leakage of proteinaceous fluid into the pulmonary interstitium and corresponding damage to the alveolar–capillary interface; an early proliferative phase (3 to 10 days), with proliferation of alveolar type II cells, cellular infiltration of the septum, and organization of hyaline membranes; and a late proliferative phase (7 to 10 days), with fibrosis of the alveolar septum, ducts, and hyaline membranes.
Frequently, the radiographic changes can lag behind the clinical picture in ARDS considerably.
A 59-year-old woman with a long-standing history of gastroesophageal reflux disease (GERD) underwent a Nissen fundoplication that was complicated by 2 L of blood loss and hypotension in the OR. Her vital signs are an HR of 103 beats/min, a BP of 100/70 mmHg, an RR of 16 breaths/min, and an Sao2 of 96%. Her urine output was 15 mL of urine/h over the last 4 h. Laboratory results include a urine osmolality of 600 mOsm/kg, urine sodium concentration of 15 mEq/L, plasma sodium concentration of 140 mEq/L, urine creatinine concentration of 20 mg/dL, and plasma creatinine concentration of 1.5 mg/dL.
What is the next step in management?
A. Flushing the Foley catheter with 60 mL of normal saline
B. Hemodialysis
C. Nephrology consultation
D. Decompressive laparotomy for abdominal compartment syndrome (ACS)
E. Administration of a 1000-mL fluid bolus of normal saline as a fluid challenge
ANSWER: E
COMMENTS: Acute renal failure is a serious morbidity for post- surgical patients, with mortality rates greater than 50%.
Renal failure can be prerenal, renal, or postrenal.
The most common cause in surgical patients is hypovolemia, as is the case in this patient from blood loss in the OR.
Some indicators for prerenal causes include urine osmolality greater than 500 mOsm/kg, fractional excretion of sodium (FENa) of less than 1%, and urine sodium concentration of less than 20 mEq/L, whereas an FENa greater than 3% and urinary sodium concentration greater than 40 mEq/L are indicative of parenchymal or postrenal causes.
Medications, IV contrast material–induced nephropathy, rhabdomyolysis, and transfusion reactions are all options to consider.
This patient’s FENa is 0.8%.
A 46-year-old brittle diabetic and hypertensive woman is brought to the ICU after being found unresponsive in her bed. After undergoing a CT scan of her head, abdomen, and pelvis with IV contrast media, she is transferred to the ICU. The ICU team places a central line, orders an echocardio- gram, and places a bladder catheter. Her urine output has been approximately 10 mL/h for the last 4 h. Her FENa is calculated to be 2.4%. Which of the following is not consistent with acute tubular necrosis (ATN)?
A. Oliguria
B. FENa greater than 2%
C. Urine osmolality of 200 mOsm/kg
D. Creatinine clearance greater than 125 mL/min
E. Sodium wasting
ANSWER: D
COMMENTS: A creatinine clearance of 125 mL/min represents a normal renal function.
ATN is characterized by a rise in plasma creatinine concentration [decrease in creatinine clearance or glomerular filtration rate (GFR)], a urine volume that is reduced (oliguric) or normal, changes in the findings on urinalysis, and a FENa greater than 1%–2%.
Oliguria, or urine output less than 500 mL/24 h, is a frequent but not an absolute feature of ATN.
Whether oliguria occurs may depend on the severity of the renal injury or the relative reabsorption of filtrate at the tubular level.
Even if a patient’s GFR falls to 10 L/day (normal, 180 L/day), a urine output of 1 to 2 L/ day would still be normal as long as 8 to 9 L of filtrate was reabsorbed.
In cases of well-preserved tubular function, as in prerenal forms of acute kidney injury (ARF), FENa is low, consistent with the sodium-avid state.
As tubular dysfunction progresses, the ability of nephrons to reabsorb sodium is disrupted, and a greater percentage of the filtered sodium is excreted in urine.
As a result, FENa will be greater than 1%–2% because of inappropriate sodium wasting by altered tubular function.
Loss of urinary concentrating ability is an early feature of ATN.
A urine osmolality of less than 350 mOsm/L is consistent with ATN, whereas an osmolality greater than 500 mOsm/L suggests a prerenal cause of ARF.
However, lower values can be seen during prerenal ARF thus limiting the value of this test as a sole indicator of tubular function.
A 62-year-old man with peripheral vascular disease, diabetes, and bilateral tissue loss in the lower extremities is admitted for angiography of his lower extremities. He has chronic renal failure and his serum creatinine level is 5.0 mg/dL, which has been his baseline for the last 3 years. Which of the following agents is indicated to reduce the risk for IV contrast–induced nephropathy?
A. Calcium channel blocker
B. Aggressive diuresis
C. Saline volume expansion before and after the procedure
D. Acetylcysteine given only after exposure to contrast material
E. Mannitol and saline hydration
ANSWER: C
COMMENTS: In most cases, radiocontrast agents can lead to a reversible form of ARF.
The pathogenesis is not well established, but two proposed mechanisms of injury are renal vasoconstriction and direct tubular toxic effects.
The risk is minimal in patients with normal renal function, including those with diabetes, and the renal failure is nonoliguric and transient in most cases.
Severe renal failure requiring short- or long-term dialysis is rare and most likely to occur in patients whose baseline creatinine level is greater than 4 mg/dL. Risk factors for the development of contrast-induced nephropathy include underlying chronic renal failure with a plasma creatinine level greater than 1.5 mg/dL, diabetic nephropathy with renal insufficiency, CHF, multiple myeloma, and a large volume of contrast material.
Saline volume expansion in the precontrast and postcontrast periods is the only preventive measure consistently shown to be of benefit.
Hydration with furosemide may increase the risk for contrast-induced nephropathy when compared with saline alone.
Furthermore, the use of saline solution and mannitol does not have any benefit over the use of saline alone.
Calcium channel blockers given to minimize renal vasoconstriction after exposure to contrast media have not been conclusively shown to prevent renal failure.
The role of nonionic contrast agents is not clearly defined. Studies seem to support the use of isosmolar non-ionic agents in high-risk patients, especially those with diabetes.
There are conflicting data on the role of acetylcysteine and sodium bicarbonate infusions in the prevention of contrast-induced nephropathy, but given its relatively safe side-effect profile and the few series supporting its use, use of both can be justified, particularly in high-risk patients.
A rational approach to preventing con- trast-induced nephropathy in high-risk patients, such as the patient in question, would include acetylcysteine (600 mg orally twice daily the day before and on the day of exposure to contrast mate- rial), saline volume expansion before and after the procedure, and an isosmolar nonionic contrast agent. Several recent meta-analyses have shown that sodium bicarbonate infusion can decrease the damage associated with contrast-induced nephropathy if given both before and after the procedure as well.
The former may be more important for patients with renal dysfunction and diabetes.
Choose the situation that does not require immediate renal replacement therapy.
A. A 27-year-old bipolar patient, after running a half marathon, taking a prescribed lithium dose and found to have ataxia, confusion, and inverted T waves
B. A 68-year-old man after sigmoid colectomy with new-onset seizures and blood urea nitrogen (BUN) of 150 mg/dL
C. A 58-year-old man after a motor vehicle collision with multiple long-bone fractures, BUN of 120 mg/dL, creatinine of 2.8 mg/dL, and diffuse bleeding
D. A 71-year-old woman with diabetes maintained on an insulin drip after total abdominal hysterectomy and bilateral salpingo-oophorectomy with an FENa of 0.7% and urine output less than 20 mL/h for last 7 h
E. A 45-year-old man with respiratory distress after massive resuscitation for a septic episode, bilateral lung haziness on chest radiography, and coarse crackles who is unresponsive to diuretics
ANSWER: D
COMMENTS: Indications for acute dialysis treatment include:
(1) persistent hyperkalemia refractory to medical management;
(2) pulmonary edema unresponsive to conventional therapy;
(3) severe acidemia;
(4) symptoms of uremia such as anorexia, nausea, and vomiting;
(5) uremic encephalopathy, seizures, asterixis, uremic pericarditis, and uremic bleeding; and
(6) overdose with a dialyzable toxin such as lithium or ethylene glycol. Renal replacement therapy is needed in 1%–2% of patients with ARF, and as many as 15% of patients may ultimately require dialysis at some point in their life.
It may be indicated for symptomatic fluid overload, sepsis, uremic complications, and severe electrolyte or acid-base disorders.
Frequently in the ICU, continuous renal replacement therapy is superior to intermittent hemodialysis or peritoneal dialysis, but in the United States, it is only used in 10%–20% of ICU patients.
Proponents of this method over others argue that it allows better hemodynamic stability and prevention of shifts in intracerebral water, minimizes the risk for infection, and provides continuous control of fluid status and acid-base abnormalities.
Complications include the need for anticoagulation and a high level of nursing care.
A 68-year-old woman with a history of GERD, cholelithiasis, and coronary artery disease is seen in the ED with nausea, vomiting, and epigastric pain. Laboratory tests showed amylase and lipase values of 259 and 1782 units/L, leukocy- tosis of 18,300/mm3, and a prothrombin time (PT) and international normalized ratio (INR) of 47 s and 1.9, respectively. The patient received 6 L of crystalloid solution because of hypotension and required intubation. After 48 h, the hemoglobin has dropped by 2 g. What are the factors that have the strongest correlation with stress-related bleeding in critically ill patients?
A. Mechanical ventilation and hypotension
B. Coagulopathy and renal failure
C. Steroids and sepsis
D. Mechanical ventilation and steroids
E. Mechanical ventilation and coagulopathy
ANSWER: E
COMMENTS: Risk factors for stress-related mucosal lesions are mechanical ventilation longer than 48 h, coagulopathy, significant burns, and head injury.
These lesions have been found in 25%– 100% of ICU patients within 48 h of admission, but clinically significant bleeding occurs in only 5%–10%.
Patients with risk factors should receive prophylaxis until consuming an enteral diet of at least 50% of their caloric intake.
You are caring for a 55-year-old male who is in the ICU 5 days after multiple blunt traumatic injuries. He was intubated in the OR for the repair of a femur fracture on hospital day 1 and has not yet been extubated. He continues to fail his SBT with RSBI higher than 105. What is the most effective strategy to liberate this patient from the ventilator?
A. PS wean
B. AC ventilation with daily SBT
C. SIMV wean
D. Early tracheostomy before day 10
E. PCV with daily SBT
ANSWER: A
COMMENTS: The most efficient strategy to wean patients from the ventilator has been studied many times and remains somewhat controversial.
It is clear that the most effective way to identify those patients who are ready to have a trial of extubation is the daily SBT.
However, those who have failed repeated SBTs may require a more targeted and purposeful weaning technique in order to avoid the complications associated with the long-term mechanical ventilation in the ICU setting.
Early tracheostomy, when compared to late tracheostomy, does improve ICU length of stay and number of ventilator days; however, it has not shown direct benefit over other modes of weaning mechanical ventilation and will lead to a higher rate of tracheostomy.
When compared directly, SIMV weaning is not as effective as PS weaning, and there is some evidence that PS weaning improves diaphragmatic dysfunction over both AC and pressure-control modes.
Regardless of strategy, daily SBT and reassessment of readiness for extubation remain appropriate.
A 37-year-old woman comes to the ED complaining of a severe headache. She undergoes an emergency head CT scan, which shows subarachnoid hemorrhage; an angiogram identifies an arteriovenous malformation, which is subsequently embolized. Four days later, her serum sodium concentration is 122 mEq/L. Which is the most correct statement regarding the syndrome of inappropriate secretion of antidiuretic hormone (SIADH) and cerebral salt wasting (CSW)?
A. SIADH and CSW share the same underlying pathophysiology and cannot be reliably distinguished.
B. SIADH and CSW can be differentiated by measuring urine sodium and serum uric acid concentrations.
C. SIADH and CSW can be differentiated by measuring urine osmolality and sodium concentration.
D. Assessment of extracellular fluid volume will best differentiate between SIADH and CSW.
E. Regardless of the diagnosis, treatment of the hyponatremia is the same.
ANSWER: D
COMMENTS: Hyponatremia is common in the setting of central nervous system disease. Most often it results from inappropriate SIADH.
With SIADH, the hyponatremia initially results from ADH induced water retention. This volume expansion activates natriuretic mechanisms that induce the loss of sodium and water, with the patient typically being restored to a nearly euvolemic state.
With chronic SIADH, the loss of sodium (and often potassium) is much more significant than the water retention.
CSW is characterized by hyponatremia and loss of extracellular volume from inappropriate sodium wasting in urine. Patients with CSW meet the laboratory criteria for SIADH: hyponatremia, elevated urine osmolality (>100 mOsm/kg), elevated urine sodium concentration (>40 mEq/L), and low serum uric acid concentration.
However, they also have clinical evidence of hypovolemia (decreased skin turgor, elevated hematocrit, decreased weight, and hypotension) rather than the nearly euvolemic state seen with SIADH.
Furthermore, volume repletion with isotonic saline in patients with CSW will lead to a dilute urine (and eventual correction of the hyponatremia), whereas isotonic saline administration may worsen the hyponatremia of SIADH because the sodium is retained while the water is excreted.
SIADH is usually treated by fluid restriction; however, this must be done with caution in patients with SIADH because of the risk of hypotension and cerebral infarction. Iso- tonic saline may be used but requires careful monitoring of the serum sodium concentration; if a further fall in serum sodium occurs, a switch to hypertonic saline may be necessary.
CSW generally responds well to volume repletion with isotonic saline. Salt tablets and mineralocorticoids (such as fludrocortisones) may also be useful as adjunctive measures.
A patient is admitted to the surgical ICU after a prolonged laparoscopic cholecystectomy, which required conversion to an open procedure. The patient was reintubated for respira- tory distress in the recovery area. Upon arrival to the unit, you obtain an arterial blood gas: pH 7.46, Paco2 23, and Pao2 85. Which of the following is true?
A. The primary problem is metabolic with respiratory compensation.
B. No changes should be made to the ventilation as the kidneys will compensate for this abnormality.
C. This acid-base disturbance is consistent with septic shock.
D. Minute ventilation should be decreased.
E. PEEP should be increased.
ANSWER: D
COMMENTS: Arterial blood gas is commonly used to adjust ventilation parameters in order to optimize a patient’s respiratory function and maintain homeostasis.
This patient has a respiratory alkalosis with low Paco2 contributing to increased pH.
Pao2 is in the normal range and will maintain saturation of hemoglobin with oxygen.
Adding PEEP will increase the Pao2 and is unnecessary for this patient.
Decreasing the minute ventilation, however, either by changing the RR or Vt, will increase CO2 retention and thereby decrease the pH.
This patient’s primary disturbance is respiratory distress, and while the renal system does compensate for prolonged acid-base disturbance, it requires a much longer duration than do our respiratory compensatory mechanisms.
Sepsis is generally associated with metabolic or lactic acidosis.
An 80-kg, 65-year-old woman with severe lupus is admitted to the ICU after exploratory laparotomy for sigmoid diverticulitis (Hinchey type IV). She is given a stoma and brought to the ICU intubated. Her vital signs are a tempera- ture of 97.5°F, HR of 105 beats/min, BP of 70/50 mmHg, and Sao2 of 96%. In the first hour her urine output is 20 mL; she has received 4 L of crystalloid and one unit of packed red blood cells (PRBCs), and her antibiotics have been redosed. Her CVP is 10 mmHg, but she remains hypotensive.
Choose the next intervention that will be most beneficial?
A. Additional 2 L of a normal saline bolus
B. Hydrocortisone, 100 mg IV
C. Administration of furosemide for low urine output
D. Initiation of vasopressor therapy with norepinephrine or dopamine
E. Aggressive rewarming
ANSWER: D
COMMENTS: In a patient in septic shock who is adequately volume resuscitated (shown by a CVP of 10 mmHg) and is unresponsive to fluid challenges, vasopressor therapy should be started.
Administration of vasopressors can quickly restore BP; in the Sur- viving Sepsis Guidelines, norepinephrine administered centrally is the initial vasopressor of choice.
Epinephrine, phenylephrine, and vasopressin should not be administered as the initial vasopressor to patients in septic shock.
Epinephrine can be used as the first alternative agent in septic shock when BP is poorly responsive to norepinephrine.
Dobutamine should be used in patients with myocardial dysfunction as evidenced by elevated cardiac filling pressures and low CO.
In general, the rate of fluid administration should be reduced if cardiac filling pressures increase without concurrent hemodynamic improvement.
Norepinephrine therapy is started in septic patient. Later, vasopressin, 0.03 units/min, is added, but the patient remains hypotensive with a MAP below 55 mmHg. Her hemoglobin concentration is 9.0 g/dL. After performing an echocardiogram, dobutamine infusion was started at a maximum of 20 mcg/kg/min; pH is 7.21 with a Pco2 of 34 mmHg. The patient remains hypotensive. What is the next step?
A. Increase the cardiac index to predetermined supranormal levels.
B. Administer hydrocortisone, 100 mg IV.
C. Have a family discussion about withdrawing care.
D. Perform an adrenocorticotropic hormone (ACTH) stimulation test.
E. Switch the ventilatory mode to AC.
ANSWER: B
COMMENTS: Although there is still much debate in the critical care literature about steroids, IV corticosteroids are recommended in patients with septic shock who despite adequate fluid replace- ment require vasopressor therapy to maintain adequate BP.
Random cortisol levels may be helpful in determining a patient’s benefit from steroid therapy, although it is not required.
Consideration can be made to discontinue corticosteroid therapy in patients with a random cortisol level of greater than 25 mcg/dL.
An ACTH stimulation test is not recommended to identify the subset of patients with septic shock who should receive hydrocortisone.
A 70-kg, 33-year-old woman who had not seen a physician in 10 years arrives at the ED with symptoms of dyspnea, fatigue, weight gain, diplopia, and dysphagia following an urgent laparoscopic cholecystectomy 10 days ago. On examination, she is awake and alert. She is afebrile with an HR of 80 beats/min, BP of 120/70 mmHg, and RR of 29 breaths/min. Her heart sounds are normal and breaths are bilateral and shallow. She has ptosis and significant proximal muscle weakness in all extremities. She is drooling slightly and having difficulty swallowing. Her vital capacity is 500 mL and her laboratory tests are pending. Which of the following treatments is the most appropriate to initiate next?
A. Administration of pyridostigmine
B. Endotracheal intubation
C. Administration of steroids
D. Administration of IV immunoglobulin
E. Administration of levothyroxine
ANSWER: B
COMMENTS: This patient is having a myasthenic crisis, which is a consequence of an autoimmune attack on the acetylcholine receptor complex.
There is clinical weakness that is mostly marked after prolonged muscle exertion and should be considered in any patient with respiratory distress and cranial nerve findings.
The myasthenic crisis with respiratory failure develops in approximately 20% of patients and necessitates intubation.
It can be precipitated by bronchopulmonary infections, sepsis, surgical procedures, tapering of steroid medications, pregnancy, and some drugs.
Upper airway muscle weakness can lead to the collapse of the airways and aspiration.
Patients with marginal vital capacity (<15 mL/kg), weak cough or voice, and worsening negative inspiratory force should be considered for intubation.
A 73-year-old male with stage IV colon cancer is intubated in the ICU 5 days after undergoing palliative resection of his primary tumor. He becomes acutely febrile and tachycardic with increased oxygen requirement. His BP drops to 88/50 mmHg. A bedside echocardiogram demonstrates a hyperdynamic left ventricle and right ventricular strain. Which of the following is the optimal treatment for this patient?
A. Surgical embolectomy
B. Systemic tissue plasminogen activator (tPA)
C. Catheter-directed tPA
D. Initiation of therapeutic heparin drip
E. Placement of inferior vena cava (IVC) filter
ANSWER: C
COMMENTS: Therapeutic anticoagulation is the mainstay of treatment for confirmed or suspected PE.
The goal range for partial thromboplastin time (PTT) in the treatment of venous thromboembolism is 60 to 90s, and the drip should be titrated to this value.
Massive PE is defined as hypotension with systolic BP < 90 mmHg, while submassive PEs are those with systolic BP > 90 mmHg but with right heart strain or right ventricular dilation on echocardio- gram.
Thrombolysis is an option for many nonsurgical patients diagnosed with massive or submassive PE.
Contraindications to systemic tPA include recent head trauma, ischemic stroke (within 3 weeks), any prior intracranial hemorrhage, or neoplasm.
Relative contraindications include age > 75, recent surgery (within 3 to 4 weeks), pregnancy, or remote ischemic stroke.
For patients with massive or submassive PE who do not meet criteria for systemic tPA, a more recent consideration is catheter-directed tPA.
While more studies are ongoing, early randomized trials of catheter- directed tPA in postsurgical patients have demonstrated improve- ment in right ventricle (RV) function at 24 h without increase in bleeding complications.
Which of the following sites for central venous catheter placement is associated with the lowest rate of catheter-asso- ciated blood stream infections?
A. Internal jugular vein
B. Subclavian vein
C. Femoral vein
D. Both A and B are equivalent
E. All sites are equivalent if sterile technique is maintained
B
You are attempting to place a central venous catheter in the right internal jugular vein of a hemodialysis patient who is in the ICU after below-knee amputation for a severe diabetic foot infection. Which of the following is true regarding the central line placement?
A. The widespread use of ultrasound has been shown to reduce complication rates regardless of the site.
B. The risk of complication increases after three attempts by the same proceduralist.
C. If ultrasound is used, a chest radiograph is unnecessary prior to attempts on the contralateral side.
D. Routine exchange of catheters reduces infectious complications.
E. Aspiration of dark blood confirms appropriate venous placement.
ANSWER: B
COMMENTS: Nearly 15% of patients who receive central venous catheters will have an associated complication. While there is an obvious risk associated with their placement, many of these com- plications are related to catheter-associated infection or thrombosis.
Experience reduces the likelihood of complications with line placement, and it has been shown that the complication rate after three attempts is nearly six times that of the complication rate after only one attempt by any one proceduralist.
Ultrasound does reduce the risk of complication with internal jugular catheter placement but does not reliably improve outcomes with subclavian catheter placement.
Regardless of the use of ultrasound guidance, pneumothorax is a potential complication and does not obviate the need for a chest x-ray.
A recent meta-analysis demonstrated 4.5 infections per 1000 femoral venous catheter placements versus only 1.2 infections per 1000 subclavian venous catheter placements.
Likewise, subclavian catheters were also demonstrated to be associated with fewer bloodstream infections than internal jugular venous catheters.
A 66-year-old woman who has been in the ICU for 2 weeks following total hip replacement complicated by massive infection and sepsis is complaining of right calf pain. She gets out of bed to go to physical therapy and develops severe dyspnea, tachycardia, and hypotension. Pulse oximetry reading is 75%. A CT angiogram shows bilateral clots in the pulmonary arteries. With regard to PE, which of the following is true?
A. Early chest radiographic abnormalities are rarely present in patients with PE.
B. A shunt abnormality is present early after the PE and a V/Q abnormality becomes the mechanism for hypoxemia in later stages.
C. Thrombolytic therapy has been shown to reduce mortality rates in comparison to heparin in patients with PE.
D. Heparin should never be given until the diagnosis of PE is absolute.
E. More than 33% of patients with PE have negative lower extremity duplex studies for deep vein thrombosis (DVT).
ANSWER: E
COMMENTS: DVT occurs in 30% of ICU patients and is moni- tored by governing bodies in the United States; all ICUs should have a prevention protocol.
High-risk factors are thoracic or general procedures requiring general anesthesia for longer than 30 min, active malignancy, neurosurgical procedures, coronary artery bypass grafting (CABG), CHF, and respiratory failure, along with the traumatic injury.
ICU patients almost always have at least one risk factor and need prophylaxis. Options include pharmacologic treatment with low-molecular-weight heparin (LMWH), unfractionated heparin, or pneumatic compression devices. In regard to diagnosis, duplex ultrasound has a specificity and sensitivity greater than 95%.
Many emboli can be silent, but symptoms of small-to-medium emboli are usually pulmonary (i.e., dyspnea, chest pain, and cough).
Tachypnea and tachycardia are present as well.
Massive PE often produces cardiovascular findings such as elevated PA pressure and right heart strain.
Angiography is the definitive diagnostic technique for this disease, but a helical CT scan of the chest with infusion has shown excellent specificity.
Even without pulmonary infarction, radiographic abnormalities appear as diaphragmatic elevation, atelectasis, and effusion.
For treatment of DVT, heparin therapy over a period of 5 to 7 days with an overlap with warfarin constitutes the treatment of choice.
Warfarin should be continued for 6 to 12 weeks for calf vein and large- vein thrombosis and up to 6 months for PE.
A 25-year-old male patient with Von Hippel–Lindau (VHL) syndrome is found to have bilateral adrenal masses identified on a CT of the abdomen. His medication list includes both an angiotensin-converting enzyme (ACE) inhibitor and calcium channel blocker for hypertension. As part of his preoperative preparation, what medication(s) should he receive?
A. β-blockade
B. α-blockade
C. α-blockade followed by β-blockade
D. β-blockade followed by α-blockade
E. Hydrocortisone
ANSWER: C
COMMENTS: A rare genetic syndrome, VHL is associated with numerous benign tumors that have potential malignant transformation or other physiologic consequences.
Pheochromocytoma is one of these associated lesions and should be suspected in any young patient with the disorder and hypertension.
All patients with pheo- chromocytoma should undergo preoperative α-blockade to negate the activity of the tumor.
Typically this is accomplished with twice- daily dosing of phenoxybenzamine or another α-blocking medication.
The dose is generally started at a low level and increased until orthostatic hypotension develops.
At this point, with the patient sufficiently α-blocked, there is often rebound tachycardia for which a β-blocker is then started.
These medications are continued through the perioperative period until the patient has had the pheochromocytoma surgically excised.
If the patient is also adrenally insufficient, stress-dose steroid at the time of the operation may be indicated.
A 56-year-old male with hypertension and diabetes is anticoagulated following an emergent right femoral-popliteal arterial bypass. He has been continually oozing from his fasciotomy sites, and his hemoglobin has drifted down in the past 3 days to a level of 7.8 g/dL. On review of his chart you see that in the preoperative clearance note from cardiology he had a hemoglobin level of 13.0 g/dL and no significant cardiac disease. His family is concerned about how pale he has been during this ICU stay. His vital signs are an HR of 86 beats/min, BP of 128/69 mmHg, and Sao2 of 96%. What is the appropriate answer regarding a blood transfusion for this patient at this time?
A. Transfuse five units of PRBCs to reach the preoperative hemoglobin level of 13 g/dL.
B. Check complete blood count (CBC) levels daily and hold transfusion until the hemoglobin level is lower than 9 g/dL.
C. Start erythropoietin at 40,000 units daily.
D. Transfuse PRBCs to a level greater than 10 g/dL.
E. Check daily CBC levels and hold transfusion until the hemoglobin level is lower than 7 g/dL.
ANSWER: E
COMMENTS: Anemia is very common in critically ill patients; in the United States, approximately 85% of patients spending more than 1 week in the ICU receive one or more units of PRBCs in their first week.
Blood is a scarce and expensive resource and is associated with morbidity, including transfusion reactions, infections, and worse outcomes.
Historically, patients received transfusions if their hemoglobin level dropped below 10 g/dL.
However, a multicenter prospective randomized clinical trial in 1999 showed that transfu- sion for a hemoglobin level of less than 7 g/dL had the same 30-day mortality rate as transfusion when the hemoglobin level was less than 10 g/dL (except in patients with the significant cardiac disease).
This patient had preoperative cardiac clearance and is not presently showing any signs of hemodynamic instability.
Patients with anemia of critical illness have been shown to have a blunted response to both endogenous and exogenous erythropoietin.
A multicenter trial showed a mild increase in hemoglobin, but it is unclear in the literature whether this improves clinical outcomes.
The routine use of which of the following is associated with a lower rate of VAP in the ICU setting?
A. Ventilator weaning protocol
B. Chlorhexidine oral rinse
C. Daily sedation vacation
D. H2 blocker
E. Maintaining the head of bed at 30 to 45 degrees
ANSWER: A
COMMENTS: Most of the items are routinely included on “VAP bundles” in ICUs across the country, although not all are aimed at specifically preventing VAP.
The use of H2 blockers and DVT prophylaxis are indicated for nearly all mechanically ventilated patients given their increased risk for stress ulcer and thromboembolic disease; however, they play no role in the reduction of pneumonia or liberation from the ventilator.
Chlorhexidine oral rinse and head- of-bed elevation are also standard practice for ventilated patients, and while not often harmful, their efficacy has been unable to be proven or widely replicated in randomized trials.
It is widely accepted, however, that an established ventilator weaning protocol does reduce overall days of mechanical ventilation, which in turn results in a decreased rate of VAP.
Daily SATs do not have a significant effect on ventilator days, ICU length of stay, or rates of VAP.
Other considerations include the role of early tracheostomy as well as newer technologies like endotracheal tubes with the aspiration of subglottic secretions and their potential applications going forward.
A 47-year-old man with hepatitis C cirrhosis and hepatocellu- lar carcinoma is in the ICU following orthotopic liver transplant. Preoperatively, he developed renal failure secondary to hepatorenal syndrome and remains on dialysis but otherwise is recovering well. On postoperative day 5, his platelet count is noted to be 70,000 per microliter from 150,000 per microliter one day prior. What is the most likely diagnosis?
A. Consumptive coagulopathy
B. Laboratory error
C. Hemodilution
D. Heparin-induced thrombocytopenia
E. Idiopathic thrombocytopenic purpura (ITP)
D
The diagnosis of heparin- induced thrombocytopenia (HIT) is confirmed. What is the next best step?
A. Argatroban drip
B. Oral anticoagulation with Coumadin
C. Hold all anticoagulation
D. Lepirudin
E. Transition from heparin to Lovenox
ANSWER: A
COMMENTS: Type II HIT has developed in this patient. Type I HIT occurs in 1%–2% of patients and causes transient sequestration of platelets with a drop in the count to less than the normal range or a 50% fall in the platelet count within the normal range.
In general, this is of little consequence. Platelet levels normalize in a few days after heparin is discontinued.
Type II is more severe, and antiplatelet antibodies develop in 0.1%–0.2% of patients exposed to heparin.
It is associated with thromboticcomplications in more than 30% of cases and should be suspected in a patient in whom resistance to anticoagulation, thromboembolic events, and a fall in the platelet count greater than 30% or a count of less than 100,000/mm3 develop.
Once HIT is suspected, all sources of heparin, including LMWH, should be discontinued. Warfarin can worsen the prothrombotic state and should not be used before complete anticoagulation is achieved with argatroban or lepirudin, both antithrombin agents.
Lepirudin undergoes renal elimination, which should be noted in situations such as this patient with renal insufficiency. Argatroban is metabolized hepatically and is the best choice in this situation.
A 60-year-old man with renal failure who has been undergoing dialysis for the past 2 years is admitted for cellulitis surrounding the fistula site on his right upper extremity. Antibiotics are started, and the patient is observed. On hospital day 4, his fistula clots and he is taken to the OR for revision. On the following day, he is febrile, coughing up thick green sputum, and dyspneic despite having undergone dialysis that morning. A chest radiograph shows an infiltrate in his right lower lobe, and laboratory tests show a WBC count of 18,000/mm3. Which characteristic of nosocomial pneumonia listed below is not correct?
A. Characterized by onset within 24 h of hospital admission
B. Purulent sputum
C. Isolation of the pathogenic organism from blood or the lung
D. Elevated WBC count
E. Infiltrate on chest radiography
ANSWER: A
COMMENTS: Hospital-acquired pneumonia (HAP) is the second most common of all nosocomial infections in the United States.
The Centers for Disease Control and Prevention’s definition of nosocomial pneumonia is a clinical one that requires pneumonia to occur more than 48 h after hospital admission and excludes any infections that are present or incubating at admission. The other two criteria include appropriate findings on physical examination or an infiltrate on chest radiography plus one of the following: purulent sputum, isolation of the pathogenic organism from blood or the lung, identification of a virus from the lower respiratory tract, or serologic or pathologic evidence of recent infection.
Many clinical studies have shown that early, appropriate, and adequate antibiotic therapy can reduce the mortality rate from HAP, currently listed as anywhere from 24% to 76%. T
he American Thoracic Society presumes that early-onset pneumonia is due to Haemophilus influenzae, methicillin- susceptible Staphylococcus aureus, Streptococcus pneumoniae, or anaerobes.
Late-onset HAP occurs more than 4 days after admission and is usually caused by gram-negative organisms, especially Pseudomonas aeruginosa, Acinetobacter, Enterobacteriaceae (Klebsiella, Enterobacter, Serratia), or methicillin-resistant S. aureus (MRSA). Broad-spectrum antibiotics should be started early and deescalated, not escalated, when culture sensitivities are known.
This patient does not require intubation at this time, and low-volume, lung-protective ventilation is best used for ARDS. Patients with HAP do not need bronchoscopy daily. Chest therapy, elevation of the head of the bed, and ambulation are all methods to improve pulmonary toilet.
A 27-year-old patient presented with a prolonged ICU course for Fournier’s gangrene. Upon admission 5 days ago he had arterial and central lines placed along with a Foley catheter, which has since been removed. He now complains of diffuse body ache, anorexia, and cough with thin, white sputum. He has not had flatus or a bowel movement for 24 h. Chest radiography shows bilateral haziness at the costophrenic angles. Physical examination shows no acute distress, crackles in the lung bases bilaterally, and a swollen right arm. He has some redness around the right side of his neck and chest while his abdomen is soft, distended, and tympanitic but nontender. Vital signs include a temperature of 101.6°F, HR of 100 beats/ min, BP of 128/75 mmHg, and Sao2 of 96%. Lab findings include WBC of 18,500/mm3, sodium concentration of 140 mEq/L, potassium of 4.3 mEq/L, BUN of 21 mg/dL, creatinine level of 0.8 mg/dL, and liver profile within normal limits. What is the most likely diagnosis?
A. Acalculous cholecystitis
B. HAP
C. Catheter-related bloodstream infection
D. Perforated peptic ulcer
E. Viral respiratory infection
ANSWER: C
COMMENTS: The most likely diagnosis is a catheter-related bloodstream infection.
He had a catheter placed on an emergency basis and is now experiencing fevers and malaise, with cellulitis evident in the right side of his neck.
His infection can explain the anorexia, ileus, and elevated WBC count.
Catheter-related blood- stream infection is seen in approximately 5% of patients with indwelling catheters and should be suspected if any erythema or purulence is identified at the catheter site.
The subclavian vein is the preferred site for the reduction of infection, over internal jugular or femoral locations. Once an infection is suspected, blood should be drawn through the line and peripherally for culture, and immediate removal of the catheter is suggested and the tip sent for culture.
A catheter–peripheral colony-forming unit (CFU) ratio of 8 signifies line sepsis, and a catheter tip culture with 25 CFUs confirms a catheter-related infection.
A 45-year-old male is recovering from multiorgan failure after laparotomy for a perforated gastric ulcer. He has been afebrile for 48 h and is not taking any antibiotics. His WBC count is normal and renal failure has resolved. Encephalopathy is improving, and oxygenation is ade- quate, although attempts to wean him from the ventilator have been unsuccessful. Neurologic examination shows symmetrical quadriparesis with sparing of the face and depressed deep tendon reflexes. Spinal tap is normal. Which of the following statements is true concerning his condition?
A. Nerve biopsy often shows demyelination or inflammation.
B. Failure to wean from the ventilator is due to phrenic nerve involvement.
C. Corticosteroids are the treatment of choice.
D. Serum antibodies against acetylcholine receptors are always present.
E. Plasmapheresis is the initial treatment of choice.
ANSWER: B
COMMENTS: Critical illness polyneuropathy (CPU) is an axonal motor sensory neuropathy that accompanies sepsis with encephalopathy.
It is due to primary axonal degeneration and affects motor fibers more than sensory fibers. Frequently, it is manifested as a failure to wean a patient from the ventilator because of phrenic nerve involvement despite clinical improvement.
Symmetrical quadriparesis with facial sparing and depressed deep tendon reflexes is characteristic, and electromyography confirms the diagnosis.
Spinal fluid is normal, unlike the case in patients with Guillain-Barré syndrome. Facial involvement and detection of antibodies against acetylcholine are characteristic of myasthenia gravis.
Nerve biopsy shows axonal degeneration without demyelination or inflammation.
Treatment is supportive, and corticosteroids are contraindicated.
A 63-year-old man is admitted to the ICU following a Hartmann procedure for Hinchey type IV diverticulitis 5 days earlier. The patient is intubated and maintained on AC ventilation, is tachycardic, and is febrile to 101°F. The nurse has noticed an increase in tracheobronchial secretions that are purulent in character. A chest radiograph shows a new infiltrate in the right lung. Which of the following statements is false regarding this patient’s condition?
A. The most likely organism involved is methicillin-sensitive S. aureus.
B. The frequency of ventilator circuit changes does not influence the incidence of this complication.
C. Kinetic beds and elevation of the head of the patient to 45 degrees decrease its incidence.
D. The risk for development of this complication is highest in the second week.
E. Qualitative cultures or secretions are preferred over quantitative culture techniques.
ANSWER: D
COMMENTS: VAP has significant costs and a mortality of about 25%. The risk of acquiring VAP is highest in the first week (3% per day), thereafter decreasing to 2% per day in the second week and to 1% per day in the third week.
VAP is generally categorized as early (<48 h after intubation) or late (occurring after 5 to 7 days of intubation).
Early-onset VAP is associated with bacteria that are normally sensitive to antibiotics (S. aureus, H. influenzae, and S. pneumoniae), whereas late-onset VAP is typically associated with antibiotic-resistant bacteria (MRSA, P. aeruginosa, Acinetobacter, and Enterobacter species).
The major risk factors for VAP include trauma, burns, and stay in neurosurgical units as opposed to medical ICUs.
Known risk factors include patients older than 60 years who require prolonged (>48 h) mechanical ventilatory support, aspiration, a nasogastric tube, failure to elevate the head of the bed, and endotracheal cuff pressures of less than 20 cm H2O.
Orotracheal intubation carries a lower incidence of VAP than nasotracheal intubation.
Because contamination of ventilator circuits is universal, the ventilator circuit change interval does not affect the incidence of VAP.
Heat and moisture exchangers may be associated with a slightly lower incidence of VAP than heated humidifiers.
Drainage of subglottic secretions is associated with a decreased incidence of VAP, especially early-onset VAP.
Kinetic beds and positioning of patients at 45 degrees from the horizontal are also associated with a decreased incidence.
Previous exposure to antibiotics in a pro- longed preoperative hospitalization exposes patients to health care– related infections.
Selective digestive decontamination has been reported to be associated with a decreased incidence of VAP, yet these therapies should be time limited to prevent the growth of resistant organisms.
The suspicion for VAP in this patient with a prolonged period of ventilation and new onset of fever, leukocytosis, and purulent sputum should be high, particularly if the chest radiograph shows a new infiltrate.
The diagnosis is best established by quantitative culture of secretions obtained from the lower respiratory tract. The two techniques used include protected specimen brush (PSB) sampling and bronchoalveolar lavage (BAL).
A threshold of 1000 CFU/mL for PSB and 10,000 CFU/mL for BAL is currently recommended. The presence of less than 50% neutrophils in BAL fluid has also been used to exclude pneumonia.
Even though the effect of these techniques on patient outcome is unclear, they have resulted in a significant reduction in the use of antibiotics.
A 22-year-old man involved in a motor vehicle accident is found to have a thoracic spine fracture (T6) and paraplegia. The patient is hypotensive with a systolic BP of 70 mmHg, is bradycardic with a pulse of 48 beats/min, and is breathing comfortably. Which of the following would be the most appropriate initial treatment?
A. Isotonic fluid administration
B. Steroid administration within 24 h of the injury
C. Immediate intubation
D. α-Agonist administration
E. Immediate magnetic resonance imaging
ANSWER: A
COMMENTS: Neurogenic shock refers to a condition characterized by hypotension and bradycardia that results from the interruption of the sympathetic nervous system pathways within the spinal cord.
Common causes include sensory stimulation, such as severe pain, exposure to unpleasant events or sights, high spinal anesthesia, and traumatic spinal cord injury. Clinical characteristics include a BP that is often low, as in other forms of shock.
However, the pulse rate is usually slower than normal, and the skin is flushed, warm, and dry.
CO is reduced secondary to decreased blood return to the heart because of the increased capacitance of the arterioles and venules.
Since the heart receives sympathetic input, there is a difference between injuries above and below T4.
The former depresses cardiac function and decreases venous return. The bradycardia is caused by sympathectomy of the spinal injury above the level of T4 with no capacity for compensatory tachycardia.
Treatment of neurogenic shock secondary to spinal cord injury is usually more complicated not only because of more prolonged hypotension but also because of the presence of coin- cident hypovolemic shock resulting from associated injuries.
Such patients often require ventilatory support as a result of decreased spontaneous respiration and loss of the accessory muscles for breathing. Aggressive fluid therapy should be instituted early under continuous cardiovascular monitoring.
Persistent hypotension necessitates recognition of possible hemorrhagic shock, and a vasopressor such as ephedrine or phenylephrine may be needed. If the injury is below T4, a pure α-agonist may aggravate the reflex bradycardia. Thus a drug with mixed chronotropic and inotropic effects (e.g., norepinephrine or dopamine) is preferred.
A nasogastric tube should be inserted because gastric atony, dilation, and hypersecretion develop in these patients.
Treatment of milder forms of neurogenic shock consists of removing the nociceptive stimulus.
Neurogenic shock resulting from high spinal anesthesia can usually be treated with a vasopressor such as ephedrine or phenylephrine, each of which increases CO by direct effects on the heart and by increasing peripheral vasoconstriction.
Although the administration of steroids remains controversial, their useful- ness for blunt spinal cord injury has been suggested when they are given within 8 h of injury and their administration is extended for 48 h.
Which of the following is associated with the greatest in-hospital mortality?
A. An ICU patient with an increase in the Sequential Organ Failure Assessment (SOFA) score by 2 points in 24 h
B. A patient in the ED with altered mental status and an RR of 25 breaths/min but no hypotension
C. An ICU patient requiring one vasopressor with a serum lactate value of 2 mmol/L
D. A patient on the medical ward who is alert and oriented but hypotensive and tachypneic
E. All represent sepsis with equal in-hospital mortality
ANSWER: C
COMMENTS: In the newest definitions of sepsis and septic shock, the Society of Critical Care Medicine has identified the utility of the SOFA score and its association with in-hospital mortality.
The variables include the Pao2:FiO2 ratio, platelet count, serum creatinine, and bilirubin.
Sepsis may now be indicated by an increase in an individual patient’s SOFA score by 2 points, which is associated with a 10% increase in in-hospital mortality.
The quick SOFA, or qSOFA, has been advocated for the rapid assessment of patients and consists of three variables: mental status, tachypnea (RR > 22 breaths/min), and hypotension (systolic BP < 100 mmHg).
If at least two of these criteria are met, there should be a high index of suspicion for sepsis in these patients and admission to an intensive care setting is appropriate.
Lastly, they identified that the combination of hypotension requiring at least one vasopressor along with a serum lactate value of 2 mmol/L or greater in the absence of hypovolemia is associated with a 40% in-hospital mortality rate.
These two criteria are now recognized and utilized as the definition of septic shock.
A 28-year-old male with a history of depression is brought into the ED by a family member who believes the patient is overdosed on acetaminophen.
On further questioning the patient admits to ingesting “a few handfuls” of acetaminophen tablets approximately 18 h prior to the arrival to the hospital. On assessment, the patient is awake; however, he is confused. His vital signs are an HR of 105 beats/min, BP 102/77 mmHg, RR 18 breaths/min, and Sao2 of 99%. Lab values are significant for arterial pH 7.32, INR 3.1, and creatinine 4.2. What is the best first step for management of this patient?
A. Administration of IV N-acetylcysteine
B. Stress-dose steroids
C. Aggressive fluid resuscitation with normal saline
D. Activated charcoal
E. Urgent evaluation for liver transplantation
ANSWER: A
COMMENTS: Fulminant hepatic failure is classically defined as the development of severe liver injury with impaired synthetic function (INR ≥ 1.5) and new encephalopathy in patients without preexisting liver disease.
In the United States, the most common causes of acute liver failure are acetaminophen overdose and viral hepatitis.
Acetaminophen toxicity can be difficult to predict, as there are often no early symptoms and the modified Rumack- Matthew nomogram is widely used to predict poisoning severity following acetaminophen overdose.
The use of activated charcoal for gastrointestinal decontamination is useful for patients who present within 4 h of acetaminophen ingestion; however, activated charcoal should be used with caution in patients who may not be able to protect their airway.
N-acetylcysteine is the most effective antidote for acetaminophen toxicity, and initiation of therapy within 8 h of ingestion is associated with greatly decreased morbidity.
The King’s College Criteria is used to identify patient’s with a poor prognosis with acetaminophen-induced fulminant hepatic failure.
An arterial pH less than 7.3 or a combination comprising INR greater than 6.5, creatinine greater than 3.4 mg/ dL, and grade III/IV encephalopathy are strong predictors of poor prognosis.
Patients who continue to deteriorate despite appropriate medical therapy should be considered for liver transplantation.
A 30-year-old female with a history of nonalcoholic steatohepatitis underwent a spontaneous vaginal delivery complicated by uterine atony and a large-volume bleeding, refractory to fundal massage, medical management, and uterine artery embolization. Hemostasis eventually is achieved after the patient underwent exploratory laparotomy and hysterectomy; however, the patient required rapid transfusion of 15 units of PRBCs during her resuscitation. Postoperatively, the patient is extubated and transferred to the surgical ICU for monitoring. Shortly after arrival, the patient complains of perioral numbness and paresthesias in her feet. What is the most likely cause of the patient’s symptoms?
A. Metabolic alkalosis due to alkaline transfusions
B. Overadministration of IV crystalloids
C. Low serum calcium levels in the transfused blood
D. Citrate toxicity
E. Hyperkalemia due to hemolysis of transfused blood
ANSWER: D
COMMENTS: Massive blood transfusion is classically defined as transfusion of 10 units of red blood cells within 24 h; however, many other definitions have been proposed.
There are many physiologic alterations associated with massive blood transfusion that require careful monitoring.
Large-volume transfusion of red cells can dilute serum coagulation proteins and platelets leading to a prolongation in PT and activated partial thrombo- plastin time (aPTT).
Additionally, transfused blood is anticoagu- lated with sodium citrate and citric acid.
Rapid transfusion of red blood cells can overwhelm a patient’s ability to metabolize the excess citrate, which can bind ionized calcium and can lead to clinically significant hypocalcemia.
Generally, very rapid transfusion is required to cause significant hypocalcemia; however, those with preexisting liver disease are at a greatly increased risk.
Administration of either calcium gluconate or calcium chloride is an acceptable treatment of hypocalcemia following massive transfusion.
A 67-year-old-male is brought emergently to the OR for the management of freely perforated diverticulitis. During the procedure the patient is unstable, requiring multiple vasopressors as well as large-volume fluid resuscitation. At the completion of the case, the patient was stabilized and transferred to the SICU intubated with nasogastric decom- pression. The patient is noted to have worsening abdominal distension throughout the night and decreasing urine output despite multiple crystalloid boluses. On examination, the patient has a Richmond Agitation-Sedation Scale score of −1. He has a tense abdomen with a healthy appearing ostomy and an abdominal surgical drain with minimal serosanguinous drainage. His vital signs are a temperature of 37.2°C, HR 98 beats/min, and BP 144/92 mmHg. He is mechanically ventilated, with peak airway pressures of 38 cm H2O and plateau pressures of 28 cm H20. Intravesicular pressure is measured to be 22 mmHg. What is the next best step in managing this patient?
A. Increase the patient’s sedation
B. Decrease the patient’s Vt
C. Administration of a paralytic agent
D. Broadening of antibiotic therapy
E. Emergent return to the OR for reexploration
ANSWER: A
COMMENTS: ACS is defined as an end-organ dysfunction in the setting of intraabdominal hypertension.
Intraabdominal hyper- tension refers to sustained intraabdominal pressures ≥ 12 mmHg.
Clinically, there is no defined intraabdominal pressure for ACS as end-organ dysfunction can occur at a variety of pressures between different patients; however, intraabdominal pressures ≥ 25 mmHg are frequently associated with ACS.
Bladder pressures are widely used as a surrogate measurement for intraabdominal pressure.
ACS can occur in a variety of clinical settings, including trauma, burns (>30% of the total body surface area), liver trans- plantation, and postsurgical patients.
Additionally, large-volume resuscitation has been associated with increased occurrence of ACS.
The diagnosis of ACS is generally made with the triad of a tense abdomen, decreased urine output despite fluid resuscitation, and increased airway pressures, all in the setting of abdominal hypertension.
For patients with progressive renal dysfunction or worsening shock, the definitive management of ACS is a decompressive laparotomy.
In patients where there is a concern for the impending development of ACS, supportive care measures can be made to decrease intraabdominal pressures.
Nasogastric and rectal decompression, deep sedation, chemical paralysis, limited fluid administration, and ventilator support to reduce airway pressures may be used.
In the above scenario, the patient is minimally sedated and may have improved intraabdominal pressures with increased sedative dosing.
The primary survey is best described by which sequence of steps?
A. Airway, Blood pressure, Pulses, Breath sounds, Extremities
B. Airway, Breathing, Circulation, Disrobe, Extremities
C. Airway, Breathing, Circulation, Disability, Exposure
D. Access, Blood pressure, Chest compressions, Disability, Endotracheal intubation
E. Airway intubation, Bilateral chest tube placement, Central line placement
ANSWER: C
COMMENTS: The Advanced Trauma Life Support (ATLS) Program of the American College of Surgeons has put forth a general framework on how to approach and manage an injured patient.
To streamline care, the A, B, C, D, E, and F sequence has been endorsed, which represents Airway, Breathing, Circulation, Disability, Exposure, and Focused Assessment with Sonography for Trauma (FAST).
This comprises the primary survey with the goal of identifying life-threatening injuries and supporting oxygenation, ventilation, and perfusion.
A team leader confirms that each system is intact and then moves to the next step with continued reassessment and interventions as needed.
Common interventions include endotracheal intubation or cricothyroidotomy, placement of chest tubes and central venous catheters (CVCs), and, rarely, an emergency department (ED) thoracotomy.
This is followed by a secondary survey that allows for a head-to-toe examination and a brief medical history.
A middle-aged male is found lying on the ground in an alley and is brought into the trauma bay for additional evaluation. His vital signs are stable. The only sign of trauma is a large scalp laceration. The patient is confused with a Glasgow Coma Scale (GCS) score of 7. The decision is made to intubate the patient. What is the correct order for rapid-sequence intubation in trauma?
A. In-line cervical immobilization, preoxygenation, cricoid pressure, induction, paralysis, intubate, confirm placement with CO2 detector
B. In-line cervical immobilization, preoxygenation, cricoid pressure, paralysis, induction, intubate, confirm placement with CO2 detector
C. In-line cervical immobilization, preoxygenation, cricoid pressure, induction, intubate, confirm placement with CO2 detector, paralysis
D. Tilt head back in sniffing position, preoxygenation, cricoid pressure, induction, paralysis, intubate, confirm placement with CO2 detector
E. Tilt head back in sniffing position, preoxygenation, cricoid pressure, paralysis, induction, intubate, confirm placement with CO2 detector
ANSWER: A
COMMENTS: The most commonly used method for securing a trauma patient’s airway is orotracheal intubation.
Rapid-sequence intubation consists of preoxygenating the patient for 3 min with bag-valve-mask ventilation while maintaining in-line cervical stabilization, applying cricoid pressure to limit aspiration, administering an induction agent followed by a paralytic, performing laryngoscopy, and then placing an endotracheal tube.
In-line cervical stabilization should be maintained with the help of an assistant, not a rigid cervical spine collar.
Common medications used include etomidate, ketamine, and succinylcholine.
Etomidate is an induction agent that has a quick onset of action and is indicated for patients with a suspected brain injury or open globe because it does not cause an increase in intracranial pressure (ICP).
However, it can cause adrenal insufficiency in rare cases. Ket- amine is a dissociative anesthetic that can cause tachycardia and hypertension as common side effects.
Succinylcholine should be avoided in patients with burns or a spinal cord injury because it can cause a rise in the serum potassium concentration and can lead to severe hyperkalemia.
Confirmation of tube placement should be completed with a carbon dioxide detector and chest x-ray.
A 72-year-old female presents after being ejected during a high-speed motor vehicle crash. Her heart rate (HR) is 155 beats/min, and blood pressure is 60/35 mmHg. Emergency medical technicians (EMT) were not able to obtain intravenous (IV) access. What is the best access for this patient so that fluid resuscitation can be initiated?
A. Saphenous vein cut down
B. Ultrasound-guided left internal jugular vein triple-lumen catheter
C. Right subclavian triple-lumen catheter using landmarks
D. Intraosseous (IO) access at the humerus
E. IO access at the tibia
ANSWER: D
COMMENTS: When traditional vascular access methods have not been successful, IO access can provide a means to give resuscitative fluids, medications, blood, and contrast.
The IO route has been demonstrated to have a significantly higher first-attempt success rate and can be completed in a much quicker fashion and with fewer complications.
Even experienced providers have dif- ficulty placing a CVC using landmarks. CVC in trauma has about a 50% success on the first pass and requires an average of 8 min to place.
In contrast, IO placement is over 90% successful and takes approximately 1 min to place.
Ultrasound guidance has been shown to improve central line placement. However, it is not always practical in an emergency setting because it may not be readily available, takes time to set up, and space around a patient is limited.
Many sites have been utilized for IO access. Although IO use is limited to the anterior tibia in the pediatric population, cadaver studies in adults showed the best flow rates with minimal placement or dislodgement issues in the sternum followed by the humerus.
The humerus is now the preferred position.
A 17-year-old female presents after a motor vehicle crash and is in hemorrhagic shock. A massive transfusion protocol is triggered. What is the optimal ratio in damage control resuscitation?
A. 2 plasma:1 platelet:1 red blood cell
B. 1 plasma:1 platelet:1 red blood cell
C. 1 plasma:1 platelet:3 red blood cells
D. 2 plasma:1 cryoprecipitate:1 red blood cell
E. 1 plasma:1 cryoprecipitate:1 red blood cell
ANSWER: B
COMMENTS: Approximately 1%–3% of trauma patients require a massive transfusion. The US Department of Defense’s Prospec- tive Observational Multicenter Major Trauma Transfusion (PROM- MITT) study demonstrated that early transfusion with higher plasma-to-platelet ratios was associated with decreased mortality.
The Pragmatic, Randomized Optimal Platelets and Plasma Ratios (PROPPR) trial demonstrated the optimal ratio of 1 plasma:1 plate- let:1 red blood cell versus 1 plasma:1 platelet:2 red blood cells was associated with more patients achieving hemostasis with fewer hemorrhage-related deaths without increased complications.
The overall 24-h and 30-day mortality was equal between groups. Both these studies support the early use of balanced transfusion therapy in an exsanguinating injured patient.
A 77-year-old male with a history of atrial fibrillation on dabigatran, a direct thrombin inhibitor, presents after a fall from a ladder. His HR is 130 beats/min and irregular, blood pressure is 82/44 mmHg, and FAST is positive, with fluid in the right upper quadrant (RUQ) and pelvis. Prior to proceed- ing to the operating room, what is the best reversal agent for this patient’s anticoagulation?
A. Fresh-frozen plasma
B. Prothrombin complex concentrates
C. Protamine sulfate
D. Idarucizumab
E. Platelets
ANSWER: D
COMMENTS: As the population grows older and more novel anticoagulants are prescribed, trauma surgeons need to know how to manage and reverse these medications acutely in a bleeding patient.
Warfarin, a vitamin K antagonist, has traditionally been managed with fresh-frozen plasma and vitamin K injections.
Recombinant factor VII has also been used to treat these patients and cirrhotics with an elevated international normalized ratio (INR).
However, there is an increased prothrombotic risk potential with this therapy.
Newer therapies include either 3- or 4-factor prothrombin complex concentrates (PCCs) that contain variable amounts of factors II, VII, IX, and X and proteins C and S and rapidly reverse the effects of warfarin within 30 min.
Heparin and low-molecular-weight heparin (LMWH) are reversed with variable dosing of protamine sulfate.
The effects of platelet inhibitors including aspirin and clopidogrel can be minimized with desmopressin and platelet transfusions.
Novel agents including direct thrombin or factor Xa inhibitors can be managed with activated charcoal and PCC.
A monoclonal antibody, idarucizumab, specifi- cally adheres to the thrombin-binding site of dabigatran, rendering it inactive within a minute of dosing.
A 75-year-old morbidly obese male presents after a motor- cycle crash. The primary survey demonstrates an intact airway, diminished breath sounds from the left chest, GCS of 10, and limited movement of upper extremities. His HR is 122 beats/ min, and blood pressure is 80/44 mmHg. A left chest tube is placed with 1 L of bloody output. The patient has 2 L of saline infused. His HR decreases to 116 beats/min, and blood pressure is 86/48 mmHg. FAST was indeterminate. What is the next best step to evaluate for intraabdominal hemorrhage?
A. Serial abdominal examinations
B. Diagnostic peritoneal tap
C. Computed tomography (CT)
D. Exploratory laparoscopy
E. Exploratory laparotomy
ANSWER: B
COMMENTS: This patient has several sources of shock including hemorrhage from his thorax and likely intracranial and spinal injuries.
He is too unstable to leave the resuscitation area to go for CT imaging, and an abdominal source of bleeding must be ruled out prior to the definitive management of his injuries.
Diagnostic peritoneal tap with lavage is a very sensitive, but nonspecific, test that can be used for either blunt or penetrating trauma.
In this situation, diagnos- tic peritoneal lavage (DPL) is used to determine an intraperitoneal injury.
However, it will miss retroperitoneal bleeding. DPL is performed by introducing a catheter into the abdomen via the Seldinger technique and then infusing 1 L of 0.9% normal saline.
The fluid is then returned by gravity and sent to the laboratory for analysis. A positive DPL is defined as one with greater than 100,000 red blood cells/mm3, 500 white blood cells (WBCs)/mm3, or the presence of bilious/particulate material.
A limited version of this procedure is a diagnostic peritoneal tap in which a needle is passed into the peritoneal cavity.
If blood or succus is aspirated by a 10-ml syringe, it is deemed positive. If this patient has a positive DPL, the next most appropriate step in management is exploratory laparotomy.
Serial abdominal examinations in an unstable patient are not appropriate.
A 20-year-old female presents after a motor vehicle crash. She complains of diffuse abdominal pain. Her HR is 140 beats/min, and blood pressure is 78/42 mmHg. FAST is positive. Which statement best describes the FAST examination?
A. A 3.5-MHz convex-array transducer should be used.
B. The hepatorenal space, known as the Morison pouch, is viewed between the 11th and 12th ribs in the right midaxillary line.
C. The splenorenal space is evaluated between the 9th and 11th ribs in the left posterior axillary line.
D. The bladder should
preferentially be full before the examination to allow better visualization of fluid in the pelvis.
E. All of the above.
ANSWER: E
COMMENTS: Focused assessment for the sonographic examination of trauma patients is performed as part of the ATLS secondary survey.
A 3.5-MHz convex-array transducer is used to evaluate for the presence of fluid in the abdomen.
Four areas are to be examined.
The first is the pericardial window, which is viewed with the transducer placed subxiphoid. The hepatorenal space is evaluated in the right midaxillary line, between the 11th and 12th ribs.
The splenorenal space is evaluated in the right posterior axillary line, between the 9th and 11th ribs.
The last area examined is the pouch of Douglas in the pelvis. This rectouterine/rectovesical space is evaluated with the transducer placed approximately 3 cm above the pubic symphysis.
A full bladder aids in detecting the presence of blood in this space; therefore Foley catheters should be placed after FAST has been performed.
A 23-year-old male is brought by emergency medical services (EMS) with a stab wound to the chest 2 cm medial from the right nipple. He was intubated en route; carotid pulse was present but faint, and pupils were responsive to light. After transferring the patient onto the gurney, no palpable pulses are appreciated. What is the next step in management?
A. Right tube thoracostomy
B. Right anterolateral thoracotomy
C. Median sternotomy
D. Left anterolateral thoracotomy
E. Left posterolateral thoracotomy
ANSWER: D
COMMENTS: An ED thoracotomy is performed for a select group of patients, with the overall survival rate being dependent on the mechanism and ranging from 1.5% to 19%.
It is least successful in patients with injuries caused by a blunt mechanism and is therefore usually reserved for those who initially have vital signs present but then lose these signs in the ED.
In patients with a penetrating mechanism, a thoracotomy is indicated for those who have lost their pulse and blood pressure either in the ED after initial evalu- ation or during transport to the ED.
Thoracotomy is best used when cardiac tamponade or severe thoracic hemorrhage is suspected.
The thoracotomy is performed on the left side via an anterolateral approach, regardless of the supposed side of the injury, and allows the release of pericardial tamponade, open cardiopulmonary resus- citation, and aortic cross-clamping.
Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a newer, less invasive technique that is being utilized to control intraabdominal and pelvic hemorrhage.
Outcomes are still inconclusive, and studies are ongoing to establish its routine use as an adjunct or alternative to current therapy.
A 29-year-old female is the driver of an automobile involved in a high-speed motor vehicle crash. She is 30 weeks pregnant. She complains of abdominal pain but does not have peritoneal signs. Her HR is 105 beats/min, and blood pressure is 108/66 mmHg. Which of the following statements is true regarding trauma in a pregnant patient?
A. Less than 5% of all pregnancies are affected by trauma.
B. The uterus is protected by the bony pelvis until the beginning of the second trimester.
C. A woman of 25 weeks’ gestation will have a palpable fundal height at approximately the level of the umbilicus.
D. Blood volume during pregnancy increases by approximately 30%.
E. Hypotensive patients should be placed in the right lateral position.
ANSWER: B
COMMENTS: Trauma is the leading cause of death in women of childbearing age and thus understanding the physiologic changes throughout the progression of pregnancy is imperative.
However, since approximately 10% of pregnant patients are unaware of their pregnancy, a pregnancy test is recommended for all women of childbearing age early in their resuscitation.
The most common cause of fetal death is maternal death. Therefore the focus of all initial resuscitative effort is directed toward the mother.
Although the primary and secondary surveys for a pregnant patient are virtu- ally identical to those of a nonpregnant patient, it is important to perform a focused abdominal examination.
Normal physiologic changes in pregnancy include an increase in HR by 10 to 15 beats/ min, a 25% increase in cardiac output, mild hypotension with average systolic blood pressures of 100, increased minute ventilation with resulting respiratory alkalosis, relative anemia, and a hypercoagulable state.
Blood volume may increase by as much as 50% during pregnancy, which means that a patient may not have the tachycardia and hypotension usually associated with acute blood loss until almost 30% of total blood volume is lost.
The pelvis typically protects the uterus until about 12 weeks. At about 20 weeks’ gestation, the fundal height of the uterus approximates the umbilicus, and for every week of gestation past this stage, the height increases roughly by 1 cm.
During the advanced stages of pregnancy, the uterus causes compression on the inferior vena cava (IVC), thereby leading to a decreased central venous return.
Hypotensive patients should be placed in the left lateral position, which even in patients with a suspected spinal injury can be accomplished by securing the patient firmly to the backboard, which can then be tilted to the left.
Evaluation of the fetus is accomplished by fetal heart tone monitoring and pelvic ultrasound.
Tachycardia, bradycardia, and decelerations with contractions are all signs of potential fetal distress.
A 32-year-old male presents after being assaulted by a bat to his head, face, and torso. He opens his eyes to sternal rub, localizes to pain, and is only making groaning sounds. What is this patient’s GCS?
A. 7
B. 8
C. 9
D. 10
E. 11
The patient in the previous scenario now only has extensor posturing. What is the next best step in management?
A. CT scan of the head
B. Continue to perform primary and secondary surveys
C. Bolus of hypertonic saline
D. Elevation of the head of the bed 30 degrees
E. Endotracheal intubation
A CT of the head is obtained demonstrating a 3-cm right- sided subdural hematoma with a 1-cm midline shift. The patient is taken to the operating room, and the hematoma is evacuated. Postoperatively, he is admitted to the intensive care unit (ICU), intubated, and sedated with an ICP monitor in place. Which of the following treatment measures can be used to maintain adequate cerebral perfusion pressure (CPP)?
A. Hyperventilation to a PaCO2 of 25 mmHg
B. Mannitol, 1 g/kg IV
C. Hydrocortisone, 100 mg IV every 8 h for 3 days
D. Strict blood pressure control to a systolic range of 90 to 100 mmHg
E. Reverse Trendelenburg positioning of the bed at all times
A N S W E R S : C, E, B
COMMENTS: The GCS score allows multiple health professionals to follow a patient’s neurologic status. It is based on the evaluation of three examinations—eyes, verbal, and motor—that are independently recorded and added together to obtain an overall score.
The best examination from each category is utilized.
The motor component is the most important regarding prognosis.
As with all trauma patients, repeated examinations with a focus on the fundamentals of airway, breathing, and circulation are key.
This patient demonstrates a decline in GCS score, which should prompt an evaluation of his airway and intubation.
A GCS score of 8 is often used as a marker for the need for intubation to secure an airway.
Any patient with a GCS score ≤ 14 or loss of consciousness should get a CT of the brain without contrast to evaluate for an intracranial injury; however, this is secondary in this patient.
The overall goal in treating patients with a traumatic head injury is maintaining adequate cerebral blood flow.
An estimate of this flow is obtained by calculating CPP (CPP = mean blood pressure − ICP).
The goal CPP in an adult is 60 to 70 mmHg. Therefore patients should be aggressively volume resuscitated or started on vasopressors to maintain adequate mean blood pressure.
ICP monitors are indicated in patients with a GCS score of 3 to 8 and either (1) an abnormal finding on CT of the head or (2) any two of the following: (a) age older than 40 years, (b) posturing response to pain, or (c) systolic blood pressure less than 90 mmHg.
Overall, there is a 5% infection and 1% hematoma formation rate associated with ICP-monitoring catheters.
Treatment measures used to decrease ICP include elevation of the head of the bed to 30 degrees or more, hyperventilation of patients to a PaCO2 of 35 mmHg, barbiturates, and mannitol at a dose of 1 g/kg IV.
PaCO2 should not be kept below 30 mmHg to avoid worsening the cerebral ischemia.
Steroids do not have a role in the treatment of acute traumatic head injury.
A 21-year-old male is brought in by EMTs on a backboard with a cervical collar in place after a bar fight that included falling over a stool. The patient is belligerent, and urine drug screen is positive for methamphetamines and alcohol. Primary survey is normal, and secondary survey reveals several facial fractures and multiple right hand fractures. What is the best way to evaluate this patient’s c-spine and remove his collar?
A. Clinical examination
B. Radiographic series of the cervical spine—cross-table lateral, anteroposterior, and open-mouth view of the dens
C. Flexion–extension x-rays
D. Magnetic resonance imaging (MRI) cervical spine followed by clinical examination when appropriate
E. CT cervical spine followed by clinical examination when appropriate
ANSWER: E
COMMENTS: Clearance of cervical spine precautions relies on the patient’s ability to participate in the examination.
In an awake patient with minimal risk factors, clinical examination alone is appropriate.
In an obtunded patient, many accepted algorithms are present to evaluate for injury.
According to the Eastern Association for the Surgery of Trauma, obtunded patients should have a CT of the cervical spine.
If no focal neurologic deficits are present and the patient is likely to be obtunded for greater than 72 h, the collar can be removed with a negative CT scan only.
Alternatively, MRI evaluation can be added to the workup.
If both studies are negative, the collar can be removed. If a person is likely to become appropriate within 24 h as determined by an alert mental state without distracting injuries, CT should be completed, and if negative, it should be followed by a clinical examination when the patient is appropriate.
Prolonged use of a cervical collar has been linked to pressure ulcers, increased ICP, prolonged ICU stay, and pneumonia and should be avoided.
CT allows for evaluation of the bony elements of the spine while MRI is best for soft tissue, the spinal cord, intervertebral disks, and ligaments.
Patients with spinal cord injuries, especially in the cervical area, may require early intubation for airway protection and aggressive fluid resuscitation and vasopressors to counter the neurogenic shock due to the loss of autonomic innervation.
These patients typically present with hypotension and relative bradycardia.
Regardless of suspicion for the neurogenic cause of hypotension, full primary and secondary surveys should be completed to rule out the hemorrhagic shock.
A 35-year-old male presents after being stabbed in the neck. A 3-cm wound is present at the base of the neck, just right of midline above the sternum. An expanding hematoma is noted. The patient is intubated for airway protection and taken to the operating room for exploration. What is the best initial incision to expose and control this injury?
A. Anterior border of the sternocleidomastoid muscle
B. Median sternotomy
C. Right anterolateral thoracotomy
D. Collar incision
E. Right infraclavicular incision
ANSWER: A
COMMENTS: The neck is divided into three zones, and management of penetrating injuries is based on the affected area.
Zone 1 is most inferior from the base of the neck to the cricoid cartilage and is exposed with an incision along the anterior border of the sternocleidomastoid muscle with possible extension into a median sternotomy.
Zone 2 extends from the cricoid cartilage to the angle of the mandible and is best approached with an incision along the anterior border of the sternocleidomastoid muscle.
Zone 3 is most superior from the angle of the mandible to the skull base. It is very difficult to approach and may require nasotracheal intubation, division of the digastric muscle, and subluxation of the mandible. Endovascular techniques may be also utilized in this area.
The aerodigestive tract, vascular system, and the spine all run through the neck and must be evaluated for injury.
This can include a combination of a barium swallow followed by an esophagogastroduodenoscopy (EGD), bronchoscopy, a CT angiogram, or an MRI based on clinical symptoms.
A 19-year-old male presents after a high-speed head-on motor vehicle crash into a tree. He was the unrestrained driver and hit the steering wheel with his chest. He has a sternal fracture, broken left clavicle, and a left pneumothorax. A left chest tube is placed with a resolution of the pneumothorax. What is the best initial evaluation for a blunt cardiac injury (BCI)?
A. Serial electrocardiogram (ECG) only
B. Serial troponins only
C. Echocardiogram only
D. Admission ECG and troponin
E. Admission echocardiogram and serial ECG
ANSWER: D
COMMENTS: The best way to evaluate for a significant BCI is an initial ECG and troponin. If these are both normal, BCI can be ruled out.
Patients with significant blunt trauma to the anterior chest with associated injuries, including, but not limited to, rib and sternal fractures, pulmonary contusions, hemothorax, pneumothorax, and polytrauma, should be screened.
Within this population, the incidence of BCI is 13%.
Patients who have abnormal findings on EKG, an elevated troponin, or hemodynamic instability require telemetry monitoring for 24 h.
These patients are at risk for a lethal arrhythmia, which may require immediate defibrillation.
A transthoracic or transesophageal echocardiogram is also indicated. Most common findings include myocardial contusion and right ventricle and right atrial injuries.
Left-sided, valvular, and coronary artery injuries are rare and may require cardiopulmonary bypass for repair.
A subset of patients that will have abnormal ECG and elevated troponin are those who had an acute myocardial infarction immediately prior to or during their trauma.
Cardiac CT or MRI can be used to distinguish these patients who may benefit from cardiac catheterization and anticoagulation.
A 26-year-old male presents with a stab wound to the right chest about 1 cm lateral to the sternum between the second and third ribs. The patient is awake but confused, his HR is 100 beats/min, and his blood pressure is 102/54 mmHg. He is taken to the operating room after initial resuscitation. What is the best approach to expose this injury?
A. Median sternotomy
B. Right anterolateral thoracotomy
C. Right posterolateral thoracotomy
D. Right supraclavicular incision
E. Incision over the stab wound
ANSWER: A
COMMENTS: Penetrating thoracic trauma is common, and the choice of incision can be critical in exposing and repairing the injury.
For an unstable patient in the emergency room (ER), a left anterolateral thoracotomy that can be extended across the sternum onto the right chest can provide maximal exposure to the heart and pericardium, root of the ascending aorta, descending aorta to cross-clamp, and pulmonary hilum.
A median sternotomy allows access to the ascending aorta, the innominate artery including the proximal right carotid and subclavian arteries, the left common carotid artery, and the heart.
The distal right subclavian artery can be approached via a right supraclavicular incision with resection of the middle part of the clavicle.
The proximal descending aorta and left subclavian artery are best exposed via a left posterolateral thoracotomy; however, this is not a favorable position in emergency surgery.
Alternatively, a left third intercostal space antero- lateral thoracotomy and a supraclavicular incision with resection of the middle part of the clavicle can be used.
A median sternotomy can join these incisions, completing a trapdoor incision; however, this adds significant morbidity to the procedure.
Placing a patient on cardiopulmonary bypass can assist with the repair of proximal thoracic vessels; however, this requires additional time and expertise.
A 27-year-old female is brought in after a high-speed motor vehicle collision (MVC). The patient was intubated on scene for GCS 8. HR is 98 beats/min, blood pressure is 110/58 mmHg, and chest x-ray demonstrates a widened mediastinum. CT imaging demonstrates a 2-cm intracranial epidural hematoma with midline shift, a moderate amount of fluid in the abdomen, and a pseudoaneurysm of the descending thoracic aorta. What is correct regarding the management of a blunt aortic injury?
A. Repair of the aorta needs to be completed emergently to reduce the risk of rupture.
B. Mean arterial pressure should be maintained greater than 85 mmHg.
C. Open repair of the injury has less morbidity and mortality.
D. Most patients with a blunt aortic injury die on the scene.
E. The most common site for an aortic injury is at the root of the aorta.
ANSWER: D
COMMENTS: The reported incidence of a blunt thoracic aortic injury is approximately 0.5%; however, the real incidence is likely much higher due to the vast majority of patients dying prior to arrival to a hospital.
The most common aortic injuries include pseudoaneurysms, dissections, intimal flaps, and transections.
This occurs most often just distal to the takeoff of the left subclavian artery on the medial wall due to shear forces on a relatively fixed part of the aorta.
Characteristic x-ray findings of a widened mediastinum, left apical capping, depression of left mainstem bronchus, and loss of aortic knob may initially be seen, raising suspicion for injury, and diagnosis can be confirmed with a CT angiogram of the chest.
Treatment includes strict blood pressure control with restrictive fluid resuscitation and short-acting β-blockers such as esmolol titrated to maintain systolic blood pressures between 90 and 100 mmHg.
This has reduced the incidence of rupture to less than 5% of patients who present to the hospital. Repair is now routinely delayed until other life-threatening injuries are definitively managed with minimum risk.
Both open and endovascular techniques can be utilized, with recent literature demonstrating reduced morbidity and mortality with endovascular approaches.
However, patients may suffer from complications such as endoleaks and access vessel injuries that may require additional procedures.
A 41-year-old male falls from a 12-foot ladder and lands on his left side. He fractures left ribs 2 to 9 with a flail segment, resulting in pneumothorax. After the chest tube is placed, what is the next best step in management?
A. Pain control with an epidural
B. Incentive spirometer
C. Early ambulation
D. Conservative fluid management
E. All of the above
ANSWER: E
COMMENTS: Rib fractures are one of the most common injuries in trauma.
Chest x-rays diagnose less than 50% of rib fractures, while CT scan detects nearly 100% of significant fractures.
Fractures of ribs 1 to 3 can be associated with major thoracic vascular injuries, while fractures of ribs 9 to 12 can puncture intraabdominal organs such as the liver and spleen.
The ideal treatment of rib fractures is centered on pain control and aggressive pulmonary toilet.
Pain regimens include scheduled IV and per os (PO) medications, patient-controlled analgesia (PCA), intercostal blocks, and epidurals.
Pulmonary toilet includes aggressive suctioning, deep breathing and coughing, incentive spirometer use, and early ambulation to decrease atelectasis.
Conservative fluid management is encouraged to decrease pulmonary edema, which can worsen pulmonary contusions that are associated with rib fractures.
Rib plating is making a resurgence with many proponents stating that early rib plating within 72 h can decrease many of the complications associated with severely displaced rib fractures, including prolonged need for ventilator support and pneumonia.
A 37-year-old female comes in with a stab wound to the right chest just lateral to the sternal border. HR is 130 beats/min, blood pressure is 74/58 mmHg, and jugular venous distention is noted on examination with muffled heart sounds. Which option provides the appropriate diagnosis and treatment?
A. Tension pneumothorax: right thoracotomy
B. Tension pneumothorax: right tube thoracostomy
C. Tension pneumothorax: median sternotomy
D. Cardiac tamponade: pericardial window
E. Cardiac tamponade: left tube thoracostomy
ANSWER: D
COMMENTS: Many life-threatening injuries to the chest, such as a massive hemothorax, tension pneumothorax, open chest wound, and cardiac tamponade, must be identified on clinical examination and require prompt intervention.
The clinical examination requires visual inspection of the chest rise for symmetry, open wound with air bubbles, paradoxical motion, and jugular venous distention.
Palpation can detect crepitus and instability of ribs and sternum, while auscultation identifies absent or diminished breath sounds or dullness of heart tones.
Extended FAST can also be used as part of the primary survey to detect a pneumothorax or pericardial effusion.
Once the diagnosis is determined, immediate intervention must take place.
A tension pneumothorax is classically described with absent breath sounds, hypotension, distended neck veins, and tracheal deviation and requires urgent chest tube placement.
Many start with needle decompression; however, many times this intervention is done incorrectly, provides a false sense of security, and delays definitive treatment with tube thoracostomy.
Cardiac tamponade presents with distended neck veins, muffled heart sounds, and hypotension due to fluid in the pericardial sac, decreased right atrial filling, and decreased venous return.
This requires a pericardiocentesis or pericardial window.
A 21-year-old man is taken to the ED with a gunshot wound to the right side of his chest. HR is 126 beats/min and blood pressure is 88/46 mmHg. A right-sided chest tube is placed, with the return of 1200 mL of blood. He is resuscitated with 2 L of lactated Ringer’s solution, and his vital signs return to within normal limits. His chest tube output is rechecked 4 h later, and the total amount in the collection container is 2300 mL. What is the next most appropriate step in management?
A. Chest CT
B. Stat hemoglobin/ hematocrit
C. Right thoracotomy
D. Left anterolateral thoracotomy
E. Admission to the ICU for continuous cardiac monitoring and pulse oximetry
ANSWER: C
COMMENTS: This patient has a massive hemothorax, which is defined as greater than 1500 mL of blood loss on initial placement of tube thoracostomy, continuing loss greater than 200 mL/h for 4 h, or a total of 2500 mL in 24 h after the initial placement.
This is an indication that there is ongoing bleeding that requires surgical intervention.
Additional indications for an urgent thoracotomy include tracheal, esophageal, great vessel, or lung injury.
Penetrating injury to the lung parenchyma may present with a large and persistent air leak.
This may be best managed with a tractotomy, which utilizes a stapler passed into the tract through the lung parenchyma to control the air leak and bleeding.
A 38-year-old car mechanic is taken to the ED after having been pinned underneath a car. On chest radiography, multiple rib fractures are noted, as well as an air-fluid level consistent with the stomach being above the level of the left diaphragm. Which of the following statements regarding this injury is true?
A. Right-sided diaphragmatic rupture is more common than left-sided rupture.
B. There is a 30% incidence of coexisting pelvic fractures.
C. The best initial radiographic assessment for this type of injury is FAST.
D. In most acute diaphragmatic ruptures, repair can be completed with primary repair.
E. There is a 60% incidence of a coexisting thoracic aortic injury.
ANSWER: D
COMMENTS: Diaphragmatic injury/rupture occurs in 3%–5% of patients suffering major blunt abdominal trauma.
Although this injury is uncommon, it is associated with a high incidence of coexistent injuries, including pelvic fractures (15%), hepatic and splenic injuries (40%), and rupture of the thoracic aorta (5%).
The left side is affected three times more often than the right side.
The use of CT imaging of these patients has significantly decreased the incidence of missed injury.
Once a diagnosis of diaphragmatic rupture has been made, treatment is operative.
In this situation, in which large diaphragmatic rupture is strongly suspected, laparoscopy is typically avoided because insufflation of the abdomen may cause a tension pneumothorax.
However, laparoscopy may be useful to evaluate for a penetrating diaphragm injury. In the acute setting of a blunt diaphragmatic injury, laparotomy is the preferred operative approach. It allows reduction of any organs back into the abdominal cavity, as well as thorough inspection of all intraperitoneal contents.
In the acute setting, even large defects can be closed primarily with a # 0- or # 1-monofilament or braided nonabsorbable suture.
Diagnosing small diaphragmatic injuries can be difficult in as much as up to almost half of all patients have normal findings on physical examination at initial evaluation.
Missed diaphragmatic injuries tend to enlarge over time, which may lead to herniation and strangulation of abdominal organs.
Primary repair is not usually feasible because of the rapid atrophy of diaphragmatic muscle fibers.
A thoracotomy is generally performed for a chronic diaphragmatic hernia since it provides better access to the adhesions usually found in the chest.
A 46-year-old female presents after a high-speed head-on motor vehicle crash. The patient was wearing a seatbelt and is noted to have an abrasion across her neck and abdomen. CT of the abdomen demonstrates no solid organ injury and no pneumoperitoneum with trace free fluid in the pelvis. Abdominal examination is benign. What is the next appropriate management step?
A. Nil per os (NPO), admit for serial abdominal examinations
B. NPO, admit for serial CT scans
C. Diet and discharge home
D. Immediate repeat CT with PO contrast
E. Immediate exploratory laparotomy
ANSWER: A
COMMENTS: The incidence of a blunt small bowel injury is less than 1% of all traumatic injuries reported; however, it is associated with significant morbidity and mortality.
A high index of suspicion must be used when evaluating for a blunt bowel injury.
CT findings can be nonspecific with bowel wall thickening, fat stranding, mesenteric edema, and free fluid without solid organ injury.
The presence of seatbelt sign or a lumbar vertebral body fracture significantly increases the risk of a small bowel injury.
A patient without signs of peritonitis who is alert and appropriate can be monitored with clinical examinations.
CT with oral contrast has not been shown to enhance the detection of these injuries and can lead to a delay of treatment and risk aspiration.
If the patient has an unreliable examination, DPL may be attempted to look for amylase, bilirubin, particulates, or WBC > 500.
Alternatively, a diagnostic laparoscopy or laparotomy may be completed.
The patient from the previous scenario also has a CT angiogram of her neck performed. She is found to have a right carotid artery dissection. The patient has a normal neurologic examination with no deficits. No other injuries are present. What is the next step in management?
A. Operating room for neck exploration
B. Perform endovascular stenting
C. Anticoagulation with heparin and aspirin
D. No intervention, discharge home with follow-up CT angiogram in 1 week
E. Repeat imaging with formal angiogram to confirm known lesion
ANSWER: C
COMMENTS: Blunt cerebrovascular injury (BCVI) refers to inju- ries to the carotid and vertebral arteries. Patients at risk include those with a neck hematoma or arterial bleeding, bruit, neurologic deficit, CT brain with stroke, Lefort II or III fractures, basilar skull fracture involving the carotid canal, cervical spine fracture or ligamentous injury, diffuse axonal injury with GCS ≤ 6, and near- hanging with anoxia.
These patients should be screened with a CT angiogram of the neck. Some may require a traditional angiogram if CT images are inadequate.
Injuries are graded from I to V.
Grade I injury is a dissection with <25% luminal narrowing, while grade II is ≥25% narrowing, a thrombus, or intimal flap.
A pseudoaneurysm is a grade III lesion, and total occlusion is grade IV.
These are all treated with systemic anticoagulation with heparin, with a partial thromboplastin time (PTT) goal of 40 to 50 and an antiplatelet agent, aspirin or clopidogrel. Anticoagulation has decreased the incidence of stroke in these patients, which most often occurs during the first week after injury. Grade V injuries are transections with free extravasation and require immediate operative or endovascular management.
Repeat imaging is completed 7 to 10 days after the initial injury. If no lesion is seen, the injury has healed and antithrombotic therapy is stopped.
An 8-year-old child hits a curb with his bicycle, which causes him to flip over the handlebars. He had no initial symptoms and was monitored at home by his parents. However, 2 days after the incident, he begins having nonbilious emesis. He is brought to the ED and undergoes CT of the abdomen and pelvis, which demonstrates a duodenal hematoma. What is the next step in management?
A. Initiation of NPO status and gastric decompression with a nasogastric tube
B. EGD to assess for luminal compromise
C. Drainage of the hematoma via laparoscopy
D. Drainage of the hematoma via laparotomy
E. Resection of the injured portion of the duodenum with primary anastomoses
ANSWER: A
COMMENTS: Blunt injuries to the duodenum can be difficult to diagnose.
Duodenal hematomas typically occur up to 3 days after injury with a gastric outlet obstruction type of clinical picture.
The duodenal lumen is narrowed because of the hematoma itself and the associated edema. CT with oral contrast enhancement and upper gastrointestinal studies are useful in diagnosing this condition.
If no other indication exists for exploration, treatment is conservative and consists of placement of a nasogastric tube for decompression and parenteral nutrition.
Typically, these hematomas and their symptoms resolve within 7 to 15 days after injury.
Operative exploration is reserved for patients in whom the symptoms do not resolve within this period.
A patient with multiple gunshot wounds to the abdomen is taken to the operating room. On exploration she is found to have two small holes in the first part of the duodenum and a 2-cm lateral defect in the second part of the duodenum. The ampulla is intact and cannulated. Resulting pancreaticochol- angiogram demonstrates normal anatomy. What is the best management for this patient?
A. Primary closure with internal drainage
B. Pancreaticoduodenectomy
C. Gastrojejunostomy
D. Omental patch only
E. Serosal patch only
ANSWER: A
COMMENTS: Management options for duodenal injuries include repair, reinforcement, intraluminal decompression, and enteric diversion.
These can all be used in varying degrees depending on the nature of the injury and surgeon’s preference.
Two-layer primary repair may be completed for small injuries; however, with injuries involving the retroperitoneal duodenum or greater than 50% of the lumen, additional steps should be taken to prevent complications.
Primary repairs can be reinforced with additional tissue such as a rotational flap of peritoneum from the abdominal wall, omentum, or a piece of small bowel (Thal patch). Internal drainage to reduce intraluminal pressure can be completed by passing a nasogastric tube postpyloric into the proximal duodenum or retrograde from the jejunum into the proximal duodenum.
An enteric diversion while maintaining enteral nutrition can be completed with a Billroth II gastrojejunostomy or placement of a nasojejunal tube. A temporary alternative is a pyloric exclusion with a stapler or hand-sewn closure of the pylorus and a distal feeding jejunostomy; however, most open up within 4 weeks.
Pancreatico-duodenectomy is only indicated in trauma if the damage to both the duodenum and pancreas is beyond repair and the patient is hemodynamically stable.
Assessment of the pancreas and extrahepatic biliary tree is also mandated with duodenal injuries due to their close proximity to the duodenum.
A 44-year-old male presents with a single gunshot wound to the abdomen. He is hemodynamically stable and taken to the operating room. On exploration, his injuries are found to be limited to four small bowel injuries 8 cm apart, each with destruction of 20% of the bowel wall, and a through-and- through injury to the ascending colon with destruction of 30% of the bowel wall. How should these injuries be managed?
A. Resection and anastomosis of the small bowel injuries and primary repair of the colon injury
B. Primary repair of both the small bowel and colon injuries
C. Primary repair of the small bowel injuries, primary repair of the colon injury, and creation of a diverting ileostomy
D. Resection of the small bowel injuries and exteriorization of the colon injury as a colostomy
E. Resection and anastomosis of all injuries
ANSWER: A
COMMENTS: Treatment of bowel injuries relies on the amount of damage to the viscera and stability of the patient. Patients who are hemodynamically stable and have injuries that involve less than 50% of the circumferential bowel with no vascular disruption can undergo primary repair without the need for diversion.
Resection is indicated for injuries involving greater than 50% of the wall circumference, multiple injuries in a short segment, or both.
Anastomosis can be hand-sewn or stapled. However, there may be a slight decrease in the number of complications with a hand-sewn technique.
This can be completed with a running absorbable full- thickness suture for the inner layer and an interrupted silk suture for the outer seromuscular layer.
Complications occur in approximately 10% of cases and include anastomotic leaks, deep space abscesses, and enterocutaneous fistulas. They are increased in damage control cases and those with other intraabdominal injuries, especially pancreaticoduodenal injuries.
Broad-spectrum antibiotics should be given preoperatively and discontinued 24 h postoperatively.
A 42-year-old male unrestrained driver struck his steering wheel against his abdomen during a motor vehicle crash. He is hemodynamically stable but complains of abdominal pain. CT of the abdomen demonstrates a moderate amount of free fluid with no solid organ injuries. He undergoes an explor- atory laparotomy, at which time complete transection of the pancreatic neck is found. What is the most appropriate management of this injury?
A. Roux-en-Y pancreaticojejunostomy to the distal end of the pancreas with oversewing of the proximal pancreatic stump
B. Distal pancreatectomy with oversewing of the proximal pancreatic stump
C. Primary repair and drainage of the pancreatic duct
D. Pancreaticoduodenectomy
E. Total pancreatectomy
ANSWER: B
COMMENTS: Operative management of pancreatic injuries centers on the location of the injury and whether the duct is involved.
Approximately 50% of the pancreas is located on either side of the superior mesenteric artery. For pancreatic wounds with an intact duct, drainage of the area with soft closed suction drains suffices.
If the main pancreatic duct is injured to the left of the mesenteric vessels, as in this patient, distal pancreatectomy with drainage of the proximal stump is indicated.
The proximal pancreatic duct should be individually ligated with nonabsorbable suture, if possible, and the parenchymal tissue oversewn or stapled across with a stapler.
The spleen should be preserved if the patient’s hemodynamic status allows. Roux-en-Y pancreaticojejunostomy to the distal end of the pancreas with oversewing of the proximal pancreatic stump carries a high rate of leakage.
A pancreaticoduodenectomy and total pancreatectomy would be reserved for injuries that involve extensive devitalization of the duodenum and pancreas.
Primary repair is technically difficult and does not address the transected pancreatic tissue. Intraoperative cholangiography and pancreaticogram, or postoperative endoscopic retrograde cholangiopancreatography (ERCP) or magnetic resonance cholangio- pancreatography (MRCP), can aid in defining critical anatomy.
During exploratory laparotomy in a patient with multiple gunshot wounds to the abdomen, a through-and-through gunshot wound is noted in the left lobe of the liver. Brisk bleeding is seen from the bullet track. Which is an appropriate operative maneuver for this injury?
A. Pringle maneuver
B. Tractotomy
C. Omental packing
D. Large mattress sutures traversing the bullet track
E. All of the above
ANSWER: E
COMMENTS: With regard to hepatic injuries, there are three overall goals of treatment: (1) control of hemorrhage, (2) debridement of nonviable tissue, and (3) adequate drainage.
Multiple operative techniques can be used to establish control of bleeding, and often a combination of these techniques is used.
The Pringle maneuver is direct compression of the portal triad, either manually or with a vascular clamp. This is helpful in identifying whether the bleeding source is from the hepatic artery or portal vein versus hepatic veins or retrohepatic vena cava.
The clamping time should be minimized as much as possible with 5 min of flow for every 15 min clamped.
These patients tend to be hypovolemic and, as a rule, do not tolerate hepatic ischemia well. Omental packing is performed by first creating a pedicle of omentum and then placing it across or in the defect.
This creates a well-vascularized “packing” of the liver that also has its own natural hemostatic properties. Large mattress sutures using a 0-chromic on a blunt tipped needle work by compressing the bullet track with the surrounding liver parenchyma.
A tractotomy is the act of opening the already present wound to fully examine the track and identify the bleeding vessels. This then allows directed individual vessel ligation.
Historically, selective hepatic artery ligation has been used and involves ligation of the hepatic artery branch to the involved lobe. Although this is still a viable option, it is associated with a fairly high rate of abscess formation and hepatic necrosis.
A 32-year-old female is a restrained passenger in a high- speed motor vehicle crash. Initial workup shows an HR of 95 beats/min, blood pressure of 110/82 mmHg, and hemoglobin of 12.2 g/dL. On FAST, a moderate amount of fluid is seen in the RUQ, between the liver, kidney, and diaphragm. A grade IV liver laceration is seen on CT with no active extravasation. Her vital signs 6 h after admission are an HR of 100 beats/min and blood pressure of 105/80 mmHg. What is the next most appropriate step?
A. Exploratory laparotomy
B. Angiography
C. Repeated FAST
D. Diagnostic laparoscopy
E. Repeated hemoglobin determination
ANSWER: E
COMMENTS: The overall success rate for nonoperative management of blunt hepatic injuries is about 90%. Patients with grade IV and V injuries are able to be treated without surgery between 75% and 80% of the time.
Requirements for nonoperative therapy include hemodynamic stability, no signs or symptoms of peritonitis, and a transfusion requirement of no more than two to four units of packed red blood cells.
This patient is hemodynamically stable, and therefore further imaging with CT is warranted. The initial CT can not only localize the injury but, in the case of solid organ injuries, also provide information regarding active hemorrhage.
The patient should be closely monitored in an intensive care setting with serial abdominal examinations and hemoglobin determinations.
Angiography is a helpful adjunct to nonoperative treatment, but it is usually reserved for situations in which active extravasation or a “blush” is seen on CT.
Repeated CT is advised for patients who do experience a decrease in their hemoglobin to reevaluate the liver damage and to look for any active extravasation that would be amenable to angiographic embolization.
The patient in the previous scenario is discharged home on hospital day 4 without needing operative intervention. She returns to the clinic 2 months after discharge with persistent dull continuous RUQ pain. She denies any fevers or chills, and all laboratory studies, including a hepatic function panel, are within normal limits. CT of the abdomen and pelvis is performed and reveals a localized homogeneous fluid collection directly adjacent to the liver. What is the correct diagnosis and treatment?
A. Hemobilia: exploratory laparotomy and ligation of bleeding vessel
B. Hemobilia: ERCP with stent placement
C. Biloma: image-guided percutaneous drainage
D. Biloma: exploratory laparotomy with external drainage
E. Hepatic abscess: angiogram
ANSWER: C
COMMENTS: Because of the increasing number of patients with significant liver lacerations being treated nonoperatively, posttreatment complications are being encountered more often.
Such complications include hemobilia, biloma, hepatic necrosis, and abscess.
Hemobilia occurs when a connection exists between the biliary and arterial systems, and it is typically manifested as RUQ pain, melena, and jaundice. Hemobilia can be diagnosed by CT with IV contrast enhancement or upper endoscopy and is usually treated by angiography with embolization.
Patients with hepatic necrosis or abscess (or both) typically have RUQ pain, fever, leukocytosis, and, at times, localized peritonitis. It can be appreciated on CT with IV contrast enhancement as nonperfused liver parenchyma sometimes associated with a heterogeneous fluid collection. This condition warrants laparotomy with debridement.
Bilomas occur as a result of leakage of bile and typically close spontaneously over time. The fluid collections themselves are best treated with image-guided percutaneous drainage when localized, as in this patient. If the fluid collection is not amenable to percutaneous drainage, ERCP is recommended because biliary stents and sphincterotomy can reduce intrahepatic biliary pressure and increase healing.
A 22-year-old construction worker falls off of a ladder and lands on his left side. He fractures left ribs 6 to 12 and has a grade II splenic laceration. HR is 88 beats/min, and blood pressure is 110/76 mmHg. Hemoglobin is 12.3 g/dL. The patient is admitted to the ICU for serial hemoglobins and monitoring. Six hours later, the HR is 104 beats/min, blood pressure is 100/68 mmHg, and hemoglobin is 9.1 g/dL. What is the next step in management?
A. Exploratory laparoscopy
B. Exploratory laparotomy
C. Angiography
D. Continue serial examinations
E. Transfuse two units, and continue serial examinations
ANSWER: C
COMMENTS: The annual incidence of a blunt splenic injury is 40,000 patients, of which over 90% are managed without surgery.
Nonoperative management, including observation, serial hemoglobins and abdominal examinations, limited blood transfusions, and angiography with possible embolization, is utilized for the remaining majority of patients.
Although controversy exists regarding who should undergo angiography, the literature suggests that those with contrast blush or extravasation on initial CT or American Association for the Surgery of Trauma (AAST) grade III to V splenic injuries may benefit the most from intervention, reducing the need for delayed splenectomy.
This strategy is limited to hemodynamically stable patients with reliable examinations.
Complications associated with angiography and embolization include splenic abscesses, acute kidney injury, hematomas, and coil migration.
Patients should be observed in the hospital or can be discharged home after 24 to 72 h of monitoring, with strict instructions to return to the hospital for any signs of bleeding. Most patients who fail nonoperative management require a splenectomy within 5 days of the injury.
Transfusions of greater than two to four units of packed red blood cells, hypotension, tachycardia, or peritonitis are triggers to convert to operative management.
The patient in the previous scenario is being monitored in the ICU. HR is now 122 beats/min, blood pressure is 88/56 mmHg, and hemoglobin is 8.2 g/dL. What is the next step in management?
A. Exploratory laparoscopy
B. Exploratory laparotomy
C. Angiography
D. Continue serial examinations
E. Transfuse two units, and continue serial examinations
ANSWER: B
COMMENTS: Patients with hypotension, tachycardia, or other injuries that limit reliable serial examinations should undergo urgent splenectomy.
In this case scenario, the patient initially was appropriate for embolization but deteriorated despite intervention and became unstable, necessitating a trip to the operating room for a splenectomy.
Although giving a transfusion is warranted, due to the significant drop in hemoglobin, tachycardia, and hypotension, surgical intervention is indicated.
Patients who respond to resuscitation and become relatively stable in the operating room with a limited splenic injury may benefit from splenorrhaphy or partial splenectomy.
This can be completed by ligating the blood supply to the damaged part of the spleen, letting the tissue demarcate, and debriding nonviable tissue.
The remaining spleen can be wrapped in an absorbable mesh or primarily repaired by approximating the splenic capsule with a pledgeted mattress suture.
Patients who undergo splenectomy should be vaccinated against encapsulated organisms, specifically pneumococcus, meningococcus, and Haemophilus influenzae, prior to discharge.
Immune function remains preserved after embolization.
Which option provides the most appropriate management for the injury described?
A. Blunt mechanism: zone 3 nonexpanding retroperitoneal hematoma: exploration
B. Blunt mechanism: zone 2 expanding retroperitoneal hematoma: angiogram
C. Penetrating mechanism: zone 1 expanding hematoma: observation
D. Penetrating mechanism: zone 1 nonexpanding hematoma: exploration
E. Penetrating mechanism: zone 2 nonexpanding hematoma: angiogram
ANSWER: D
COMMENTS: The major abdominal vasculature is located in the retroperitoneum, which is divided into three zones.
Management of injuries is based on the mechanism, blunt versus penetrating, if there is a concern for ongoing bleeding, and which zone is involved.
Zone I is the central retroperitoneum and contains the aorta and its branches, the vena cava, and the proximal renal vessels.
The lateral areas are zone II and contain the kidney, proximal collecting system, and distal renal vessels.
Zone III is the pelvis and its con- tents including the iliac vessels.
Most hematomas resulting from blunt trauma should not be explored other than zone 1 injuries or pulsatile expanding hematomas.
All penetrating injuries must be explored due to the risk of injury to other retroperitoneal organs such as the duodenum, pancreas, colon, rectum, and bladder.
The only exception is a stable retrohepatic hematoma.
Obtaining proximal and distal control prior to exploration of a hematoma is ideal but not always possible.
With blunt trauma, angiography with embolization may be used as an adjunct in nonexpanding hematomas.
A patient presents with multiple gunshot wounds to the extremity and right lower quadrant. In the operating room, upon entry into the abdomen, a large amount of hemoperitoneum is encountered and all quadrants are packed immediately.
Upon reinspection, the patient is noted to have an injury to the infrahepatic vena cava. How can you best expose this injury?
A. Transect the right renal artery
B. Right medial visceral rotation
C. Left medial visceral rotation
D. Transect the pancreas
E. All of the above
ANSWER: B
COMMENTS: Rapid exposure and control of abdominal vessels are critical in patients with life-threatening hemorrhage.
The principles of proximal and distal control should always be attempted prior to entering a contained hematoma.
However, once bleeding has started and the injury is identified, direct pressure with a finger may allow for temporary control.
Left medial visceral rotation, which requires the division of the lateral attachments of the colon and spleen allowing for mobilization to the right toward midline, exposes the aorta and the left renal hilum.
The distal aorta and iliac arteries can be exposed by lifting up the transverse colon and dissecting at the base of the mesocolon.
The IVC and right renal hilum are best approached with right medial visceral rotation, which divides the colon and duodenum’s lateral peritoneal attachments allowing for mobilization of the ascending and transverse colon, duodenum, and pancreas cephalad and to the left toward the midline.
Suprahepatic IVC may require the division of the diaphragm or even a sternotomy for control within the pericardial sac. Supraceliac control of the aorta at the diaphragm can temporarily curb the bleeding when the patient is in extremis and can be used while attempting definitive vascular control.
The vena cava can be controlled with sponge sticks placed proximal and distal to the injury. There are a few special maneuvers that can be utilized for repair of intraabdominal vascular injuries. Exposure of the back wall of the vena cava can be done through an anterior venotomy, allowing for repair.
Superior mesenteric artery injuries may require transection of the pancreas for exposure, and the right iliac vein may require transection and subsequent repair of the right iliac artery for exposure.
A 23-year-old male presents with multiple gunshot wounds to the abdomen and right leg. During exploration, the patient is found to have a grade IV liver laceration and multiple enterotomies. He also has a destructive injury to his proximal superficial femoral artery with no distal pulses. Anesthesia tells you that the patient’s temperature is 36°C; he has received 10 units of product and is on vasopressors. Most recent arterial blood gas (ABG) shows a pH of 7.15 and a lactic acid that is twice the normal value. Which of these is a trigger to transition to damage control surgery in this patient?
A. Body temperature less than 37°C
B. Arterial pH less than 7.2
C. Base deficit greater than 6
D. Hemoglobin less than 7
E. Oxygen saturation less than 90%
ANSWER: B
COMMENTS: Damage control surgery is a staged resuscitation strategy with three phases that include the initial operation, resuscitation in the ICU, and return to the operating room for definitive treatment.
Goals for the initial procedure include control of hemorrhage with sutures and packing, limiting fecal contamination and restoring critical blood flow. In the ICU, the patient is aggressively resuscitated with blood products, fluids, and vasopressors with the goal of obtaining a normal physiologic state.
Once the patient is stable, a plan can be made to return to the operating room for definitive surgical management and evaluation for missed injuries. The trigger to employ a damage control strategy is metabolic failure defined by hypothermia, metabolic acidosis, and coagulopathy despite hemorrhage control.
Published guidelines include an arterial pH of ≤7.2, lactic acid > 5 mmol/L, base deficit < −15 in a patient younger than 55 years or 50% normal.
In the previous scenario, what is the best treatment option for the superficial femoral artery injury?
A. Ligation of the artery
B. Placement of temporary intravascular shunt
C. Definitive repair with a reversed saphenous vein
interposition graft from the contralateral leg
D. Definitive repair with an in situ saphenous vein interposition graft
E. Definitive repair with a polytetrafluoroethylene (PTFE) graft
ANSWER: B
COMMENTS: The patient in the above scenario is in extremis and requires a quick establishment of distal perfusion.
Although ligation is an option, it puts the lower extremity at risk of ischemia and amputation.
Placement of vascular shunts require proximal and distal control, debridement to clean edges, thrombectomy with a Fogarty catheter, regional heparinization, proper shunt selection, securing the distal end first with a 0 silk tie to allow for back bleed- ing, and then securing the proximal end to allow reestablishment of flow.
Fasciotomy should be considered based on ischemia time. This will allow perfusion and an increased chance for limb salvage while other life-threating injuries are being managed.
Dwell times have ranged from 3 to 36 h and do not require systemic anticoagulation. They are routinely used for peripheral arterial injuries but have also been selectively used for extremity venous and truncal vascular injuries.
Definitive repair can be completed during the next trip to the operating room with the best choice being a reversed saphenous vein interposition graft from the contralateral leg.
The patient is a 52-year-old male involved in a high-speed head-on motor vehicle crash. He arrives to the ED unstable with BP 80/60 mmHg and HR 125 beats/min. Initial x-ray workup reveals an open-book pelvis fracture. Despite 2 L of crystalloid, the patient remains tachycardic and hypotensive. What techniques can be used to control bleeding in this patient?
A. Interventional radiology (IR) angiogram
B. Preperitoneal packing
C. External fixator
D. Pelvic binder
E. All of the above
ANSWER: E
COMMENTS: Pelvic injuries are present in approximately 10% of blunt trauma patients. Pelvic fractures can be classified accord- ing to the force vector that caused the injury: anteroposterior compression, lateral compression, or vertical shear fractures.
The overall mortality in these patients is 6%. However, it increases to greater than 30% when patients present with hemorrhagic shock.
Bleeding is usually from branches of the internal iliac artery or the extensive venous plexus surrounding the sacrum.
Early control of pelvic hemorrhage is critical. Placement of a pelvic binder or external fixator works by decreasing the volume of the pelvis and temporarily stabilizes the fractured bones, preventing additional injury.
Preperitoneal packing completed through a low midline or supra- pubic incision carried through the fascia allows for three rolled lap pads to be placed into the preperitoneal space on each side of the bladder, resulting in volume reduction and tamponade of bleeding.
This can be done in the operating room in conjunction with a laparotomy being completed for other injuries through a separate incision.
Bilateral internal iliac artery embolization with a temporary agent, such as gelatin material, is the preferred angiographic treatment in unstable patients.
This provides quick control by limiting flow through the large number of collaterals feeding the pelvis and allowing time for a clot to form.
REBOA is now being used in a limited number of centers as an adjunct for early control of pelvic bleeding and increasing mean arterial pressure in patients presenting in hemorrhagic shock with isolated pelvic trauma.
For the patient in the previous scenario, a pelvic binder is placed and blood pressure and HR improves. A negative urethrogram is completed, and a Foley catheter is inserted. The urine output is bloody, and a cystogram demonstrates a bladder injury. Which combination of injury and management is correct?
A. Extraperitoneal bladder injury = operating room for primary repair
B. Extraperitoneal bladder injury = suprapubic catheter placement
C. Intraperitoneal bladder injury = operating room for
primary repair
D. Intraperitoneal bladder injury = maintain Foley catheter
E. Intraperitoneal bladder injury = cystoscopy
ANSWER: C
COMMENTS: Approximately 5% of pelvic fractures will have an associated bladder injury. The majority of these will present with hematuria and can be diagnosed with a CT or traditional cystogram.
Contrast extravasation into the retroperitoneum is seen as flame- shaped densities surrounding the bladder, which is characteristic of an extraperitoneal injury.
With an intraperitoneal injury, contrast leaks into the abdomen, outlining loops of bowel.
Approximately 80% of injuries are extraperitoneal and can be treated with a Foley catheter for 10 to 14 days.
An intraperitoneal bladder injury requires operative exploration of the bladder, identification of ureteral ori- fices and bladder neck, and a two-layer repair with absorbable suture.
A closed suction drain is left next to the repair, and the Foley catheter remains in place for 10 to 14 days.
A repeat cystogram is completed at 10 days to evaluate the healing process. The Foley catheter can be removed at that time if no extravasation is noted.
A 22-year-old man undergoes proctoscopy and exploratory laparotomy for a transpelvic gunshot wound. A 2-cm, partial-thickness laceration is found in the distal portion of the extraperitoneal rectum. What is the appropriate surgical management of this injury?
A. Resection of the injured area and anastomosis with a diverting colostomy
B. Primary repair with a diverting colostomy
C. Diverting colostomy only
D. Presacral drainage only
E. Primary repair only
ANSWER: C
COMMENTS: Repair of rectal injury largely depends on location, intraperitoneal versus extraperitoneal.
The posterior rectum and distal third of the anterior rectum are not serosalized, and an injury in these regions is considered extraperitoneal. Extraperitoneal rectal injuries should be treated chiefly by fecal diversion.
Nondestructive intraperitoneal lacerations that are less than 50% of the circumference of the rectal wall should be repaired primarily after debridement of any devitalized tissue in the absence of peritonitis.
Presacral drainage, which historically had been used rather rou-tinely, has been decreasing in use and has not been shown to decrease the complication rate.
A 27-year-old female presents with multiple gunshot wounds to the abdomen. She is immediately taken to the operating room for an exploratory laparotomy. She is found to have a mid-ureter injury with a 2-cm segment loss. During the surgery, the patient becomes hypotensive, requiring vasopressors. What is the best damage control treatment option for an unstable patient with a ureteral injury?
A. Ligation of the injured ureter
B. Percutaneous nephrostomy
C. Ureteral drainage via a single-J stent, which is externalized to the skin
D. Placement of a bridging stent
E. All of the above
ANSWER: E
COMMENTS: When a trauma patient is unstable on the operating room table and damage control has been initiated, time should not be spent on primary repair of a ureteral injury.
Surgical options for this type of situation consist of simple ligation of the ureter, placing a percutaneous nephrostomy through the renal parenchyma into the renal pelvis, inserting a catheter into the proximal end of the damaged ureter and bringing it out through the wound, or placing a catheter or stent in the proximal and distal ends of a small-segment ureteral injury.
These methods will allow for urinary diversion until the patient is stable.
A 30-year-old male is brought to the ED after being involved in a motorcycle crash. He is hemodynamically stable. Blood is noted at the urethral meatus. On portable pelvic radio- graphs, he is found to have bilateral pubic rami fractures. He has not yet voided since admission. Which of the following is the best next step?
A. Wait for the patient to void freely before attempting transurethral bladder catheterization.
B. Initially attempt gentle transurethral bladder catheterization but stop if resistance is encountered.
C. Obtain a urethrogram before attempting transurethral bladder catheterization.
D. Insert a suprapubic cystostomy tube.
E. Perform CT of the pelvis with three-dimensional reconstruction.
ANSWER: C
COMMENTS: Approximately 10% of all patients with a pelvic fracture have a concomitant urethral injury.
Findings on physical examination, such as blood at the meatus, perineal ecchymosis or hematoma, or inability to void, should raise suspicion for a urethral injury.
If any of these signs or symptoms is present, or there is a significant anterior pelvic fracture, a urethrogram should be obtained to exclude an injury before transurethral catheterization is attempted.
Bladder decompression and drainage are the mainstays of treatment of urethral injuries, either via suprapubic cystostomy for complete disruption or with a bridging transurethral catheter for partial tears.
A 36-year-old male presents after a prolonged extrication from a motor vehicle crash. The patient has bilateral femur fractures and an open left tibia-fibula fracture with significant tissue loss and no distal pulses. Which state- ment is correct regarding the management of a mangled extremity?
A. This patient requires angiography prior to going to the operating room.
B. A mangled extremity severity score ≥ 5 is predictive of need for amputation.
C. In a hemodynamically unstable patient, the definitive vascular repair should be completed first.
D. Bony injury should be reduced prior to definitive vascular repair.
E. Optimal maximum time to surgery should be less than 24 h from injury.
ANSWER: D
COMMENTS: A significant injury to a limb requires assessment of multiple factors including bone, soft tissue, nerve function, vasculature, and overall hemodynamic status to assist with the decision for limb salvage versus amputation.
Although multiple scoring systems, including the mangled extremity severity score (MESS) and the Ganga Hospital Score, have been created to help evaluate and manage mangled extremities, none have been predictive to determine which limb can be salvaged versus amputated.
Despite these findings, experts recommend considering primary amputation with a MESS ≥ 7, delay of greater than 6 h to treatment, and in hemodynamically unstable patients.
Imaging with CT angiogram or formal angiography may assist the surgeon. However, in the setting of “hard signs,” including ongoing hemorrhage, expanding hematoma, a bruit or thrill, signs of ischemia, or absent pulses, patients should be taken directly to the operating room for exploration.
Orthopedic injuries are reduced first and temporarily stabilized, which may unkink vessels and allow for reperfusion and better evaluation of a soft tissue injury.
The patient in the previous scenario is taken to the ICU for postoperative monitoring. It is noted that his urine output has decreased in the past 2 h and is very dark. Urinalysis is positive for blood, but there are no red blood cells on microscopic analysis. What is true regarding his diagnosis?
A. Best treatment includes aggressive IV fluid resuscitation.
B. All patients with rhabdomyolysis require dialysis.
C. The renal failure from rhabdomyolysis typically resolves within 3 to 5 days.
D. Severe hyponatremia is a frequent complication.
E. Alkalinization to a pH between 8 and 9 is an important treatment goal.
ANSWER: A
COMMENTS: Rhabdomyolysis is the breakdown of muscles that causes a release of myoglobin.
Myoglobin causes tubular obstruction and vasoconstriction, which leads to acute tubular necrosis and acute kidney injury.
There are a variety of causes of rhabdomyolysis including crush injury, multiple trauma, seizures, illicit drugs, and several medications, including many antibiotics and antipsychotics.
Creatine kinase is the most specific marker for diagnosis, and higher levels correlate with a greater injury.
Additional tests show the described characteristic urinalysis, hyperkalemia, hypocalcemia, and elevated creatinine.
Treatment includes preventing additional muscle breakdown, aggressive IV fluid resuscitation, and managing complications including electrolyte imbalances and renal failure, which may require renal replacement therapy.
Indications for dialysis include hyperkalemia, metabolic acidosis, and hypervolemia.
Treatment with bicarbonate infusion has been used to alkalinize urine to a pH of 6 to theoretically prevent myoglobin precipitation in the tubules; however, there are minimal data to support this practice.
Overall prognosis with early and aggressive volume resuscitation is good, with most patients recovering to baseline renal function within 2 weeks to 3 months.
A 34-year-old male presents with a gunshot wound to his left thigh with no pulses in his feet. The patient is taken immediately to the operating room, and a superficial femoral artery injury is repaired with a saphenous vein interposition graft. At the end of the surgery, the patient had equal pulses bilaterally and was neurologically intact. Five hours postoperatively, the left distal pulses are diminished and he begins to experience pain with passive dorsiflexion and extension. Which of the following statements is true regarding compart- ment syndrome in an extremity?
A. Fractures are the cause of approximately 30% of all compartment syndromes.
B. The lateral compartment of the lower part of the leg is the most commonly affected.
C. A compartment pressure of 25 mmHg negates a need for fasciotomy.
D. Loss of pulses is an early clinical development.
E. A four-compartment fasciotomy should be performed.
ANSWER: E
COMMENTS: Compartment syndrome of the extremity is an extremely important diagnosis to make as early as possible because of the significant risk for permanent limb dysfunction and potential loss.
Causes of compartment syndrome include crush injury, reperfusion after a time of ischemia, and fractures, which account for 50% of cases.
The anterior compartment of the lower part of the leg contains mostly type I (slow twitch) muscle fibers and is encased by dense fascia, thus making it most vulnerable to the development of ischemia.
The diagnosis is largely clinical, with pain out of proportion to the findings on examination, pallor, paresthesias, paralysis, poikilothermia, pulselessness, and tense compartments being the hallmark symp- toms.
Because of the fact that even after an hour of ischemia, impulses can still be conducted through peripheral nerves, par- esthesias are a late sign of compartment syndrome.
In addition, even though compartment pressures of 30 mmHg or higher are classically quoted, lesser pressures do not prove that there is adequate tissue perfusion, and if other signs or symptoms of compartment syndrome are present, fasciotomies should still be performed.
A 24-year-old male presents after a motorcycle crash. He is found to have multiple left-sided rib fractures, a grade II splenic laceration, and a small 2-mm subdural hematoma. His GCS score is 15. The patient is admitted to the ICU for serial hemoglobin and neurologic checks. Clinical examination, hemoglobin, and repeat CT of the head at 48 h remain stable. What is the most appropriate deep vein thrombosis (DVT) prophylaxis to initiate at this time?
A. Early ambulation only
B. Sequential compression devices only
C. Retrievable IVC filter
D. Subcutaneous heparin 5000 units daily
E. Subcutaneous Lovenox 30 mg twice a day
ANSWER: E
COMMENTS: Trauma patients, especially those with multiple injuries, including intracranial hemorrhage, pelvic and extremity fractures, and spinal injuries, are at significant risk of having a DVT.
This is also a population that has an increased risk of bleeding, and standard prophylaxis protocols have been modified to account for this.
All patients should have sequential compression devices upon admission, and chemical prophylaxis with either heparin 5000 U three times per day or enoxaparin 30 U twice a day should be started as early as possible.
LMWH has been shown to be superior in this patient population.
Patients with truncal hemorrhage with stable hemoglobin values for 24 h are at minimal risk of bleeding with the initiation of chemical prophylaxis.
Controversy has been placed around patients with traumatic brain injuries. Many recent studies have shown that it is safe to start chemical prophylaxis as early as 24 h after a stable brain CT without increased risk of progression of hematoma.
Few patients will have contraindications to pharmacologic prophylaxis and should be considered for weekly extremity surveillance duplex ultrasound or placement of a retrievable IVC filter.
Risks of placing an IVC filter include dislodgement, perforation, and thrombosis. These should be removed at the earliest occasion when pharmacologic prophylaxis becomes appropriate and the risk of bleeding is minimized.
A 79-year-old female falls at home. In the ER, she is found to have a pelvic fracture with a large retroperitoneal hematoma. While waiting for angioembolization by Interventional Radiology (IR), the patient becomes hypotensive and is transfused with two units of packed red blood cells and two units of fresh-frozen plasma. After IR, the patient starts to complain of shortness of breath, has desaturations, and requires intubation. Which statement best describes a transfusion-related acute lung injury (TRALI)?
A. Onset occurs 24 h after a transfusion.
B. Onset occurs most often after transfusion with fresh- frozen plasma.
C. Clinical findings include dyspnea, hypertension, and bradycardia.
D. Treatment includes plasmapheresis.
E. Affected patients cannot receive blood transfusions in the
future.
ANSWER: B
COMMENTS: The reported incidence of TRALI varies from 1% to 15% of patients receiving transfusions with a mortality rate of 5%–10%. It occurs 50 to 100 times more often in critically ill patients.
It can occur after transfusion of any component of blood but is most associated with fresh-frozen plasma and red blood cells.
Several hypotheses exist regarding its pathogenesis, including human leukocyte antigen–specific antibody in the donor directed against an antigen in the recipient, resulting in an inflammatory response causing damage to the endothelial lining of the lungs.
Criteria for diagnosis include acute onset, usually within 6 h of transfusion, hypoxemia with a PaO2/FiO2 ratio less than 300, and bilateral infiltrates on chest x-ray in a patient with no alternative risk for lung injury.
Symptoms include dyspnea, tachypnea, tachycardia, hypotension, and fever. Treatment is supportive, with approximately 70%–90% of patients requiring ventilator support.
Being diagnosed with TRALI does not affect the ability to receive blood transfusions in the future. However, risk reduction maneuvers including restrictive transfusion policies and washing of stored blood products should be employed with future transfusions.
A coal mine explodes in a rural part of the country. There is only one small local hospital, and critical patients will need to be airlifted to the closest Level 1 Trauma Center. Which patient should be triaged to the expectant category?
A. A 22-year-old male with a broken femur
B. An 18-year-old female with 90% total body surface area (TBSA) burns with agonal breathing
C. A 38-year-old male with multiple left rib fractures and decreased breath sounds
D. A 29-year-old female with a traumatic amputation of her right forearm
E. A 34-year-old male with a fractured thoracic spine and traumatic paralysis
ANSWER: B
COMMENTS: A mass casualty incident involves an influx of hundreds of casualties that overwhelms the capacity and resources of a hospital, resulting in suboptimal and delayed care.
Field triage is defined as sorting casualties according to their needs, considering their chance of survival, and is key in providing the greatest benefit to the maximum number of patients in these emergencies.
Sort, Assess, Lifesaving Interventions, Treatment/Transport (SALT) triage allows for quick determination of which patients will benefit the most from immediate hospital transfer.
Approximately 15% of patients will be critically injured in any event, and limited resources such as ICU beds, ventilators, and operating rooms need to be directed toward these critical patients with a high likelihood of survival with intervention.
Causalities defined as expectant will vary depending on casualty numbers, type and severity of injuries, and resource availability.
To minimize a large resource expenditure on a patient with a low likelihood of survival, these patients are kept out of the hospital until the immediate surge subsides.
During the annual Memorial Day parade of your hometown, a large explosion occurs along the parade route, with multiply injured persons and fatalities at the scene.
Prehospital EMS providers, first responders, and bystanders begin to administer first aid to those injured and start transfer of patients to the local hospital. As an on-call general surgeon, you and your colleagues stand ready in the emergency department while preparing for a potential mass casualty event. Hospital administrators have activated the disaster/mass casualty plan, triage officers are designated, and the incident command plan is in effect.
- A pre-hospital provider encounters an injured female with a below knee traumatic amputation and multiple truncal fragment wounds with labored breathing (Figure 67-1). The first priority in the initial care of this patient should be?
A. Airway
B. Breathing
C. Circulation/control of life-threatening hemorrhage
D. Disability
E. Evacuation
C.
Traditional teaching of advanced cardiac life support (ACLS) and advanced trauma life support (ALLS) concepts stress the “ABCDE” mantra (airway, breathing, circulation, disability, and exposure), in which airway control is paramount.
However, in the setting of combat injuries and civilian catastrophes such as blast injuries, immediate control of life-threatening hemorrhage takes precedence as fatal hemorrhage can rapidly occur while addressing other elements of the primary survey.
Hemorrhage remains the leading cause of potentially preventable morbidity and mortality in both military and civilian trauma, reinforcing the importance of pre-hospital efforts to control bleeding and prevent exsanguination after severe injury.
The experiences gained during combat operations in Iraq and Afghanistan have
led to a change in the priorities of treatment that are taught to combat medics and first-responders.
As the most likely cause of potentially preventable death in these scenarios is hemorrhage, the standard ATLS approach of focusing first on the airway has been changed to a primary focus on C, or the control of hemorrhage, as the first priority. T e next priorities would be on assessing the airway and breathing for life-threatening issues such as airway obstruction, tension pneumothorax, or an open pneumothorax (“sucking chest wound”).
Which of the following pairs of hemorrhage source and preferred management is correct?
A. Junctional hemorrhage—Tourniquet placed directly over the injury
B. Extremity hemorrhage—Hemostatic dressing and direct pressure
C. Truncal hemorrhage—Permissive hypotension and hemostatic resuscitation
D. Pelvic hemorrhage—Early use of rFactor Vila
E. Intra-cranial hemorrhage—Reversal of hypercoaguable state and neurosurgical intervention
C
Major extremity hemorrhage can be effectively controlled in both the pre-hospital and hospital setting using an effective proximal tourniquet. Application of tourniquets to control major hemorrhage should be placed as distal as possible yet proximal to the site of injury, to control hemorrhage and limit the extent of tissue ischemia.
Hasty tourniquets applied in combat under lire or prior to moving a patient to
a safer location may be placed expediently anywhere proximal on the injured extremity and later moved distally.
Approximately one-third of bleeding deaths after explosive events arc due to extremity hemorrhage, with the remaining two-thirds attributed to junctional bleeding or non-compressible truncal hemorrhage (Figure 67-2).
“Junctional” injuries are defined as injuries to the groin, axilla, neck, or
perineum. These injuries present major challenges to hemorrhage control as damaged deep vascular structures transition from the extremities to major
cavities beyond the effective reach of a proximal tourniquet.
Direct pressure and topical hemostatic adjuncts are often the only currently available treatments of potential benefit before proximal surgical control can be achieved. Non-compressible truncal hemorrhage is the most feared and fatal type of bleeding as it is not amenable to pre-hospital hemorrhage control measures, and requires higher-level interventions such as surgery or angioembolization.
Significant pelvic hemorrhage may result from complex bony injuries and damage to the pelvic vasculature. Treatment of pelvic fractures may include
pelvic sheeting, commercial or improvised binders, and forms of external fixation, that aim to stabilize the pelvic ring. Surgical control of pelvic hemorrhage includes open and catheter based therapies as well as pre-peritoneal pelvic packing to tamponade hemorrhage.
Permissive hypotension is the concept that avoiding normal or elevated blood pressure in a bleeding patient prior to surgical hemorrhage control limits blood loss.
The goal is to maintain an adequate arterial pressure for critical organ perfusion while limiting overpressurization from vigorous fuid resuscitation that
may exacerbate hemorrhage.
Although there was initial interest in the use of activated recombinant factor VII (rFactor Vila) as an adjunctive therapy for bleeding, subsequent studies have found little to no benefit and it also would not be used as a prehospital therapy for pelvic bleeding.
The treatment of traumatic intracranial hemorrhage begins with reversal of any identified coagulopathy, not hypercoagulable state, treatment of associated cerebral edema, and possible neurosurgical interventions.
Distribution of preventable bleeding deaths from battlefield wounds by site of hemorrhage:
Torso 48%
Extremity 31%
Axilla/Groin 21%
The principles of damage control surgery include which of the following?
A. Primary focus upon control of hemorrhage only
B. Avoiding the use of temporary abdominal closures
C. Appropriate triage based upon injuries and available resources
D. Colostomy for all colon injuries
E. Definitive repair of all abdominal injuries
C.
Damage control surgery (DCS) is a concept that includes the principles of limiting further physiologic insult to a severely injured patient through therapid surgical control of life-threatening hemorrhage and enteric spillage, to minimize further bleeding, restore tissue perfusion, and prevent sepsis. The goal is to avoid prolonged, initial operative procedures that may further exacerbate hypothermia, coagulopathy, and/or acidosis.
Temporary closures of the abdomen and thorax may be employed to shorten
the procedure length and allow for urgent or planned re-operation in this population. Once bleeding and gastrointestinal spillage arc controlled, there are no further attempts to address other non-life-threatening abdominal injuries at the initial surgery.
The operation is terminated and the patient is returned to the ICU for resuscitation and restoration of normal physiology and coagulation. Following
physiologic restoration these patients arc taken back to the operating room for definitive treatments and closure.
In mass casualty situations and resource-constrained environments, DCS allows limited surgical personnel to provide critical surgical procedures to severely injured patients rapidly, and then either evacuate them to higher levels of care or clear the operating room for additional patients.
The concept of damage control or hemostatic resuscitation includes which of the following?
A. Limited use of colloid solution resuscitation
B. 3:1:1 PRBC:FFP:Platelet transfusion strategy
C. Empiric transfusion of cryoprecipitate
D. Administration of tranexamic acid (TXA) for treatment of hyper fibrinolysis
D. Damage control resuscitation (DCR) or hemostatic resuscitation is the concept of limiting further blood loss before surgical hemorrhage control is obtained, as well as replacing shed-blood volume with a balanced blood product based resuscitation that restores the capacity to carry and deliver oxygen and addresses derangements ol the coagulation system.
DCR research has focused upon improved morbidity and mortality with limitation of crystalloid infusion to prevent hemodilution (colloid solutions
are, in general, not advocated for trauma resuscitations), acidosis and worsening of coagulopathy, in favor of transfusion ratios approaching 1:1:1 of
packed red blood to fresh frozen plasma and platelets.
Additional targeted treatment of specific coagulation abnormalities based upon traditional studies (PT/INR, PTT, fibrinogen) and point of care testiing such as thromboelastography is recommended, to avoid unnecessary transfusion and appropriate resource utilization.
Permissive hypotension is the concept that avoiding normal or elevated blood pressure in a bleeding patient prior to surgical hemorrhage control limits
blood loss.
The goal is to maintain an adequate arterial pressure for critical organ perfusion while limiting over-pressurization from vigorous fuid resuscitation
that may exacerbate hemorrhage. Previous studies in civilian trauma patients have confirmed a favorable survival advantage by limiting pre-hospital resuscitation but heterogeneity in clinical trials such as optimal blood pressure target and f uid resuscitation type have yet to yield definitive conclusions.
Current research has identified early derangements of the coagulation system that appear to confer an increased risk of morbidity and mortality after
trauma, termed the acute coagulopathy of trauma.
Hyperfibrinolysis is a key component of this condition. and targeted pharmacologic intervention with the antifibrinolytic agent, tranexamic acid (TXA), has been linked to a survival advantage in several studies of bleeding trauma patients. The use of TXA in the setting of major hemorrhage and massive transfusion situations is now recommended in the early treatment (< 3 hours from injury) in civilian and combat injuries.
Primary blast injuries include which of the following?
A. Damage to gas filled organs due to extreme pressure changes
B. Truncal injury sustained as victim is thrown through the air by blast
C. Crush injuries from structural collapse around the patient
D. Penetrating injury from debris and fragments propelled by the blast force
A.
Blast injuries are traditionally classified based upon the discrete mechanism of injury involved. Primary blast injuries involve damage to gas-filled organs such as the intestine, lungs, and middle ear as well as the brain.
These injuries result from overpressurization due to the blast force. Rupture of the tympanic membrane is a frequently encountered primary blast injury, but the absence does not rule out other types of blast injury.
Secondary blast injuries result from injury due to flying debris and fragments
that are propelled by the blast. These are the most frequently sustained type of blast injuries.
Tertiary injuries occur when a person is thrown through the air by the blast, while Quaternary injuries include other blast effects such as burn injury, inhalation of toxic gases, or injury due to collapse of structures around the person.
Lastly, quinary injuries are the result of contamination by chemical, radiologic, or biologic materials from the blast itself or other injured persons.
In addition to the injury classification described above, the severity of injury sustained after a blast mechanism depends upon the patient’s proximity to
the blast, the energy of the blast itself, and whether or not the blast occurred in a closed space. Persons injured by a blast in an enclosed space such as a
vehicle or building frequently sustain a higher rate of lethal primary blast injury as well as increased frequency ot secondary penetrating injuries.
A 35-year-old man is brought to the emergency department after an altercation at a bar. He has a 3 cm stabwound to his right chest, approximately 5 cm lateral to and just superior to his nipple. He is able to tell you that the wound is from a knife. He is oriented and appropriate, although intoxicated, and complains loudly of pain in his right chest. His initial vital signs are as follows: HR 96, BP 110/63, RR 20,98% saturation on room air.
What is your first step in the management of this patient?
A. Perform a tube thoracostomy.
B. Perform the primary survey and examine for any other wounds.
C. Perform a FAST (focused assessment with sonography for trauma) scan to identify intraabdominal injury.
D. Obtain a chest radiograph to identify presence of pneumothorax or hemothorax.
B.
In any trauma patient, the first priority is to ensure stable A,B,C’s, airway, breathing, and circulation, which may include emergent interventions (e.g.,tube thoracostomy).
In this patient with stable vital signs, the initial step is to perform a primary and secondary survey—a brief head to toe physical exam. A common mistake in the setting of penetrating trauma is failure to identity multiple injuries.
Common locations for missed penetrating injuries can be in the back, axilla, or perineum, so a complete head to toe survey is critical.
Most patients can be stabilized enough to undergo a secondary survey, but any problems identified on the primary survey should be immediately addressed. Once all injuries arc identified, they can be prioritized for diagnostic imaging or operative repair.
Both chest X-ray and FAST scan can be used as adjuncts to the secondary survey, but they do not replace the need lor a head-to-toe assessment of the
patient. In the initial evaluation of a trauma patient, priorities are:
- identifying all wounds,
- determining if urgent lifesaving intervention is indicated, and
- determining if additional testing is needed.
Despite fluid resuscitation, the patient’s blood pressure suddenly becomes 60/palpable. His trachea is midline and his breath sounds are reduced over the right hemithorax, with dullness
to percussion. What is the best next step in management?
A. Place a 36F chest tube into the right pleural cavity at the 2nd interspace in the midaxillary line.
B. Place a 36F chest tube into the right pleural cavity at the 5th interspace in the mid- or anterior axillary line.
C. Place an 18 g angiocath into the 2nd intercostal space at the midclavicular line.
D. Take the patient immediately to the operating room for thoracotomy.
E. Initiate a massive transfusion protocol to stabi¬
lize the patient for computerized tomography
(CT) scan to identify the source ol the hypoten¬
sion.
B.
In the setting of penetrating trauma to the chest, the differential diagnosis for hypotension includes tension pneumothorax, cardiac tamponade, and hemothorax.
Classically, a tension pneumothorax will present with deviation of the trachea away from the injury, increased percussion and decreased breath sounds with distended neck veins. However, these can be late findings and may be difficult to appreciate in a busy and noisy trauma bay.
If a tension pneumothorax is suspected, the first step would be placing
an large bore (14 or 18 gauge) angiocath to needle decompress the thoracic cavity. The diagnosis would be confirmed by a rush of air from the needle, and a chest tube should then be placed.
In this patient, the absence of tracheal deviation along with dullness to percussion makes a hemothorax the more likely diagnosis, and a chest tube the appropriate next step.
The preferred method for tube thoracostomy is to enter the “safe triangle” bounded by the anterior border of the latissimus, the lateral border of the pectoralis major, and a horizontal line at the level of the nipple (males) or infra-mammary crease (females). This positioning minimizes the likelihood of entering the abdominal cavity, injuring muscle or breast tissue, or underlying structures such as the internal mammary artery, and avoids the major chest wall musculature that can cause significant pain with chest tube insertion.
Which of the following is a correct indicator for operative intervention paired with an appropriate operative approach for this patient?
A. Greater than 500 cc blood from the chest tube upon initial placement—right posterolateral thoracotomy in the operating room.
B. Cardiac arrest in the trauma bay—left anterolateral thoracotomy in the emergency room.
C. Persistent transfusion requirements to maintain stable blood pressure—median sternotomy in the emergency room.
D. Second entry wound identified below the costal margin—transverse anterior thoracotomy (clamshell incision) in the operating room.
E. An entry wound media) to the midclavicular
line—median sternotomy in the emergency room.
B.
Accepted indications for emergency department thoracotomy in the setting of penetrating thoracic trauma are loss of pulses with previously witnessed cardiac activity and unresponsive, persistent, hypo¬
tension.
In blunt trauma, indications are rapid exsanguination from the chest tube (> 1500 cc on initial placement with unresponsive hypotension.
Survival rates after emergency thoracotomy are up to 30% for penetrating trauma, but closer to 1% for blunt trauma patients.
The goals of an emergency department thoracotomy are to control hemorrhage (which may require cross-clamping the descending thoracic
aorta), allow access for internal cardiac massage, and treat potential cardiac tamponade. Access to the heart, descending aorta, and mediastinum requires a left thoracotomy incision.
Regardless of the side of injury, traumatic arrest warrants a left thoracotomy for access to the mediastinal structures. If necessary, the incision can be extended to the right chest (clamshell thoracotomy) for access to the right thoracic cavity.
Stable patients with penetrating trauma may stillrequire exploration in the operating room. Traditionally, anterior abdominal stab wounds warranted
mandatory laparotomy to rule out intraabdominal injury, although recent evidence has raised the possibility of expectant management for the stable patient with penetrating injuries.
Thoracic injury to “the box,” the area defined by nipples, sternal notch, and
xiphoid process generally warrants operative exploration as well.
In a stable patient, however, it is reasonable to proceed with additional diagnostic studies. Although some have advocated an extensive workup including esophagoscopy, bronchoscopy, and a pericardial window, more recent data indicates that a high-quality CT scan provides excellent imaging of the thorax and mediastinum, and additional studies can be performed based on the clinical exam and CT findings.
In a patient who undergoes tube thoracostomy, indications to proceed to the operating room are:
> 1500 cc on initial placement, > 150-200 cc/hr for
> 3 hours, or hemodynamic instability requiring persistent blood transfusions.
If this patients wound were located in the neck above the cricoid cartilage (but below the angle of the mandible), which of the following diagnostic tests would be definitely indicated?
A. None; manage expectantly with admission for serial exams.
B. Computed tomography (CT) of the neck with CT angiography (CTA) of the cervical vessels.
C. CTA or angiography plus bronchoscopy.
D. CTA or angiography, bronchoscopy, and esophagogastroduodenoscopy (EGD).
B.
Zone I of the neck extends from the clavicles to the cricoid cartilage.
Zone II is from the cricoid cartilage to the angle of the mandible, and Zone III is from the angle of the mandible to the skull base.
The majority of penetrating injuries, as with the patient in this case, occur in Zone II.
For unstable patients with signs of major vascular or airway injury, management of penetrating neck trauma involves securing an airway and proceeding directly to the operating room for neck exploration.
These signs include stridor, massive subcutaneous air, gurgling or bubbling
through the wound, hemoptysis/hematemesis, and pulsatile bleeding or rapidly expanding hematoma.
Historically, all Zone II injuries that breached the platysma mandated operative exploration. This is no longer widely practiced, and stable patients with
no hard signs of vascular or airway imaging can be managed expectantly with appropriate diagnostic tests.
CTA has similar sensitivity to operative exploration for identifying vascular and soft tissue injuries. CT imaging can also provide valuable information about potential injuries to the esophagus or trachea that can guide the selective use of additional studies to evaluate these structures.
Esophageal injuries are frequently asymptomatic, and morbidity significantly increases if repair is delayed beyond 24 hours.
Contrast esophagography or esophagoscopy is recommended for all Zone II injuries that breach the platysma and have cither physical exam or CT scan
findings concerning for an esophageal injury. Similarly, flexible bronchoscopy can be used selectively based on any exam or CT imaging findings concerning for airway injury.
The patient has 800 cc initial drainage from the right-sided chest tube, which then slows down over the next few hours. He is admitted to the floor on telemetry for monitoring, and remains stable. A follow up chest radiograph the next morning demonstrates significant residual basilar fluid. What is the most appropriate next step?
A. Go to the operating room tor a video-assisted thoracoscopic surgery (VATS) to evacuate the retained hemothorax.
B. Go to the operating room for a right anterolateral thoracotomy.
C. Place a pigtail catheter to drain the residual hemothorax.
D. Observation and serial chest X-rays.
A.
Retained hemothorax is a relatively commonproblem among patients who present with a moderate or large volume hemothorax with either blunt or penetrating trauma.
Although observation only is an option, this carries the risk of developing an infected hematoma (empyema) or fibrothorax. If there is still a significant amount of clotted blood in the thoracic cavity that is not adequately drained by the initial chest tube, then there are several options for management.
These include placement of a second chest tube (or removal and replacement of the initial chest tube) in a better position to evacuate the fluid collection or
administration of local lytic therapy (TPA or urokinase administered through the chest tube) to attempt to break up the clot and allow drainage through the
chest tube.
Although these can be effective in select cases, they have been associated with relatively high failure rates. Since the retained hemothorax likely consists of clotted blood, a small-bore pigtail catheter is unlikely to achieve adequate drainage. There has been a trend toward the increased use of early
VATS to evacuate the hematoma and place a well-positioned chest tube under direct visualization.
This approach can also be useful if there is suspicion for an associated diaphragm injury that can be repaired simultaneously. Median sternotomy would not be indicated for evacuation of a retained hemothorax.
You wake to the sound of your pager and the familiar refrain overhead, ‘Trauma team to the trauma room. Trauma team to the trauma room’
Your pager reads: 23YOM GSW TO CHEST/ABD/RT THIGH. GCS 15 HR 100 BP 90/P RR30 98%’NRB. ETA 3MIN.
As you reach the trauma bay, your patient arrives in extremis. He is unresponsive, his breathing is agonal with oxygen saturation in the low 80s despite ventilation with a bag valve mask,and his radial pulse is weakly
palpable with a rate of 105 beats per minute. Paramedics have established two large bore peripheral IVs and have begun infusing two liters of normal saline.
They report that the patient was shot three times at close range with an unknown firearm. The first wound in the right upper chest was characterized as “sucking” on the scene and has been dressed with an occlusive dressing, taped on three sides. They have already performed a needle decompression. The second wound is in the left lower quadrant of the abdomen and is hemostatic. The final wound is located in the right mid-thigh and is presently
hemostatic. Paramedics tell you that the bleeding was “pulsatile” prior to the application of a tourniquet.
- Your first priority for this patient should be:
A. Establishing a definitive airway.
B. Performing a chest X-ray.
C. Removing the tourniquet on the patient’s right lower extremity.
D. Placing a left-sided tube thoracostomy.
E. Placing a central venous catheter.
- Your patient undergoes a rapid sequence intubation, has a left-sided tube thoracostomy placed with prompt return of air and 1800 mL blood, and has the remainder of the two liters of crystalloid infused via EMS. You remove the tourniquet and immediately appreciate pulsatile bleeding. Distal right lower extremity pulses are not palpable prior to the re-application of this device and
with resultant hemostasis. The patients heart rate has increased to 120 beats per minute wit a blood pressure of 86/44. With your primary survey completed, which of the following injuries necessitates urgent operative intervention?
A. Gunshot wound to the chest only.
B. Gunshot wound to the abdomen only.
C. Right lower extremity injury only.
D. Right lower extremity injury and the chest injury.
E. Right lower extremity injury, abdominal injury,
and chest injury.
Gunshot wounds fall under the broad classification of penetrating trauma and comprise up to 10% of all major trauma in the United States.
The energy imparted to tissue can be calculated using the kinetic energy equation:
Ke= ½m(∆v)2,
where m is the mass of the projectile and ∆v, is the change in velocity before and after contact.
Simplistically, it can be inferred that higher caliber firearms and those projecting higher velocities will cause more grievous injury. This assumes, of course, that the entirety of the projectile’s kinetic energy is imparted to the tissue. Those bullets that enter and exit do not expend all of their kinetic energy on the body.
Furthermore, the projectile’s behavior in the body is a function of its relative density. Lower density projectiles (e.g., lead or so-called “hollow-point” bullets) will tend to expand, creating a progressively enlarging wound tract
with a comparatively small entrance wound and a large exit wound. High density and/or high velocity projectiles tend to pass directly through tissue but can cause significant indirect injury via cavitation. Even further, high density tissue like bone can dramatically alter the initial trajectory, deflecting the projectile in nearly any direction. It is imperative that patients who have sustained gunshot wounds undergo a systematic evaluation with complete anatomic exposure and physical examination.
- A.
The primary survey on trauma patients follows an algorithmic approach to prevent overlooking potentially life-threatening pathology. Patients with gunshot wounds arc no exception. Evaluation and stabilization of the patient^ airway to ensure adequate oxygenation and ventilation represents the first
step in resuscitation.
This sort of vignette is ubiquitous on board examinations and the admonition is to “Keep it Simple,” by following the algorithm delineated by Advanced Trauma Life Support.
Remember the acronym ‘ABCDE’ for the primary survey. This involves assessing the patient^ airway and maintaining in-line cervical spine immobilization, ensuring adequacy of the patient^ breathing by assessing both oxygenation (via pulse oximetry) and ventilation (evaluating respiratory rate and effort), circulation (pulse examination, addressing life-threatening bleeding), disability (neurologic examination), and exposure (strip patient and perform rapid scan for injuries). It is important to be mindful that with a team approach in a working trauma, much of the above can be performed simultaneously.
For our patient, his unresponsiveness, agonal breathing, and oxygen desaturation are concerning and a definitive airway is indicated.
While a chest X-ray will be performed and the left-sided needle decompression will need to be supplanted by a tube thoracostomy, these are of subsidiary importance to securing the patientk airway. A central venous catheter is not necessary at this time given the presence of two large bore peripheral IVs. While it will be important to take down the patient’s tourniquet to perform
a detailed extremity evaluation, the report of pulsatile bleeding in the field is suggestive of vascular injury and given present hemostasis, this can be deferred until the initial resuscitation has been performed.
E.
Knowing the indications for operative intervention is essential to caring for patients having sustained traumatic injuries. For penetrating thoracic trauma, immediate resuscitative thoracotomy (the so-called “Emergency Department T oracotomy”) is indicated for witnessed pulseless electrical activity (overall survival 4% to 5% for gunshot wounds vs. 18% to 24% for stab wounds).
Urgent thoracotomy (within 1 to 4 hours of admission) is indicated for: initial chest tube output > 1500 mL, evidence of ongoing bleeding at a rate of 200-300 mL/h, massive air leak, or cardiac tamponade.
For abdominal trauma, indications for laparotomy include hemodynamic instability, peritonitis on examination, or evisceration. Strong consideration
should also be given to exploration for those patients with an abdomen that cannot be evaluated clinically (e.g., due to altered mental status, distracting injury, paralytic/sedative administration, etc.).
Hard signs of arterial injury include pulsatile hemorrhage, cxpanding/pulsatile hematoma, bruit or thrill over wound, absent distal pulses, or evidence to suggest extremity ischemia (pallor, poikilothermia, pain, paralysis). So-called ‘soft signs” include non-expanding hematoma, peripheral nerve deficit, history of pulsatile hemorrhage at the time of injury, and unexplained hypotension.
Any patient presenting with hard signs of vascular injury should undergo prompt exploration as the positive predictive value of physical examination for arterial injury approaches 100%.
In the absence of hard signs, an alternate means of performing a bedside evaluation is with the injured extremity index (analogous to an ankle-brachial index, also known as an arterial pressure index) with a normal value of > 0.9 having a reported sensitivity/specificity of 95/97% respectively for major vascular injury. A normal physical examination and injured extremity index virtually exclude major arterial injury.
Regarding penetrating chest trauma, which of the following is correct?
A. Tamponade physiology requires accumulation of at least 150cc of blood in the pericardial space.
B. 85% of injuries can be managed with tube thoracostomy alone.
C. Great vessel injuries arc common in penetrating chest trauma.
D. Lung injury that requires operative intervention is more common following blunt injury.
E. Prophylactic antibiotic use reduces the incidence of post-traumatic empyema in the setting of retained hemothorax.
B. Most thoracic injuries can be managed with tube thoracostomy; only 10% to 15% of thoracic trauma requires operative intervention. Tamponade physiology classically only requires 50cc of blood in the pericardial space and is characterized clinically by Beck’s Triad (jugular venous distention, muffled heart sounds, hypotension), occasionally with a narrowed pulse pressure, and the presence of an effusion on FAST examination.
Patients with tamponade physiology should receive aggressive volume administration because they will be dependent on their preload to generate
cardiac output.
Decompressive pericardiocentesis may be performed though in the setting of trauma, but this is often a temporizing measure. Definitive surgical management in this setting of trauma involves the creation of a pericardial window.
The reported incidence of great vessel injury in penetrating chest trauma is only 4%, as the majority of these patients exsanguinate prior to presentation. Gunshot wounds to the mediastinum should raise suspicion and the diagnosis can be confirmed with CT angiography. If present, urgent exploration is warranted.
Lung injury that requires surgical intervention
is more commonly encountered with penetrating trauma. T c majority oi these injuries can be man¬
aged with pulmonary tractotomy (for penetrating
non-hilar injuries) or nonanatomic stapled resec¬
tions. Inadequately evacuated hemothorax can result
in secondary in lection (post-traumatic empyema)
or fibrothorax (entrapped lung). Unfortunately,
prophylactic antibiotics do not appear to prevent
the secondary development of infection in this set¬
ting. Chest tubes arc often unsuccessful in remov¬
ing clotted blood and consideration should be given
to operative exploration for patients with retained
hemothorax.
Regarding this patient’s penetrating abdominal wound, which of the following is correct?
A. Injuries to the bowel may be primarily repaired if less than 75% of the bowel’s circumference being involved.
B. The most common organ injured is the large bowel.
C. FAST (focused assessment with sonography for trauma) examination is poor at detecting hollow viscous injuries.
D. All patients with penetrating abdominal injuries that violates the posterior fascia must undergo an exploration but a laparoscopic one may suffice.
E. The operation of choice in an unstable patient having sustained penetrating abdominal injury is a limited laparotomy with extension only if
injuries are suspected.
C.
While a FAST examination is a useful bedside adjunct to detect the presence of free intra-abdominal or pericardial fluid, it is operator dependent and has a poor sensitivity with respect to hollow viscous, retroperitoneal, and diaphragmatic injuries.
A negative FAST examination docs not rule out intra-peritoneal injury. There is evidence to suggest that hemodynamically stable patients with abdominal gunshot wounds and no evidence of peritonitis on exam may undergo evaluation via computerized tomography of the abdomen to determine whether further operative intervention is required. Even if the posterior fascia is violated, elective non-operative management with observation and serial examinations is a safe alternative to reflex operative exploration in a major trauma center with in-hospital surgical support.
In general, primary repairs can be done on both small and large bowel if 50% or less of the circumference is damaged. The most commonly injured abdominal organ with penetrating trauma is the small bowel. For unstable patients with penetrating abdominal injuries, a full laparotomy incision should be made so that all of the injuries can be identified quickly.
A 60-year-old male restrained driver is involved in a high-speed head-on motor vehicle collision. He is heavily intoxicated and uncooperative, therefore he is intubated at the scene and brought to the nearest Level I trauma center. Upon arrival he is able to shrug his
shoulders to questions. Initial vita) signs indicate a pulse of 48 bpm and a blood pressure of 78/39 mm Hg. His respiratory status appears stable on the current ventilator settings and initial primary trauma evaluation fails to reveal any major external signs oi injury.
Subsequent secondary trauma survey reveals the patient is able to shrug his shoulders but demonstrates no motor or sensory function below his deltoids. Questionable rectal tone is present. A cervical collar is in place, but the patient demonstrates tenderness to palpation in the midiinc of the cervical spine.
- What is the most likely cause of this patient’s hypotension?
A. Splenic rupture
B. Acute blood loss
C. Flail chest
D. Spinal shock
E. Beta-blockade
D.
Spinal cord injury following a traumatic cervical spine injury typically results from blunt compression injury to the cord itself. Typically the central grey matter is affected first while the peripherally located white matter fiber tracts may be relatively spared.
If the spinal cord injury is severe enough, neurogenic or spinal shock may occur. The most basic definition of this is inadequate tissue perfusion due to paralysis of vasomotor input, most commonly due to loss of sympathetic tone and significant disruption of the vasodilator and vasoconstrictor balance. It is commonly characterized by bradycardia, hypotension, decreased peripheral vascular resistance, and decreased cardiac output.
Common physical examination findings demonstrate flaccid paralysis of the extremities with no sensory function, lack of rectal tone, lack of foley
catheter sensation, and priapism in males. If the spinal cord injury occurs at C5 or above then respiratory depression may occur.
As this patient demonstrates some deltoid function, this indicates a lower cervical cord injury. Presence of a shoulder shrug should not fool the examiner. T is motor function is provided by the 11th cranial nerve.
The most common classification of spinal cord injuries occurs via the ASIA system:
A = Complete (No motor or sensory function is preserved in
the sacral segments S4-S5)
B = Incomplete (Sensory but no motor function is preserved below the neurological level and includes the sacral segments S4-S5)
C = Incomplete (Motor function is preserved below the neurological level, and more than half of key muscles below the neurological level have a muscle grade less than 3)
D = Incomplete (Motor function is preserved below the neurological level, and at least half of key muscles below the neurological level have a muscle grade of 3 or more E = Normal
Which of the following is not a component evaluated by the NEXUS criteria for clearing a patient’s cervical spine from injury such that the cervical collar can be removed?
A. Pain with passive motion ol the patient’s neck
B. History of Ambien use
C. Any other injury
D. Altered mental status
E. High velocity mechanism ol injury
E.
Any patient suspected of a cervical spine injury and therefore potentially unstable cervical spine should be placed in cervical immobilization with a rigid collar. Maintenance of in-line cervical alignment during intubation as well as log-roll precautions must be upheld during transfers.
Per the NEXUS criteria, a patient can be cleared with a 99.8% negative predictive value for cervical spine injury if the following criteria are met:
Meets all low-risk criteria?
- No posterior midline cervical-spine tenderness
- No evidence of intoxication
- Anormal level of alertness
- No focal neurologic deficit
- No painful distracting injuries
YES = No Radiography NO = Radiography
Which of the following therapeutic measures is considered a current standard treatment option for this patient’s spinal shock?
A. Limited boluses of normal saline or LR to prevent spinal cord edema
B. Bed rest
C. Selective vasopressor treatment to keep MAPs >85
D. Administration of methylprednisolone bolus at 30 mg/kg followed by continuous infusion at 5.4 mg/kg/hr for 23 hours
C.
Current treatment protocols for spinal shock involve the mainstays of aggressive fluid resuscitation and vasopressors. Vasopressor choice is left to the discretion of the treating physician based on the patient’s co-morbid factors. A goal MAP of > 85 sustained for 7 days has demonstrated some promise for improving a patient’s outcome.
Usage of high dose steroids in acute spinal cord injury is a controversial topic and has been for quite some time. Various large trials (NASCIS I, II, III) have demonstrated mild benefits with the administration of methylprednisolone bolus of 30 mg/kg followed by 23 hours or continuous infusion at 5.4 mg/kg/hour.
However, these studies have also demonstrated significant deleterious side effects with high dose steroids leading to the Congress of Neurosurgeons to declare that high dose steroids’ risks outweigh their benefits, and are thus
not recommended.
Imaging reveals a fracture dislocation of the midcervical spine with a resultant spinal cord injury. Computed tomographic angiography (CTA) reveals a traumatic vertebral artery dissection. Which of the following is associated with a markedly increased chance of cervical vascular injury and thus requires an evaluation with CTÄ?
A. Neurological examination out of proportion with computerized tomography (CT) head findings
B. Seat belt sign
C. C5 spinous process fracture
D. Glasgow coma scale < 10
E. Le Fort I fracture
A.
Blunt carotid or vertebral artery injuries can be a potentially lethal injury if missed upon initial trauma evaluation. Level II evidence exists neck CTA screening in trauma patients with an exam out of proportion to their cranial imaging (i.e., a comatose patient with minimal traumatic intracranial damage). Level III evidence exists for such screening in trauma patients with GCS 8 or below, petrous bone fractures, diffuse axonal injury, C1-3 fractures, any cervical spine fracture with subluxation, cervical spine fracture through the foramen transversarium, or Le Fort II/III injuries.
Surprisingly, despite its widely believed association with cervical vascular injuries, presence of an isolated “seat belt sign” with no other above listed injuries is only associated with a 1% yield for blunt cervical vascular injuries. Treatment of such blunt injuries attempt to prevent intracranial ischemic injuries.
Previously aggressive treatment with open surgical or endovascular repair, often in the form of stenting or coiling, provided the mainstay of treatment. However, current emerging evidence suggests these lesions, if diagnosed prior to evidence of ischemia, can be quite benign if treated with antithrombotic
medications.
Currently, either anticoagulation via heparin/Coumadin or anti-platelet medications via aspirin 325 mg daily are widely used.
A 32-year-old male, unrestrained driver, is involved in a high-speed motor vehicle collision. After a prolonged extraction, the patient is found to be somnolent and is intubated on the scene. After arrival in the trauma center, a complete evaluation reveals a non-displaced linear skull fracture and multiple areas of intracranial contusions with diffuse edema but no large mass lesions. No other systemic injuries are discovered. His neurologic exam demonstrates small but reactive pupils, presence of corneal, gag, and cough reflexes, lack of eye opening to voice or painful stimulation, brisk withdrawal of both legs and his right arm to painful stimulation as well as localization of his left arm to painful stimulation.
What is the patients Glasgow Coma Scale (GCS)?
A. 5
B. 6
C. 7
D. 8
E. 9
C.
The Glasgow Coma Scale (GCS) is the most basic method of quickly communicating a patient’s neurologic examination. It is comprised of three components.
Thus, a non-responsive comatose patient has a GCS of 3 while an awake, oriented patient would demonstrate a GCS of 15.
Intubated patients automatically receive just 1 point for verbal response. If a
patient’s motor exam is asymmetric, the best response is used for grading. Thus this patient’s exam is E1, V1, M5 for a total GCS of 7. For intubated patients, many providers use the convention of adding a “T” following the GCS score, so this patient would be described as a “GCS 7T”!
Which of the following are indications for the use of intracranial pressure monitoring in traumatic brain injury?
A. Intracranial injury demonstrated on computerized tomography (CT) scan and GCS of 8 or below.
B. Lack of intracranial injury on CT scan, but age> 40, SBP < 90, and motor posturing on exam.
C. Minor neurologic injury but lack of neurologic examination due to need for systemic paralytics in treatment of other injuries.
D. All of the above.
E. None of the above.
D.
Insertion of an intracranial pressure monitor can be used to evaluate and treat elevated ICP or as a surrogate for a neurologic examination in those who require sedation or chemical paralysis for other injuries (such as a trauma patient with an open abdomen on paralytics).
The most common indication for an ICP monitor is a patient with a traumatic intracranial injury on imaging and a GCS of 8 or less. These patients will have an elevated ICP 60% of the time.
Patients with a normal head CT scan will only demonstrate elevated ICP 13% of the time. This occurs most commonly in patients over 40 years of age who demonstrate posturing on examination and hypotension.
Which of the following should be implemented in this patient following external ventricular drain placement and admission to the ICU?
A. Elevation of the head of bed to up to 10 degrees so measurement of the intracranial pressure (ICP) remains calibrated
B. Maintain hemoglobin levels > 10 g/dL
C. Maintenance of a cerebral perfusion pressure of 60 or above
D. Allow hypercapnia
E. Administration of high levels of positive end-expiratory pressure (PEEP) to aid in oxygenation
C
The Monro-Kellie doctrine states that the skull is a fixed compartment with 3 basic components: brain (80%), cerebrospinal fluid (10%), and blood (10%).
An increase in any one of these components requires an equal decrease in one or both of the other two to prevent an increase in intracranial pressure. Typical cerebral blood flow compromises 15-20% of the cardiac output; a decrease in this may result in unmet cerebral metabolic demands.
The primary goal of treatment of severe brain injury is to maintain adequate cerebral blood flow and oxygen delivery, but it is dif cult to readily measure these parameters. However, cerebral blood flow can be roughly estimated by
cerebral perfusion pressure (CPP = MAP - ICP), and is commonly used to guide therapy.
In uninjured patients, the brain will maintain cerebral perfusion via autoregulation over estimated CPP ranges of 50 to 150.
However, patients with severe brain injury will commonly exhibit loss of autoregulation, which means that their cerebral blood flow will be directly
dependent on an adequate mean arterial pressure (MAP) and a normal intracranial pressure (ICP).
This is why there is so much attention paid to maintaining a normal to slightly elevated blood pressure and aggressive measures to avoid ICP elevations in
patients with severe brain injury.
All attempts at treating elevated intracranial pressure keep this Monro-Kellie hypothesis and its relationship with cerebral perfusion pressure in mind.
The first steps toward the treatment of a patient with elevated intracranial pressure begin with many simple bedside maneuvers. Initial steps should include elevation of the head of bed to aid cerebral venous outflow, seizure prophylaxis, maintenance of hemoglobin of at least 7 g/dL or above, avoidance of elevated intra-adominal pressure, and adequate pulmonary support.
Pulmonary support should focus on avoidance of hypoxia, hypercapnia, and excessive PEEP. Elevated levels of PaCO2 lead to intracranial vasodilation and cerebral blood volume, thus elevated ICP. Excessive PEEP may lead to increased intra-thoracic pressure and thus impaired cerebral venous outflow.
However, patients with severe brain injury will commonly exhibit loss o autoregulation, which means that their cerebral blood ow will be directly dependent on an adequate mean arterial pressure (MAP) and a normal intracranial pressure (ICP). T is is why there is so much attention paid to maintaining a normal to slightly elevated blood pressure and aggressive measures to avoid ICP elevations in patients with severe brain injury.
On post-admission day 2, the patient’s intracranial pressures rise to the low 30s. Which of the following maneuvers can be used to reduce his intracranial pressure?
A. Increased sedation with propofol only because other sedatives can increase cerebral metabolic demand
B. 3% hypertonic saline
C. Permissive hypotension
D. Transient periods of hypoventilation
E. Administration of methylprednisolone
B.
If elevated ICP occurs, more aggressive methods of treatment include increased sedation (via propofol or barbituates to decreased cerebral metabolic demands), paralytics, mannitol or both rheologic and osmotic effects, and hypertonic saline.
Steroids should be avoided in intracranial trauma. Despite the usage of dexamethasone with other causes of cerebral edema, steroids are associated with elevated mortality in trauma patients with severe brain injury due to the myriad of side effects. Hypotension should be avoided to help maintain the CPP.
A 27-year-old female presents to the emergency department after a motorcycle crash. She was hemodynamically unstable on arrival and is currently receiving 2L of crystalloid via large bore peripheral IVs. Glasgow Coma Scale (GCS) is 12. She is breathing spontaneously and has no obvious extremity trauma. Initial radiographs demonstrate normal cervical alignment without fracture, right side ribs 4 through 8 fractured, a small right side pulmonary contusion, no free air under the diaphragm, and a pelvis film that shows widening ofthe pubic symphysis by 4 cm along with diastasis of the left sacroiliac joint. Abdominal ultrasound is negative for free fluid. The patient is currently on her menses.
- With regards to the pelvic injury, the patient’s hemodynamic instability is most likely related to:
A. Disruption of the anastomis of the external iliac/deep epigastric and obturator vessels (the Corona Mortis)
B. Arterial injury of the superior gluteal artery and vein at the level of the greater sciatic notch
C. Post-traumatic closed soft tissue degloving injury in which the skin and subcutaneous tissue separate from the fascia superficial to the underlying musculature (Morel-Lavallee lesion)
D. Disruption o the anterior sacral venous plexus.
E. Rupture o the pelvic oor structures (sacrospinous and sacrotuberrous ligaments) with vaginal laceration by the anterior pubic symphasis ragments
D.
Hemodynamic instability after blunt trauma is due to ongoing hemorrhage until proven otherwise, with the common locations being the chest, abdomen, pelvis, or extremity/cxtcrnal bleeding.
The normal chest X-ray and abdominal ultrasound in conjunction with the abnormal pelvis X-ray make the pelvis the most likely source of bleeding in this
patient.
Although arterial injuries in association with major pelvic trauma can occur, the majority of bleeding occurs at the venous plexus located on the anterior aspect of the sacrum and sacroiliac joints.
This historically has responded best to pelvic packing orfracture reduction, rather than immediate angiography. Injuries to the superior gluteal arteries posteriorly and the Corona Mortis anteriorly have been reported and can be devastating, but they are far outnumbered by the venous lacerations of the presacral venous plexus.
Morel-Lavallee lesions are common after blunt force trauma, but do not typically lead to hemodynamic instability seen from the deep pelvic venous lacerations.
