Trauma

An 18-year-old man is bitten on the leg by what appears to be a rattlesnake. A tourniquet has been placed above the wound, and the patient arrives at the emergency department 70 minutes after the injury. There are two fang marks with 15 cm of edema and erythema surrounding the wound. What should immediate treatment include?

Administration of four ampules of antivenin This patient's response is considered moderate to great in regard to envenomation and requires 3-5 vials of antivenin IV in 500 mL of normal saline. The tourniquet should not be removed until the antivenin therapy is instituted. Incision and suction will be of benefit only if accomplished within 30 minutes of sustaining the bite, and excision of the bite area is valuable only if performed within 1 hour.

A newborn boy was examined to exclude congenital dislocation of the hip (CDH). Which of the following tests is relative to the management of CDH?

Abduction of the flexed hip causes a click (Ortolani's sign) It is important to recognize congenital dislocation of the newborn soon after birth. Delay in initiating appropriate treatment may lead to permanent hip joint disease. There may be apparent shortening of the thigh, although with the hip and knee flexed

A 45-year-old man with a skull fracture of the temporal bone

Acute extradural hematoma Atemporal skull fracture crossing the middle meningeal artery grove with lucid interval are pathognomonic of an extradural hemorrhage.

A12-year-old girl is brought into the emergency department after an unprovoked attack and bite by a raccoon. The bite is on the left lower leg. Which treatment should be provided?

Administration of a 5-day course of HDCV and a single dose of HRIG with up to half of the dose administered directly around the wound . A 5-day course of vaccine and a single dose of HRIG should be administered. They should not be administered jointly into the gluteal area, because administration in this area results in lowering neutralizing antibody titers. Where feasible, up to half of the dose of HRIG should be infiltrated into the area around the wound.

A 20-year-old woman presents to the emergency department after being hit in the face during a baseball game. On physical examination, the patient's blood pressure is 90 mm Hg, and there is significant bleeding from the nose that cannot be controlled either by fracture reduction or by anterior and posterior nasopharyngeal packing. What is the next step in management?

Angiographic evaluation and embolization Because it is not possible to identify the specific vessels injured by physical examination, angiography with embolization is indicated. Insertion of a nasogastric tube in patients with midfacial trauma should be avoided because of the presence of a false passage to the brain

A 65-year-old man is brought to the hospital after being hit by a car. His blood pressure is 150/90 mm Hg, and pulse is 120 bpm. There is deformity just below the left knee and no distal pulses palpable in that leg. Plain films show proximal tibia and fibula fractures. What is the next step in management?

Angiography In a stable patient presenting with peripheral vessel occlusion following blunt trauma, angiography is indicated to plan the appropriate operative approach. An angiogram can also document preexisting arterisclerosis, collateral circulation, and distal runoff. Doppler ultrasound is useful to localize the injury site but gives less information regarding collateral circulation. Immediate operation to control bleeding and restore flow is indicated if the patient's condition is unstable.

A20-year-old woman presents to the emergency department with a stab wound to the neck above the angle of the mandible. The patient's blood pressure is 110/80 mm Hg, pulse rate is 100 bpm, and respiration rate is 24 breaths per minute. Between initial presentation and insertion of intravenous lines, the hematoma in the upper neck enlarges significantly. What should be the next step in the patient's management?

Angiography In considering management of neck wounds, three zones are described. Zone III refers to the area above and posterior to the angle of the mandible (see Fig. 12-4). Angiographic definition of the site and extent of arterial injury is important because of the difficulty in exposure of internal carotid injuries near the base of the skull. Such injuries may require the use of extracranial-intracranial arterial bypass

A football player extends his right arm to make a tackle but experiences intense pain on tackle contact with subsequent inability to move the right arm. Examination reveals swelling and tenderness about the shoulder with loss of the normal deltoid contour. Which is the most likely diagnosis?

Anterior dislocation of the shoulder The mechanism of injury (abduction and external rotation) combined with the characteristic observable deformity of deltoid contour loss makes anterior dislocation the best choice. The common site of shoulder joint dislocation is inferior, because the rotator cuff muscles are absent there

An 18-year-old man is brought to the emergency department after falling down a flight of stairs and losing consciousness for 3 minutes. A cervical collar is in place. The cervical spine is considered to be free of serious injury following which procedure?

Anteroposterior (AP), lateral, and odontoid views of the neck Clearing the cervical spine usually consists of obtaining normal findings on AP, lateral, and odontoid views of the cervical spine.

A 60-year-old woman runs her car off the road and it hits a telephone pole. She presents to the emergency department with severe anterior chest pain and a blood pressure of 110/80 mm Hg. A chest x-ray shows a questionably widened mediastinum. The next step in management should be which of the following?

Aortogram The most definitive test for aortic injury is the aortogram, even though only 20-30% of patients with widened mediastinum demonstrate it. A transthoracic echocardiogram does not image the aorta wall; however, a transesophageal echocardiogram may have more value in experienced hands

A40-year-old housewife trips over the garden hose, landing on the patio with an outstretched hand. Swelling and pain in the wrist rapidly occur, but findings on emergency room x-rays are negative for fracture or dislocation. In addition to the swelling, there is restriction of wrist dorsiflexion and palmar flexion as well as some tenderness of the anatomic snuffbox at the base of the thumb. What is the best treatment?

Apply a cast to the wrist and repeat the wrist x-ray in 10-14 days Tenderness in the anatomic snuffbox (the interval between the extensor pollicis longus and the extensor pollicis brevis and abductor pollicis longus tendons) may signify a fracture of the carpal scaphoid (navicular) bone. Initial x-ray findings are often negative, but the fracture line often shows up in a repeat x-ray taken after 10-14 days

A34-year-old man is brought into the emergency department with a large open knife wound to the left thigh. The patient's systolic blood pressure is 90 mm Hg. Blood is spurting from the wound. What is the initial management step?

Apply direct pressure with sterile gauze Apply direct pressure with sterile gauze. Direct pressure is the best choice. Attempting to clamp vessels can cause further vascular or nerve injury. Tourniquet is used only if direct pressure fails. As soon as direct pressure is attempted, a second person should insert a large-bore peripheral intravenous line

A 42-year-old man is hit on the left side of his body by a car and is brought to the emergency department with fractures of the left tenth, eleventh, and twelfth ribs and left tibia and fibula fractures. The patient's blood pressure is 120/90 mm Hg, pulse rate is 100 bpm, and respiration rate is 24 breaths per minute. He has hematuria and left flank pain. Intravenous lines are inserted. IVP shows no excretion from the left kidney but normal excretion from the right. What would be the next step in management?

Arteriography Arteriography is used to assess possible renal artery injury in these circumstances. It is used if the kidney is not visualized with an IVP or CT a scan. Operative intervention without arteriography is not necessary in a stable patient. Peritoneal lavage is useful in determining the presence of intraperitoneal bleeding; if arteriography shows a need for surgery, peritoneal lavage will not be necessary

An 18-year-old man is brought to the emergency department with a stab wound just to the right of the sternum in the sixth intercostal space. His blood pressure is 80 mm Hg. Faint heart sounds and pulsus paradoxus are noted. Auscultation of the right chest reveals decreased breath sounds. The initial management of this patient should be which of the following?

Aspiration of the right chest cavity In a patient presenting with a chest wound in shock, the priorities are airway, breathing, and circulation. Thus, aspiration of the right chest to rule out a tension pneumothorax should be performed first. Aspiration of the pericardium does not definitively rule out cardiac injury; a pericardial window provides both diagnosis and decompression. An echocardiogram is not indicated in an unstable patient

A47-year-old man awakens with low back pain after a weekend of gardening. He recalls no specific incident of trauma and has never had back pain before. There is no radiation of the pain and no disturbance of normal bowel or bladder function. The ROM of the low back is painful and restricted in all planes, and there is paraspinal tenderness from L2 to L5 on the right. Scoliosis and kyphosis are absent. Findings on straight-leg-raising test are negative, reflexes are active and equal, and the patient can walk on his heels and toes. Findings on x-rays of the lumbar spine are normal. Which is the best treatment?

Bed rest for 48 hours, anti-inflammatory agents, heat to the low back, and nonnarcotic analgesics In the absence of bladder or bowel disturbance, or sciatic symptoms, a neurological defect caused by a herniated disk is unlikely. A short period of rest, along with heat, antiinflammatory agents, and analgesics, is the best treatment for a soft-tissue inflammatory lesion of the lumbar region

A 22-year-old woman presents to the emergency department with a chief complaint of severe left upper quadrant (LUQ) pain after being punched by her husband. Her blood pressure is 110/70 mm Hg, pulse is 100 bpm, and respiration rate is 24 breaths per minute. The best means to establish a diagnosis is which of the following?

CT of the abdomen The best means to establish the diagnosis is CT scan of the abdomen. It will demonstrate solid-organ injury and the appropriate amount of fluid (blood) in the peritoneal cavity. It also serves as a baseline for a patient being treated conservatively for spleen and liver injuries

A47-year-old woman involved in a skiing accident suffered a severe blow to the middle upper abdomen. Physical examination revealed diffuse tenderness, but there was no evidence of rebound tenderness or guarding. What test would be performed to rule out traumatic pancreatitis?

CT scan with oral and intravenous contrast This gives the best sensitivity and specificity in diagnosing blunt trauma to the pancreas. ERCP could be useful in studying the integrity of the pancreatic duct, but a CT scan is more accurate in revealing traumatic pancreatitis without major ductal injury. An upper GI series may show widening of the duodenal C-loop. An isolated serum amylase elevation is not diagnostic of pancreatic injury. Repeated testing of amylase levels, if amylase levels increase with time, may be more diagnostic of traumatic pancreatitis than a single value

A 60-year-old woman presents with a stab wound to the back just above the iliac crest. She is in stable condition.

CT with intravenous and oral contrast A CT scan with intravenous and oral contrast can best rule out possible retroperitoneal injury caused by a stab wound.

A 70-year-old woman is hit by a car and injures her midabdomen. The best way to rule out a rupture of the second part of the duodenum is by which mode?

CT with oral and intravenous contrast CT scan with oral and intravenous contrast is the most sensitive and specific study to diagnose injuries to the retroperitoneal duodenum

A22-year-old man is found to have a complete transection of the common bile duct following a gunshot wound to the abdomen. There is also a through-and-through wound to the edge of the right lobe of the liver that is not bleeding at the time of surgery. How should the bile duct injury be managed?

Choledochojejunostomy and cholecystectomy Although it may be technically possible to perform a primary anastomosis for a complete transection, these invariably lead to bile duct structure. It is important to remember that debridement of the duct following a gunshot wound increases the tension on the anastomosis. The best method for the early treatment of injuries to the common bile duct is a duct-tosmall bowel anastomosis

A 25-year-old man presents to the emergency department with a gunshot wound to the abdomen. On exploratory laparotomy, he is found to have multiple small-bowel enterotomies, transverse colon enterotomy, and a partial injury just to the left of the midline of the pancreas. The pancreatic duct appears intact. What is the appropriate management of the pancreatic injury?

Closed-suction drainage and lavage Routinely performing distal pancreatectomy for all penetrating injuries to the body or tail of the pancreas significantly prolongs the operative time and contributes to additional hemorrhage and possible hypothermia. Approximately 25% of patients undergoing distal pancreatectomy develop an intra-abdominal abscess. Distal pancreatectomy is the procedure of choice if there is an obvious disruption of the pancreatic duct in the body or tail. Closed-suction drainage is preferred to suction drainage because of the lower incidence of abscess formation with closedsuction drainage. If there is an injury to the duodenum, a pancreaticogram can be performed through the injury site; however, a normal duodenum should not be opened to secure an intraoperative pancreaticogram

An 18-year-old man presents to the emergency department with a gunshot wound to the left chest in the anterior axillary line in the seventh intercostal space. A rushing sound is audible during inspiration. Immediate management is which of the following?

Closure of the hole with sterile dressing The immediate treatment is the closure of the hole by any means available. Sucking chest wounds allow shift of the mediastinum to the opposite side. Thoracotomy is not usually required. Laparotomy is indicated for a gunshot wound below the fourth intercostal space, but it should follow respiratory stabilization. A chest tube will be required, following closure of the sucking wound, to prevent a tension pneumothorax

A60-year-old man crashes his car into a bridge abutment and is found slumped over his steering wheel. In the emergency department, the signs and symptoms of pericardial tamponade are evident. These findings are most likely attributable to which of the following?

Coronary artery laceration Tamponade from blunt trauma to the heart is usually attributable to myocardial rupture or coronary artery laceration. The left coronary artery gives off the left anterior interventricular artery that passes between the left and right ventricle on the anterior surface of the heart. The right main coronary artery passes in the sulcus between the right atrium and the right ventricle on the anterior surface of the heart.

A30-year-old man is brought to the emergency department in respiratory distress following a shotgun wound to the face. There is a possible cervical spine injury. Which is the best way to gain rapid control of the airway?

Cricothyroidotomy In a patient with a massive midface injury, cricothyroidotomy or tracheostomy should be performed, depending on the urgency of the need for airway control

A 30-year old man sustained a pelvic fracture with a large pelvic hematoma. Rectal examination reveals a large laceration in the rectal wall and a nonpalpable prostate. His vital signs have stabilized with multiple transfusions. This patient requires which of the following?

Exploratory laparotomy, urinary diversion, sigmoid colostomy, presacral drainage, and debridement of the rectal wall The patient needs a urinary diversion for the uretheral injury and a colostomy for the rectal injury.

A23-year-old man is shot with a handgun and found to have a through-and-through injury to the right transverse colon. There is little fecal contamination and no bowel devascularization. At operation, what does he require?

Debridement and closure of wounds Most gunshot injuries to the right side of the colon should be closed primarily. Resection is required only where there is extensive devitalization of tissue or injury to the mesocolon causing devascularization of the bowel.

The injury most often missed by selective nonoperative management of abdominal stab wounds is to which of the following?

Diaphragm Selective management of abdominal stab wounds, especially to the lower chest and upper abdomen, relies on physical examination and diagnostic peritoneal lavage (DPL) to identify the need for operative exploration. Small, isolated diaphragmatic lacerations may be asymptomatic and may not result in red blood cell counts required to cause a positive DPL These small diaphragmatic wounds are best detected by laparoscopy. Missed diaphragmatic injuries may cause late diaphragmatic hernias with potential morbidity and mortality

A26-year-old man is brought to the emergency department with a stab wound to the right side of the back just medial to the posterioraxillary line. His blood pressure is 120/80 mm Hg, pulse rate is 98 bpm, and respiration rate is 22 breaths per minute. Physical examination reveals no abdominal tenderness, guarding, or neurologic changes. Local exploration of the stab wound is performed using local anesthesia. The track to the wound ends in the paraspinal muscles. What would be the next step in management?

Discharge to outpatient clinic for follow-up monitoring A patient with definitive negative findings on wound exploration can be discharged from the hospital for outpatient follow-up care. It is sometimes difficult to determine the depth of a stab wound to the back because of the thickness of the paraspinal muscles. Some authors have found that nearly 20% of patients with such injuries have negative findings on exploration. Such patients can be discharged. Deeper stab wounds to the back may injure peritoneal structures without penetration of the peritoneal cavity. Thus, peritoneal lavage is less useful than a CT scan with intravenous, oral, and (particularly) rectal contrast to rule out retroperitoneal colon injuries

An 18-year-old woman who is 8-month pregnant is brought into the emergency department. She was hit by a car and now complains of abdominal pain. Her blood pressure is 80/60 mm Hg, pulse is 120 bpm, and respiration rate is 30 breaths per minute. Large-bore intravenous lines are placed through the antecubital fossa. The fetal heart rate is 160 bpm. What is the next step?

Displace the uterus to the left. The first step in restoring cardiac return in a patient in the third trimester who has become hypovolemic is to displace the gravid uterus off the vena cava by pushing it to the left

A 33-year-old man presents to the emergency department with a gunshot injury to the abdomen. At laparotomy, a deep laceration is found in the pancreas just to the left of the vertebral column with severance of the pancreatic duct. What is the next step in management?

Distal pancreatectomy Distal pancreatectomy is the procedure of choice for distal pancreatic injuries. It is essential to avoid creation of an intestinal anastomosis (such as in pancreaticojejunostomy), which can leak. An intraoperative pancreatogram is indicated to rule out more proximal duct injuries. Debridement and drainage of the defect alone may result in a pancreatic fistula.

A35-year-old woman was punched in the right side of the abdomen and chest. There was some right upper abdomen tenderness but no guarding or rebound. Results of a gastrografin upper GI study showed a coiled-spring (stack of coins) appearance of the second and third part of the duodenum. What is the most likely diagnosis?

Duodenal hematoma The coiled-spring or stacked-coin appearance of the duodenum is diagnostic of a duodenal hematoma

A19-year-old man is brought to the emergency department with a stab wound at the base of the neck (zone I) (Fig. 12-4). The most important concern for patients with such injuries is which of the following?

Exsanguinating hemorrhage Exsanguinating hemorrhage is the predominant risk, because bleeding may not be easily recognized, given that bleeding into the pleural cavity and mediastinum can occur. The abundant collateral blood supply generally protects against upper extremities or cerebrovascular compromise

In a patient who had a motor-cycle crash, a CT of the abdomen revealed a peripancreatic hematoma and indistinct pancreatic border. The most definitive test for a pancreatic injury requiring operative intervention is:

ERCP The most definitive test for a lesion requiring operative correction is demonstration of a disrupted major pancreatic duct. While CT scanning may give a suggestion of a ductal injury, and operative exploration of the area of injury may be inconclusive, ERCP is very reliable in showing a disrupted duct. Amylase testing of lavage effuent is nonspecific.

A 25-year-old man is shot in the left lateral chest. In the emergency department, his blood pressure is 120/90 mm Hg, pulse rate is 104 beats per minute (bpm), and respiration rate is 36 breaths per minute. Chest x-ray shows air and fluid in the left pleural cavity. Nasogastric aspiration reveals blood-stained fluid. What is the best step to rule out esophageal injury?

Esophagoscopy Either an esophagoscopy or a barium swallow—or both—can be used to rule out esophageal injury. The esophagogram should not be performed with Gastrografin because of its deleterious effects if aspirated into the lungs. Nasogastric tube aspiration showing blood is suggestive of an esophageal injury in this patient but is not specific. Peritoneal lavage is sensitive for an intra-abdominal injury, causing bleeding

A 17-year-old girl presents to the emergency department with a stab wound to the abdomen and a blow to the head that left her groggy. Her blood pressure is 80/0 mm Hg, pulse is 120 bpm, and respiration rate is 28 breaths per minute. Her abdomen has a stab wound in the anterior axillary line at the right costal margin. Two large-bore intravenous lines, a nasogastric tube, and a Foley catheter are inserted. The blood pressure rises to 85 mm Hg after 2 L of Ringer's lactate. The appropriate management is which of the following?

Exploratory laparotomy A patient without other sources of blood loss who presents to the emergency department with a stab wound to the abdomen and in shock should have an expeditious exploratory laparotomy. Hemorrhage control should take precedence over definitive management of a concomitant head injury. The other tests will waste precious time and are contraindicated in a patient in shock

A 16-year-old boy presents to the emergency department with a gunshot wound to the abdominal cavity.

Exploratory laparotomy All gunshot wounds clearly entering the abdominal cavity should be treated by emergency exploratory laparotomy. Over 80% of the time, injuries requiring repair will be found

A 19-year-old man presents to the emergency department with a gunshot wound through the umbilicus. The systolic blood pressure is 70 mm Hg on palpation, and his abdomen is tightly distended. Large-bore intravenous lines are placed, and Ringer's lactate is infused. What should be the next step?

Exploratory laparotomy The patient should be brought to the OR prepared and draped, with the nasogastric tube and Foley catheter inserted, and then anesthetized immediately prior to laparotomy. Some surgeons initially control the aorta through a thoracotomy incision through the seventh intercostal space. Transfusion before control of bleeding causes more bleeding.

A 26-year-old woman in her sixth month of pregnancy is brought to the emergency department. She had been punched in the abdomen. She is found to have generalized abdominal pain, tenderness, abdominal distention, ileus, and absent fetal heart sounds. The patient's blood pressure is 80/60 mm Hg; despite administration of 3 L of Ringer's lactate, her blood pressure only comes up to 90/60 mm Hg. What is the next step in management?

Exploratory laparotomy with evacuation of the uterus and closure of the uterus disruption This is the procedure of choice despite continued hypotension. Blood administration should be instituted but is not as critical as gaining surgical hemostasis. A PASG may have a limited temporizing effect but should not be used as an alternative to exploratory laparotomy. Any patient with abdominal trauma who is hypotensive should not be sent for a CT scan.

A 43-year-old woman is thrown from a car following a car crash. She presents to the emergency department with a fracture of the pelvis (Fig. 12-3). Her blood pressure is 80/60 mm Hg, pulse is 110 bpm, and respiratory rate is 26 breaths per minute. Bright red blood is found on rectal examination and bony fragments can be palpated through the rectal wall. The patient remains hypotensive despite 3 L of Ringer's lactate and 2 U of typespecific blood. What is the most important step in management?

External fixation of the pelvic fracture The most likely cause of the patient's persistent hypotension is the pelvic fracture; therefore, external fixation should be performed promptly. While the patient is undergoing external fixation in the OR, an exploratory laparotomy and colostomy should be performed for the rectal injury.

A 60-year-old man is hit by a pickup truck and brought to the emergency department with a blood pressure of 70/0 mm Hg. Peritoneal lavage showed no blood in the abdomen. The blood pressure is elevated to 85 systolic following the administration of 2 L of Ringer's lactate. An x-ray showed a pelvic fracture. What is the next step in management?

External fixation of the pelvis Early external fixation of the pelvis has been shown to reduce bleeding and mortality in patients in shock consequent to pelvic fractures. An unstable patient should not be sent for a CT scan. Selective angiography with embolization of the bleeding vessel may also be helpful in these patients. Laparotomy usually results in uncontrollable pelvic bleeding

For the patient described in question 18, urine did not extend to the leg because the membranous layer (Scarpa's fascia) is fused inferiorly with which of the following?

Fascia lata Urine may extend in the subcutaneous layer to the anterior abdominal wall and scrotal skin. Fusion of Scarpa's fascia (part of superficial fascia) with fascia lata (deep fascia) explains why urine does not extend down the thigh

A 60-year-old man is a front-seat passenger in a car crash. He is found to have three fractured ribs on the right, rupture of the liver, pelvic fracture, right femoral fracture, and a left tibial fracture. The patient is given broad-spectrum antibiotics, and his injuries are managed by surgery, requiring 12 U of blood. The patient improves initially, but on the third postoperative day, he develops hypoxia (PaO2, 55 mm Hg), with confusion, tachypnea, and petechia. What is the most likely diagnosis?

Fat embolus Fat embolus is usually associated with long bone or pelvic fractures and is associated with petechiae. Transfusion and antibiotic reactions causing hypotension would occur relatively quickly following administration

A 60-year-old man is brought into the emergency department after being hit by a car. His blood pressure is 70 mm Hg palpable, and abdomen is massively distended and tender. A large, stellate fracture of the right lower liver is noted, and despite repeated attempts at suturing, bleeding persists. The anesthesiologist notes that the pH of arterial blood is 7.2 and that the patient has become hypothermic. A total of 8 U of blood have been transfused. What is the next step in management?

Firmly pack the RUQ, close the abdomen, and plan to return to the OR within 36-72 hours. Once a patient shows acidemia and hypothermia from significant blood loss, further operative manipulations will not likely result in control of persistent bleeding. It is best to pack the RUQ firmly and return to the OR in 36 hours. It is possible that the patient has a retrocaval hepatic vein injury, but attempting to insert an intracaval shunt in the presence of acidemia and hypothermia is not likely to be successful. Hepatic artery ligation has been used infrequently in recent years, because in most cases, hepatic bleeding is venous and, therefore, not altered by the ligation

A60-year-old man is in a car crash in which he is the driver. He did not have a seat belt or an airbag. He is found to have multiple rib fractures over his right chest. His pulse is weaker during inspiration. What are the most likely diagnoses?

Flail chest Flail chest should be suspected in multiple rib fractures where the individual rib is divided in two places. Paradoxical movement results in lung compression as the flail segment moves inward during inspiration.

A 30-year-old with a side impact injury, has multiple rib fractures on the left side with pain and hypoxia.

Flail chest Multiple rib fracture with often multiple fractures in the same segment of a rib may cause flail chest and contribute to pain and hypoxia. It is the underlying pulmonary contusion that will determine the extent of respiratory failure

A7-year-old boy falls off his bicycle, landing on the left elbow. He presents to the emergency room with massive, tense swelling of the elbow with painful and restricted elbow motion. X-rays show a displaced fracture of the distal end of the humerus. Which of the following is the most serious complication of this fracture?

Forearm compartment syndrome (Volkmann's ischemia) Ischemia contracture may result in deformity and disability of the hand, which impairs function of the entire upper extremity, not only of the elbow area.

A 15-year-old girl had an injury to the right retroperitoneum with duodenal contusion. What is the test required to exclude a rupture of the duodenum?

Gastrografin study Rupture of the duodenum would show in an extravasate Gastrografin study. Contusion of the head of the pancreas might show a widening of the duodenal C-loop. If barium enters the peritoneal cavity, it causes severe peritonitis

A 40-year-old woman was involved in a car crash. She was unconscious for 5 minutes. Xray revealed a depressed fracture in the frontal region. Which of the following statements is true of skull fracture?

In the anterior cranial fossa, it may produce rhinorrhea Skull fractures should be explored only if they are compound, if a depressed fracture is present, or if an intracranial lesion requires exploration. Compound fracture implies that the fracture site communicates with the exterior. Rhinorrhoea is caused by leakage of CSF through a fractured cribriform plate.

A 25-year-old man fell down from his bicycle and hit a concrete wall on his left side. An ultrasound examination showed free fluid in the abdomen. A CT scan confirmed a grade III splenic injury. The most important contraindication for a nonoperative management of the splenic injury is

Hemodynamic instability While all other choices may be relative, hemodynamic instability is the prime contraindication for nonoperative treatment

A 40-year-old man is hit by a car and sustains an injury to the pelvis. Which of the following is most indicative of a urethral injury?

High-riding prostate on rectal examination This indicates that the urethra has been torn and the prostate rides up with the bladder. The definitive study for suspected urethral injury is a urethrogram. Inability to void and a crushed pelvis also should raise the possibility of a urethral injury

A30-year-old restrained driver was involved in a motor-vehicle crash. He is hemodynamically stable and has a large seat belt sign on the abdomen. His abdomen is tender to palpation. In this patient one should be most concerned about:

Hollow-viscus injuries A delay in diagnosis beyond 12 hours is associated with increased morbidity and mortality. There may be very few physical signs of a viscus perforation and CT findings may be subtle and not definitive. A seat belt sign across the abdomen should raise suspicion of this injury and prompt an aggressive pursuit of diagnosis by serial examination and a consideration of a peritoneal lavage or repeat CT scan

In the patient described above the most likely cause of the bleeding in the patient is injury to which of the following?

Internal thoracic (mammary) and/or intercostals arteries Bleeding that is sufficient to require thoracotomy usually comes from vessels in the systemic circulation, particularly the internal thoracic (mammary) and intercostal arteries.

Following a bullet wound penetrating the descending colon, necrotizing fasciitis of the anterior abdominal wall occurred postoperatively. Which of the following is true for this condition?

It is treated by wide excision and broad-spectrum antibiotics In addition to necrosis of the superficial and deep fascia, thrombosis of the microcirculation of the subcutaneous tissue occurs. Mortality rates have been reduced from 80% in the past to less than 12% in recent series. Polymicrobial infection is more commonly encountered, and gram-positive and gram-negative organisms are found in 70% of cases. Treatment is based on adequate debridement and use of appropriate broad-spectrum antibiotics.

A 52-year-old secretary generally wears high heels and tight-fitting shoes. She saw her practitioner because of foot pain. His diagnosis of plantar fasciitis is characterized by which of the following?

It results in part from poor selection of footwear. Plantar fasciitis may occur either with or without a calcaneal spur. Plantar fasciitis is more likely when footwear is inappropriate or there is excessive exercise (e.g., in athletes). There is pain either after exercise (in a patient who has had a period of rest) or at the end of prolonged activity. Tenderness is over the medial aspect of the plantar fascia close to the calcaneum. X-ray may reveal a tear in the periosteum or a calcaneal spur.

An 81-year-old female falls and presents to the emergency department.What injury to this tissue or structure causes lower leg extremities to be externally rotated?

Lateral meniscus Both subcapital and intertrochanteric fractures present with external rotation of the lower extremity. The lateral rotators are attached to the bone distal to the fracture line to cause this typical clinical sign. Trochanteric fractures have a better prognosis, because the blood supply to the proximal segment remains intact.

Following a car crash in which her face hit the steering wheel, a 37-year-old woman presents to the emergency department with facial deformity. Facial x-rays showed a transverse fracture through the articulation of the maxillary and nasal bones with the frontal bone. The fracture also passed below the zygomatic bone. What is the diagnosis?

LeFort II fracture The bones injured describe a Le Fort II fracture, occasionally associated with a palatal split, where the right and left maxillary are completely separated at the midline or the hard palate.

A43-year-old man is hit in the face with a baseball bat and presents to the emergency department with massive facial swelling, ecchymosis, and an elongated face. There is mobility of the middle third of the face on digital manipulation of the maxilla. What is the likely diagnosis?

LeFort III fracture The physical findings are characteristics of a Le Fort III fracture. In this injury, the fracture passes through maxilla and nasal bones and above the zygomatic bone.

Nine days following splenectomy, a 13-yearold patient presents with fever and leukocystosis. The chest x-ray shows free air under the diaphragm. What is the most likely diagnosis?

Left colon perforation Colon perforation is likely to show free air under the left hemidiaphragm. A subphrenic abscess presents with fever, leukocytosis, and a left pleural effusion. Gastric wall necrosis may likewise result in perforation with free air. There is air below the diaphragm following laparotomy, but it usually manifests symptoms clearly within the first week after operation.

A23-year-old man with a head-on collision, bent steering wheel and knee imprint on dashboard

Posterior dislocation of the hip Head-on collision and bent steering wheel should raise suspicion for head injuries, facial fractures, and deceleration injuries. The impact of knee against the dash-board forces the head of the femur posteriorly in the acetabular socket and may cause acetabular fracture

A 65-year-old man is brought into the emergency department with a gunshot wound to the neck. His blood pressure is 80/50 mm Hg. The patient undergoes rapid resuscitation and is brought immediately to the OR, where a carotid artery injury is found in zone II (between the angle of mandible and cricoid) (Fig. 12-4). The patient has no internal carotid flow; just before surgery, his neurological status deteriorates, and he becomes unresponsive. The operative management should be which of the following?

Ligation of the internal carotid artery Even those who advocate reconstruction of carotid arteries in patients with neurological deficit do not recommend attempted reconstruction in patients who are comatose. If the patient were not comatose, proximal and distal control with stenting and interposition graft would be the procedure of choice.

A 45-year-old man was a passenger in a car when he was T-boned by a truck at a high speed. He is short in breath, complains of severe pain in the chest, and is hypoxic on the pulse oximeter. The breath sounds are diminished on the left and the percussion note is completely dull. He rapidly becomes tachycardic and hypotensive.

Massive hemothorax Lateral impact may cause fracture ribs causing pain, difficulty in breathing, and may be associated with significant hemorrhage from intercostal vessels. The physical signs described are those of a massive hemothorax

A25-year-old man experiences pain in the right knee while skiing, causing his knee to twist and him to fall to the ground. His knee is swollen. He cannot bear full weight or fully extend or bend his leg. There is tenderness over the medial joint line (Fig. 12-6). Emergencyroom x-ray findings were normal, and the range of motion (ROM), although restricted, is stable to varus and valgus stress. Straight-leg raise is unrestricted. Which is the most likely type of injury?

Medial meniscus Restriction of motion ("locking"), effusion ("swelling"), and medial joint-line tenderness are the hallmarks of meniscal tears. Stability-tostress testing eliminates collateral ligament rupture, and the ability to elevate the straight leg eliminates patella dislocation and quadriceps tendon ruptures. In addition, patella dislocation would also be characterized by gross patella deformity laterally.

Which is true of intraperitoneal colon injuries?

Most can be treated by debridement and repair. The modern treatment of civilian injuries of the colon emphasizes primary repair in the vast majority. The results are excellent in terms of suture line complications. Colocolostomy is reserved for a select few patients with the most optimal circumstances. Exteriorization after repair is no longer advised.

A20-year-old unrestrained driver was involved in a motor-vehicle crash. A computed tomography (CT) of the abdomen revealed a large hematoma in the second portion of duodenum. The rest of the abdomen is normal. The initial management of this duodenal hematoma should be:

Nasogastric decompression, intravenous fluids, and gradual resumption of oral diet Intramural duodenal hematoma may occur secondary to blunt trauma of the abdomen. Usually this hematoma is submucosal and the injury is not transmural. It may cause a temporary obstruction of the duodenum and usually responds to nasogastric suction and intravenous fluids. Only if the patient has persistent obstruction (as demonstrated by an upper GI study) beyond 2 weeks, a surgical approach may be required

One week following splenectomy, a 12-year-old girl presents with nausea, vomiting, headache, and confusion. What is the most likely diagnosis?

Postsplenectomy sepsis Postsplenectomy sepsis presents with sudden onset of nausea, vomiting, headache, confusion, and sometimes coma. Abdominal findings may be essentially normal following splenectomy. Inhibition of opsonization of leukocytes is evident with increased susceptibility to pneumococcal infection

A40-year-old construction worker is pulled from the rubble after a building collapses and pins his right lower leg. X-rays in the emergency department reveal a comminuted fracture of the right tibia and fibula. The dorsal pedis and posterior tibial pulses are palpable. The patient complains of severe pain that is accentuated with dorsiflexion of the foot. The calf feels tense. What is the appropriate step?

ORIF of fracture plus three-compartment fasciotomy A tense calf with comminuted fractures (fractures exposed to exterior) and pain on dorsiflexion necessitates a fasciotomy because of the very high probability of a compartment syndrome. Arterial injury is possible (but rare) in lower leg injuries if the pulses are palpable

A 70-year-old man is brought to the emergency department following a car crash. X-rays revealed a fractured rib on the left and a fracture of the right femur. A CT scan of the abdomen showed a left-sided retroperitoneal hematoma adjacent to the left kidney and no evidence of urine extravasation. The hematoma should be managed by which of the following?

Observation A small nonexpanding hematoma with no associated urine extravasation can be managed by observation with repeat CT scan or ultrasound. If the patient becomes hypotensive, exploration through a midline incision would be indicated

A 25-year-old woman is brought to the emergency department with multiple gunshot wounds to her abdomen. Her blood pressure is 70 mm Hg. Her abdomen is massively distended. Large intravenous lines are placed, and a nasogastric tube and Foley catheter are inserted. The patient is brought immediately to the OR. After 2 L of normal saline, her blood pressure is 75/0 mm Hg, pulse rate is 140 bpm, and respiration rate is 30 breaths per minute. The next step in management should be which of the following?

Open the abdomen and use a large Richardson retractor to compress the abdominal aorta against the vertebrae just below the diaphragm. Open the abdomen and use a large Richardson retractor to compress the abdominal aorta against the vertebrae just below the diaphragm. The advantages of occluding the subdiaphragmatic aorta (as opposed to the supradiaphragmatic aorta) are that it: (a) avoids opening another major cavity; and (b) results in less diminution of blood flow to the spinal cord and renal circulation. Further attempts to resuscitate the patient with whole blood will not be successful until bleeding sites are controlled; such measures may even increase bleeding by elevating blood pressure, which reopens vessels that have already stopped bleeding.

An 86-year-old woman experiences left hip pain after a fall at home. She cannot ambulate, her hip area is swollen and painful, and her left lower extremity is shortened and externally rotated. Before the fall, she was ambulatory and had no complaint of hip, pelvic, or knee pain. In addition to the fracture of the proximal portion of the left femur, the x-ray would show which of the following?

Osteoporosis Postmenopausal osteoporosis is the common denominator in all fractures involving elderly women. In this particular fracture, it is the twisting effect on an osteoporotic femur that causes the fracture rather than the impact of the fall itself

A 60-year-old man is attacked with a baseball bat and sustains multiple blows to the abdomen. He presents to the emergency department in shock and is brought to the operating room (OR), where a laparotomy reveals massive hemoperitoneum and a stellate fracture of the right and left lobes of the liver. Which of the following techniques should be used immediately?

Packing the liver The initial operative step is packing of the liver to obtain control of the bleeding

A 40-year-old man sustained injuries to the liver, gallbladder, small intestine, and colon from gunshot wounds. At the time of surgery, a cholecystostomy was placed in the injured gallbladder to expedite operative management. Four weeks later, the patient is doing well. Which is the next step in management?

Perform a cholangiogram through the cholecystostomy tube A cholecystocholangiogram must be performed to ensure that the gallbladder is not leaking, and that there is free flow of dye in the duodenum if no abnormality is detected on the cholangiogram, the cholecystomy tube is removed. The patient should undergo followup gallbladder studies several months later, but routine removal of the gallbladder is not necessary

A31-year-old man is shot in the back of the left chest, and the bullet exits the left anterior chest. The patient's blood pressure is 130/90 mm Hg, respiration rate is 28 breaths per minute, and pulse is 110 bpm. Achest x-ray reveals hemothorax. Achest tube is inserted and yields 800 mL of blood; the first and second hour drainage is 200 mL/h and 240 mL/h, respectively. What is the next step in management?

Perform a left thoracotomy. A patient bleeding at a rate of more than 200 mL/h should have an emergency thoracotomy. Autotranfusion of blood collected through chest tube should be considered for lesser degree of bleeding but is less reliable to succeed if bleeding does not decrease

Following an injury to the shoulder joint, a New York Yankees catcher developed a "catcher's mitt hand" or shoulder and hand syndrome. There was swelling of the right upper extremity, skin atrophy, and vasomotor instability. He also complained of a burning sensation in the involved extremity. What would be the next step in management?

Prednisone for 2 weeks in resistant cases Prednisone for 2 weeks in resistant cases is given and then tapered. The "shoulder-hand" syndrome is a reflex autonomic dystrophy occurring after an injury (usually shoulder) that causes immobilization of the ipsilateral extremity. Treatment is directed toward gradual physical therapy and nonsteroidal analgesic drugs. Stellate ganglion block may be helpful in resistant cases

A 20-year-old woman presents to the emergency department with a stab wound to the abdomen. There is minimal abdominal tenderness. Local wound exploration indicates that the knife penetrated the peritoneum. What is the ideal use of antibiotic administration?

Preoperatively Antibiotics should be given preoperatively to all patients with wounds penetrating the peritoneal cavity. Intraoperative and postoperative antibiotics fail to reduce postoperative abscesses and wound infections adequately

Which would be the appropriate management of the patient described above?

Repeat upper GI series at 5- to 7-day intervals Oral feeds and fluids are withheld, and hyperalimentation is administered. The upper GI study is repeated at 5- to 7-day intervals. Surgery can usually be avoided

A30-year-old woman involved in a car crash is brought into the emergency department. Her blood pressure is 90/60 mm Hg, pulse rate is 120 bpm, and respiration rate is 18 breaths per minute. On peritoneal lavage, she is noted to have free blood in the peritoneal cavity. At the time of exploratory laparotomy, a liver laceration is noted, and there is a 2.5-cm-diameter contusion to an area of small bowel. How should the small-bowel contusion be treated?

Resection of the bowel and ileostomy Contusion of the small bowel may be larger than apparent and may lead to necrosis and perforation. Contusions of 1 cm or less in diameter may be turned in with mattress sutures. However, larger contusions should be resected. The advantage of a single-layer anastomosis is the speed of performance and the reduced likelihood of compromising the muscularis mucosa.

A 19-year-old man is brought into the emergency department with a gunshot wound that occurred 4 hours before admission. At exploratory laparotomy, an injury is noted in the transverse colon with extensive tissue destruction. There is a large amount of fecal contamination. Management of this injury should include which of the following?

Resection with proximal colostomy and distal mucous fistula The necrotic bowel is resected, the proximal end is constructed as an end colostomy, and the distal end is constructed as a mucous fistula. This is the best procedure, because it will avoid an anastomosis in a contaminated abdomen. Any procedure that involves either wound closure or anastomosis in an abdomen with extensive fecal contamination presents a significant risk of leakage and therefore should not be performed. Exteriorization should not be performed unless ischemic bowel is resected.

A 16-year-old cross-country runner experiences right midleg pain during workouts. Sometimes the pain prevents him from completing the prescribed mileage. There is midtibial tenderness but no deformity. ROM of the ankle and knee are full and painless. There is no calf tenderness or fullness, and the Achilles tendon is intact. X-ray findings for the tibia and fibula, including both the ankle and knee joints, are normal. What should the patient be advised to do?

Rest, take anti-inflammatory agents, use crutches, and undergo a bone scan. Although rest, anti-inflammatory agents, and crutches adequately treat the symptoms, the diagnosis of a stress fracture can be made only with a bone scan if the initial x-ray findings are negative for fracture

A 50-year-old man hears a "snap" and then feels pain in his right leg while lunging for a forearm drive playing tennis. He walks off the court with difficulty, but his leg is swollen and painful. Findings on x-rays of the leg and ankle in the emergency room are negative. Foot sensation is normal, but findings on the Thompson test (failure of plantar flexion to occur after squeezing the gastrocnemius) are positive. What is the diagnosis?

Rupture of the Achilles tendon Of all the conditions listed, only an Achilles tendon rupture will result in positive findings on the "squeeze" test (Thompson's sign), whereby a squeezing of the gastrocnemius muscle fails to cause plantar flexion of the foot

A64-year-old woman is admitted to the emergency department with multiple injuries. She requires a central venous pressure line. To minimize the possibility of infection, the principal management of the catheter should be which of the following?

Selection of subclavian vein over femoral vein Where possible, a single-lumen cannula should be inserted into the vein to avoid repeated attempts. The tincture of iodine should remain in contact with the skin for 30 seconds before venipuncture. Unsterile adhesive must not be placed over the entry site.

A48-year-old woman was brought to the emergency department after sustaining a stab wound to the left side of the abdomen. Exploration of the abdomen shows 1000 mL of blood, clot, and feces. There is a bleeding laceration across the middle third of the spleen but not involving the pedicle, a 3-cm laceration of the left transverse colon, and through-and-through lacerations of the stomach and the left lobe of the liver. What should be the management of the splenic injury?

Splenectomy In a patient with significant bleeding, peritoneal contamination, and multiple injuries, splenectomy is indicated. Prompt packing of the liver injury and splenectomy are the first considerations at laparotomy.

A 23-year-old man, tall and thin, was jogging one evening when he suddently felt a sharp pain in the left chest, worse on taking a deep breath and shortness of breath.

Spontaneous pneumothorax The history is typical of spontaneous pneumothorax. Physical examination will reveal diminished breath sounds on the side of collapse and x-ray will confirm the diagnosis. A tension pneumothorax will cause hypotesios

A 40-year-old man is involved in a car crash, presenting with blood pressure of 80 mm Hg. The patient is found to have subdural hematoma and a supracondylar fracture of the left femur FAST shows fluid within the abdomen. He is taken to the OR, where intra-abdominal bleeding is controlled, and the subdural hematoma is drained. The femur fracture should be treated by which of the following?

Steinmann pin insertion and traction The priorities in patient care are to control hemorrhage in the abdomen and decompress the subdural hematoma. The optional initial surgical therapy of the supracondylar femur fracture is the insertion of a Steinmann pin for traction. If traction fails to produce adequate alignment, open reduction can be performed at a later date

A 32-year-old man underwent laparotomy for trauma because of multiorgan injuries. He was discharged after 2 weeks in the hospital only to be readmitted after 3 days because of abdominal pain and sepsis. The CT scan showed an accumulation of fluid in the subhepatic space. This space is likely to be directly involved following an injury to which of the following?

Stomach Subhepatic space infection usually occurs after surgery or peritonitis in the supracolic compartment. It is an unlikely complication of biliary pancreatitis. Infections in the subhepatic space may extend to the infracolic compartment via the paracolic gutter (of Morrison). This implies a perforation of the stomach.

A 45-year-old man skidded from the road at high speed and hit a tree. Examples of deceleration injuries in this patient include:

Stomach rupture Deceleration injuries occur when the body is subjected to a sudden stop when traveling at a high speed (e.g., high-speed automobile hitting a tree, fall from a height). As the impacting part of the body comes to a sudden halt, the organs behind continue to travel forward, thus causing shearing injuries at the junction of mobile and fixed parts; such as mesenteric avulsion.

A 14-year-old boy is hit in the right eye with a stick. There is extensive ecchymosis. On physical examination, upward gaze is found to be lost. The most likely diagnosis is injury to which of the following

Superior rectus muscle Loss of upward gaze is attributable to impairment of the superior rectus muscle and occasionally the inferior oblique muscle

A 16-year-old boy presents to the emergency department with a stab wound to the anterior midneck. On physical examination, it is difficult to determine if the plane of the platysma has been violated. However, subcutaneous emphysema is found on palpation. What is the next management step?

Surgical exploration Midneck (zone II) stab wounds should be surgically explored if subcutaneous emphysema or expanding hematoma are found. Zone II midneck lesions are those between the lower border of the mandible and hyoid cartilage. Further studies are indicated if the findings just listed are not present or the platysma has not been clearly violated

A 55-year-old right-handed woman has left elbow pain laterally after cleaning up a flooded basement by wringing out water-soaked rags. X-ray findings are negative. There is tenderness and slight swelling over the lateral epicondyle of the humerus. Anatomically, this condition can be explained by which of the following?

Tendinitis of the wrist extensors The act of wringing rags results in repeated and forceful wrist dorsiflexion, causing increased pressure on the wrist extensor muscles, which have their tendinous origins from the lateral humeral epicondyle. This results in an inflammatory condition at the bone tendon junction, lateral epicondylitis, or "tennis elbow." Although this condition is common in tennis players, it occurs more frequently in the general population

A 25-year-old woman was stabbed by her boyfriend in the left chest. On examination, she has a 1-cm stab wound just inferior to her left breast in the mid-clavicular line. There is jugular venous distension and breath sounds are completely absent on the left side. She is becoming extremely dyspneic and hypoxic.

Tension pneumothorax Precordial stab wound, distended jugular veins, and hypotension should suggest a cardiac tamponade. It must be kept in mind that the same signs are those of a tension pneumothorax. Dyspnea and deviation of trachea to the opposite side, absent breath sounds, and hyperresonant percussion note should suggest the correct diagnosis

A 26-year-old man is stabbed in the right intercostal space in the midclavicular line and presents to the emergency department. On examination, subcutaneous emphysema of the right chest wall, absent breath sounds, and a trachea shifted to the left are noted. What is the most likely serious diagnosis?

Tension pneumothorax Shift of the trachea strongly suggests a tension pneumothorax. Subcutaneous emphysema is also more common with a tension pneumothorax than with the other conditions listed. Simple pneumothorax and chest wall laceration are much less serious injuries than tension pneumothorax

A 30-year-old woman is brought to the emergency department after she stepped on a rusty nail and sustained a puncture wound to the foot. The patient has been on a therapeutic dose of steroids for the past 5 years for ulcerative colitis. Her last tetanus toxoid booster was 8 years ago. What should the patient receive?

Tetanus toxoid plus human immunoglobulin and antibiotics with aerobic and anaerobic coverage Patients who are taking steroids or who are immune suppressed should receive human immunoglobulin even though previously immunized. Tetanus booster and antibiotic therapy are also necessary.

A24-year-old woman with blunt trauma to the head sustained in a car accident presents with a history of loss of consciousness for approximately 10 minutes at the scene of the accident. She is currently fully awake, oriented, and responsive. With regard to the appropriate care of this woman, which of the following statements is true?

The initial effects of elevated intracranial pressure are bradycardia and hypertension. In general, most patients with significant head injury should be admitted for observation. Skull x-rays cannot be relied upon for the diagnosis of intracranial injury, because lesions may still be present, even with normal skull xray. Elevated intracranial pressure may be present, even with the absence of papilledema. Bradycardia and hypertension (not hypotension) are the features of elevated intracranial pressure

With regard to neck injuries, which of the following is true

The internal jugular vein may be ligated unilaterally without unfavorable sequelae. In the patient who has no neurologic deficit preoperatively, every effort should be made to repair a carotid artery injury. Four-vessel angiography should be performed in stable patients with injuries in zones I and III. Careful judgment should be exercised in selecting patients with zone II injuries who are to have angiography (i.e., suspected injuries to bilateral carotid arteries or vertebral arteries) and in selecting those for observation. Carotid artery ligation might also be employed in patients who are unstable without a high incidence of neurologic deficit

A 43-year-old male clerk cuts his right hand on a broken glass door. In evaluating the hand, what should be kept in mind?

The proximal wrist crease corresponds with the wrist joint Distal crease of the wrist corresponds with the proximal portion of the flexor retinaculum. Hypothenar muscles- ulnar side Thenar muscles-thumb side of the hand. The ulnar artery contributes predominantly to the superficial and the radial artery to the deep palmar arches in the hand

A 70-year-old man is brought into the emergency department following his injury as a passenger in a car crash. He complains of right side chest pain. Physical examination reveals a respiratory rate of 42 breaths per minute and multiple broken ribs of a segment of the chest wall that moves paradoxically with respiration. What should the next step be?

Thoracentesis Thoracentesis should be performed first to rule out a tension pneumothorax or hemothorax. However, if the patient does not respond rapidly, early endotracheal intubation is necessary for patients with a flail segment of the chest wall. Intercostal nerve blocks and other means to control pain are important but should be performed after respiratory problems have been brought under control

A 40-year-old woman is brought to the emergency department following a car crash in which she was the driver. In the emergency department, her blood pressure is 80/60 mm Hg, pulse is 128 bpm, and respiratory rate is 32 breaths per minute. She complains of right lower chest wall and severe right upper quadrant (RUQ) tenderness. Her breath sounds are questionably diminished. The immediate priority is to perform which of the following?

Thoracentesis with an 18-gauge needle In a patient with respiratory distress and shock, adequate breathing is of higher priority than circulation. Insertion of an 18-gauge needle to rule out and/or treat a pneumothorax takes precedence over diagnostic tests

An 18-year-old man presents to the emergency department with a stab wound to the abdomen. His blood pressure is 80/50 mm Hg. He is brought immediately to the OR, where an enlarged hemoperitoneum is found at laparotomy. Primary repair of the hepatic artery is performed, but because of ongoing blood loss resulting in an unstable hemodynamic situation, the portal vein injury is simply ligated. Bleeding is well controlled. The patient is brought to the recovery room, where his blood pressure drops to 80/60 mm Hg and central venous pressure is 2 cm H2O. What should be the next step in management?

Transfusion of whole blood to elevate blood pressure Obstruction to the portal outflow causes acute splenic hypervolemia simultaneously with systemic hypovolemia. If not treated by overtransfusion of blood volume (in some cases, almost equal to the patient's normal blood volume), death may occur from hypovolemia. Vasopressors should never be used to correct blood pressure in the face of hypovolemia.

A70-year-old man has had a long-term "bowlegged" condition but recently his right knee has become warm, swollen, and tender. He reports no recent trauma and gets no relief with rest or Tylenol (paracetamol). He is otherwise in good health and takes no medication. X-rays show arthritis of the knee. Which would be the best treatment?

Use of a cane for ambulating, restriction of knee-bending activities, and implementation of muscle-strengthening exercises Acute synovial reactions of weight-bearing joints with underlying arthritis are a common occurrence. It is usually related to minor traumatic events. Complete immobilization may increase joint stiffness secondary to arthritis, but partial reduction of stressful motions (avoiding kneeling and squatting) and continued muscle activity would be beneficial. These will allow the synovial reaction to subside while decreasing the weakening and stiffness caused by the underlying arthritis.

A 29-year-old woman is brought to the emergency department with a gunshot wound to the abdomen. Her blood pressure is 80/60 mm Hg, pulse rate is 118 bpm, and respiration rate is 24 breaths per minute. She is brought immediately to the OR, where a large amount of blood and clots are found within the abdomen. After initial packing of the abdomen and stabilization of the patient, a retroperitoneal hematoma is found just above the renal veins. Proximal and distal control of the inferior vena cava is obtained and the blood pressure comes up to 100/60 mm Hg. Which is the most appropriate management?

Vascular repair of the injury Although injuries in the inferior vena cava can be ligated if the repair is unduly time consuming for the patient with continued hypotension, every attempt must be made to repair a suprarenal vena cava injury. Packing of the injury should be performed only if acidemia and/or hypothermia develop, because packing of the vena cava is not likely to be effective for a very long period. If an interposition graft is necessary, vein graft should be obtained from the infrarenal cava or iliac veins. A synthetic graft is likely to thrombose. An intracaval shunt generally requires a thoracotomy to gain proximal control and is reserved for retrohepatic injuries to the vena cava

A 26-year-old man presents with a tangential small-caliber gunshot wound of the anterior abdominal wall.

Wound exploration Wound exploration that convincingly documents failure of penetration through the posterior rectus fascia will most likely exclude abdominal injury from a tangential gunshot wound. A patient with negative findings on wound exploration can be discharged and followed as an outpatient. Peritoneal lavage would also rule out an intra-abdominal injury; however, it would require a subsequent period of hospital observation. A laparotomy would provide the most definitive evidence that an intra-abdominal injury did not occur, but a negative finding on laparotomy has a definitive associated complication rate