Abdominal Trauma
D. celiotomy A gunshot wound to the anterior abdomen in which the bullet clearly transverses the abdominal cavity requires celiotomy. Although some authors are beginning to question the role of mandatory celiotomy in patients with this mechanism of injury, celiotomy remains the management of choice. The likelihood of a significant intra-abdominal injury requiring therapeutic management is significant. Diagnostic peritoneal lavage, computed tomography, ultrasonography, or local wound exploration have no role in the management of patients with these injuries, in which the incidence of intra-abdominal injuries is so high.
A 21-year-old man is hemodynamically stable after a gunshot wound to the anterior abdomen, just above the umbilicus. Physical examination reveals no evisceration or peritoneal signs. The most appropriate management would be: A. ultrasonography B. diagnostic peritoneal lavage C. diagnostic peritoneal lavage and computed tomography D. celiotomy E. local wound exploration
A. tube thoracostomy This patient has respiratory distress, absent breath sounds in the right hemithorax, and shift of the mediastinum to the contralateral (left) side. This is a surgical emergency that requires rapid diagnosis and treatment. The intrapleural pressure rises and collapses the right lung and causes absent breath sounds. The pressure continues and shifts the mobile mediastinum to the left and compromises venous return, which causes tachycardia and low systolic blood pressure. This is an emergency because the next thing that is likely to happen is a further decrease in cardiac output, shock, and cardiac arrest. The diagnosis is tension pneumothorax. The emergency treatment is insertion of a chest tube to return intrapleural pressure to normal, which allows the right lung to re-expand and the mediastinum to shift back to its normal midline position. Immediate thoracotomy is unnecessary and would take too long. Insertion of a subclavian catheter for saline infusion might be helpful for this patient's other injuries. Fluid resuscitation might increase blood volume, venous return, and cardiac output, but would be of limited or no help for this patient's life-threatening tension pneumothorax. Both intubation and ventilation or tracheostomy would establish an airway and permit the use of a ventilator. However, positive-pressure ventilation would increase the rate of air entering the right hemithorax and exacerbate the tension pneumothorax.
A 21-year-old man who was the driver in a head-on collision has a pulse of 140/min, respiratory rate of 36, and blood pressure of 75 palpable. His trachea is deviated to the left, with palpable subcutaneous emphysema and poor breath sounds in the right hemithorax. The most appropriate initial treatment would be: A. tube thoracostomy B. immediate tracheostomy C. catheter insertion in the subclavian vein for fluid resuscitation D. immediate thoracotomy E. intubation and ventilation
A. inhibition of antidiuretic hormone In a healthy adult, normal urinary output is approximately 0.5 - 1ml/kg/hr, with urine sodium level ranging from 15-250 mEq/L. In this patient, even though his urine sodium level falls within the normal range, his urinary volume is 2-3 times normal. Following acute blood loss, pressure receptors signal the release of aldosterone and anti-diuretic hormone to increase sodium reabsorption and water retention in the kidney, respectively. Increased serum osmolarity will also stimulate the release of ADH, which in turn will decrease urine output. With a decreased blood pressure of 106/60 mm Hg, it is unlikely that excessive fluid administration will cause an elevated urinary output. Increased serum alcohol level causes osmoreceptors to signal that there is low osmotic pressure in the blood, which triggers an inhibition of ADH, leading to increased urinary output.
A 22-year-old man arrives in the emergency department with a stab wound to the abdomen. His blood pressure is 106/60 mm Hg. His blood alcohol level is 218 mg/dl. His urinary output is 270 ml/hr with a urinary sodium level of 44 mEq/L. His large urinary output is best explained by A. inhibition of antidiuretic hormone B. excessive fluid administration during transport C. alcoholic-induced diuresis D. high-output renal failure E. serum hyperosmolality
C. Perform a distal gastrectomy and gastroduodenostomy. This represents an AAST Grade IV injury to the distal stomach which is usually not amenable to primary repair. To achieve the best tissue viability and post-operative organ function, a distal gastrectomy is indicated. As the duodenum and pancreas are not involved, a gastroduodenostomy is an appropriate reconstruction.
A 24-year-old man sustained a gunshot wound to the epigastrium with resultant hypotension and peritonitis in the emergency department. On exploratory laparotomy, you discover a 7-cm open injury to the greater curvature of the stomach with associated destruction of the adjacent right gastroepiploic artery. The injury is 5 cm proximal to the pylorus and involves less than 50% rupture of the organ. There is no involvement of adjacent organs. What is the most appropriate surgical treatment? A. Perform a primary repair with hemostasis followed by a seromuscular closure of the defect. B. Perform a primary repair with hemostasis followed by a closure in two layers. C. Perform a distal gastrectomy and gastroduodenostomy. D. Perform a total gastrectomy with a Roux-en-Y reconstruction.
C. Repair the anterior laceration, incise the gastrocolic ligament to expose the lesser sac, inspect the posterior surface of the stomach for injury, and ensure there is no associated pancreatic injury. Whenever there are an odd number of wounds found in a hollow viscous organ, one must search carefully for a missed wound. It is much more unlikely that a single missile or object has created a tangential injury.
A 28-year-old man has sustained a 2.5-cm stab wound to the anterior abdominal wall of the left upper quadrant. Witnesses report the weapon is a 4-inch folding knife. After completing the secondary survey, no other wounds are discovered, but the patient has peritoneal signs. On exploratory laparotomy, you find a 1.5-cm laceration to the anterior surface of the stomach near the greater curve. What should be your next step? A. Repair the laceration and close the fascia. B. Place a gastrostomy tube into the gastric laceration. C. Repair the anterior laceration, incise the gastrocolic ligament to expose the lesser sac, inspect the posterior surface of the stomach for injury, and ensure there is no associated pancreatic injury. D. Perform upper GI endoscopy to assess for additional injury to the stomach
C. Biliary pleural fistula Biliary pleural fistula is a rare and dreaded complication following traumatic diaphragmatic injury. The diagnosis is made by placement of a chest tube with evacuation of bilious content. The diagnosis can be confirmed with scintigraphy. Initial treatment includes placement of a thoracostomy tube and decompression of the biliary tree by endoscopic retrograde cholangiopancreatography with sphincterotomy, or placement of a percutaneous biliary drain.
A 28-year-old man is taken to the operating room for exploratory laparotomy after presenting with a stab wound to the right anterior abdomen. Findings include a grade II diaphragmatic laceration and a small penetrating wound to the liver. There is no active hemorrhage from the liver. The diaphragm is repaired primarily. A drain is left over the liver, and a chest tube is placed. All drains are removed, and the patient is discharged on postoperative day 4. The patient returns 2 days later with shortness of breath. Chest x-ray shows a massive effusion. A chest tube is placed and bilious-appearing fluid is evacuated. What complication has occurred? A. Empyema B. Pleural effusion C. Biliary pleural fistula D. Hemothorax E. Failed primary repair
E. Exploratory laparotomy Given the mechanism of injury, physical exam and CT findings, this patient has high probability of major pancreatic parenchymal and ductal injury that needs to be explored in the operating room. MRCP may be an option in the future to evaluate for pancreatic ductal injury in the trauma setting; however, there is currently not enough experience to date to recommend MRCP at this time. ERCP is another option; however, it may cause pancreatitis and may not add to the management of this patient's injury. Exploratory laparotomy will allow definitive treatment of the pancreatic injury, as delay in treatment drastically will increase morbidity and mortality.
A 32-year-old male is involved in a high-speed motor vehicle accident. On trauma center arrival his HR is 107 bpm, BP 107/68 mmHg, RR 22 breaths/min, SpO2 93% on room air. His primary and secondary surveys are notable for diffuse abdominal tenderness with a "seatbelt sign" across the abdomen and lumbar spine tenderness. CT scan of the abdomen and pelvis shows evidence of inflammation and fat stranding around the body and tail of the pancreas. What is the next best step in management? A. Observation, trend lipase and amylase B. ICU admission, IV antibiotics C. MRCP D. ERCP E. Exploratory laparotomy
C. Right nephrectomy, resection of damaged colon without anastomosis, and transfer to ICU This patient is acidotic and hypothermic after a penetrating abdominal wound. The appropriate approach is a damage-control laparotomy. Because there is ongoing bleeding from the injured renal artery, a nephrectomy should be performed, the devitalized bowel segment resected and stapled off to limit contamination from enteric contents, and no bowel anastomosis should be perfomed at this point. Next the patient should be transferred to the intensive care unit for further resuscitation and rewarming. He can then be brought back within 24 to 48 hours for definitive repair.
A 32-year-old man who sustains multiple gunshot wounds to the abdomen is brought by paramedics to the emergency department. His blood pressure and heart rate on arrival are 88 mm Hg and 116/min, respectively. After receiving 3 L of normal saline, there is no significant change in his hemodynamics. He is immediately taken to the operating room. During laparotomy, the right renal artery is noted to have been transected, and a devitalized segment of the transverse colon is found. The patient has received 3 units of packed red blood cells (PRBCs), his blood pH on an arterial blood gas is 7.29, and his core temperature is 36.5ºC. What should be the next step in management? A. Repair or reconstruction of the renal artery, and placement of right ureteral stent B. Resection of the devitalized segment of the transverse colon and performance of a side-to-side anastomosis C. Right nephrectomy, resection of damaged colon without anastomosis, and transfer to ICU D. Change transfusion strategy to a 1:1:1 ratio of packed red blood cells, plasma, and platelets, and definitive surgical repairs E. Increasing the temperature of the operating room to raise the patient's core body temperature
B. Transarterial embolization of the bleeding vessel. An indication for angioembolization to address ongoing hepatic bleeding is transfusion of 4 units of red blood cells (RBCs) in 6 hours or 6 units of RBCs in 24 hours. Recurrent hemodynamic instability, however, often requires laparotomy with perihepatic packing for hemostasis. Patients with contrast extravasation identified on CT scan, indicating arterial hemorrhage, should also be considered as a candidate for hepatic angiography.
A 36-year-old woman presents with a grade III blunt hepatic injury with evidence of intrahepatic contrast extravasation on CT. She is normotensive but tachycardic and admitted to the ICU for monitoring. In the ICU, she continues to be tachycardic and requires 6 units of PRBCs overnight to maintain her hematocrit above 21%. Which of the following is indicated? A. Continued monitoring in the ICU. B. Transarterial embolization of the bleeding vessel. C. Immediate laparotomy. D. ERCP for identification of a possible biliary tract injury E. Exploratory laparoscopy
D. Hemodynamic stability The hemodynamic status of the patient is the primary decision factor for whether operative intervention is indicated in the hepatic-injured patient.
A 38-year-old man is involved in a motor vehicle crash. On examination he has right upper quadrant tenderness and contusion. His blood pressure is 100/60 mm Hg and pulse is 102 beats/min. Focused assessment with sonography for trauma (FAST) shows fluid in Morrison's pouch. How would you determine if nonoperative management is appropriate for this patient? A. Absence of a "blush" on computed tomography scan B. Associated injuries C. Grade of liver injury D. Hemodynamic stability E. Mechanism of Injury
A. Control liver hemorrhage with packing; perform a splenectomy and distal gastrectomy and leave the stomach in discontinuity; perform temporary abdominal closure. Hemorrhage control should take priority over control of enteric contamination. Delaying an enteric anastomosis in this severely injured, coagulopathic, and hypothermic patient is appropriate. The patient can return to the operating room for a "second look" with removal of packing, assessment of gastric resection margins, and restoration of enteric continuity.
A 42-year-old man sustained a shotgun wound to the upper abdomen while hunting. In the emergency department, the patient is hypothermic, tachycardic, and hypotensive. At laparotomy, you discover multiple bleeding punctate wounds on the anterior surface of the liver as well as multiple lacerations to the spleen. The distal stomach is completely devascularized. The anesthesiologist notes that the patient temperature is 35.7ºC, and 8 units of packed red blood cells and 5 units of fresh frozen plasma have been transfused. What is proper sequence of intervention? A. Control liver hemorrhage with packing; perform a splenectomy and distal gastrectomy and leave the stomach in discontinuity; perform temporary abdominal closure. B. Distal gastrectomy with gastrojejunostomy; pack the liver lacerations; perform a splenectomy and definitive abdominal closure. C. Control liver hemorrhage with packing; perform splenorrhaphy and distal gastrectomy and leave in discontinuity; perform temporary abdominal closure. D. Control liver hemorrhage with packing; perform splenectomy and total gastrectomy; temporary abdominal closure. E. Control liver hemorrhage with packing; perform a splenectomy and distal gastrectomy and leave the stomach in discontinuity; perform definitive abdominal closure.
B. Reduction of the spleen into the peritoneum, splenectomy, abdominal repair of the diaphragm, and closure of the laparotomy The correct approach to an acute diaphragmatic injury is laparotomy, reduction of herniated contents, primary closure with interrupted sutures, and chest tube placement.
A 44-year-old man presents to the emergency department following a high-speed motor vehicle crash in which he was a restrained driver who sustained a direct side impact. He is hypotensive, focused assessment with sonography in trauma (FAST) is positive, and chest x-ray suggests a left-sided hemothorax. A left chest tube is placed, which drains 800 mL of blood, and is productive of 100 additional mL in the 20 minutes following placement. The patient undergoes an exploratory laparotomy, which reveals a large left diaphragmatic laceration with herniation of the spleen and part of the stomach. The spleen has a grade III complex laceration with active bleeding. Optimal operative treatment includes which of the following? A. Replacement of the spleen into the peritoneum, closure of the laparotomy, performance of a thoracotomy and repair of the diaphragmatic laceration, closure of the thoracotomy, and observation of the splenic laceration in the intensive care unit B. Reduction of the spleen into the peritoneum, splenectomy, abdominal repair of the diaphragm, and closure of the laparotomy C. Closure of the laparotomy and both splenectomy and diaphragm repair through a new-incision thoracotomy, and then closure of the thoracotomy D. Splenectomy and abdominal exploration without immediate repair of the diaphragm. Plan computed tomography of the chest and delayed thoracotomy and transthoracic repair of the diaphragm during the current hospitalization. E. Replacement of the spleen into the peritoneum, transabdominal repair of the diaphragmatic laceration, and closure of the laparotomy, followed by immediate postoperative embolization of the spleen
D. Perform exploratory laparotomy. Laparotomy remains the gold standard for penetrating abdominal trauma patients with hemodynamic instability, peritonitis, and evisceration. Additional diagnostic modalities are not required if any of the above is present. Exploratory laparoscopy is contraindicated in hemodynamically unstable patients.
A 49-year-old woman presents to the emergency department with a stab wound to the right flank. Her blood pressure and heart rate on arrival are 83/62 mm Hg and 107/min, respectively, with no significant change after administration of 2 L of Ringer's lactate. Which of the following is the most appropriate next step? A. Perform focused abdominal sonography for trauma (FAST) examination. B. Obtain computed tomography (CT) of the abdomen and pelvis. C. Perform diagnostic laparoscopy. D. Perform exploratory laparotomy. E. Perform diagnostic peritoneal lavage.
A. small intestinal injury Lap belt injuries in children are characterized by abdominal wall contusions, injury to a hollow viscus, most commonly the small intestine, and lumbar spine injuries. Typically, the children are passengers in a motor vehicle involved in a sudden deceleration crash. The intestinal injuries may be induced by several factors, including shearing of the small bowel and mesentery at fixed points in the retroperitoneum with subsequent ischemia, and immediate closed-loop burst injuries on the antimesenteric border when the bowel is subjected to a sudden increase in intraluminal pressure. Injuries to the spine in children typically occur in the lumbar spine and include facet dislocations and fractures of transverse processes in the L3-L4 region. Unlike adults, in whom lap belt injuries occur in the thoracolumbar spine, children are believed to be at greater risk for lumbar injury due to their high center of gravity compared with adults and incompletely developed iliac crest. Bladder rupture and colon perforation can be observed with blunt abdominal trauma of this nature, but these injuries are less common.
A 5-year-old child is brought to the emergency department after a motor vehicle crash in which he was wearing a lap belt in a rear seat. On arrival he is tearful but alert, restrained on a long backboard, and hemodynamically stable. Ecchymoses are noted across the lower abdominal wall. This child is at greatest risk for: A. small intestinal injury B. bladder rupture C. colon perforation D. duodenal hematoma E. thoracic vertebral injury
D. Exploratory laparoscopy This patient is found to have gross blood in his stool after a stab wound to the abdomen. Despite the history of bleeding per rectum attributed to hemorrhoids, fascial perforation and bowel injury must be ruled out, and the patient should have an exploratory laparoscopy to evaluate the entire abdomen. Colonoscopy can worsen potential bowel injury and is contraindicated in this scenario.
A 52-year-old obese man is brought to the emergency department 3 hours following a stab wound to the mid-abdomen. He is alert and oriented and there are no other injuries. Local wound exploration is not suggestive of fascial perforation. Rectal examination shows gross blood. The patient admits to noticing some blood in his stool the previous week, which he attributed to hemorrhoids. What is the most appropriate next step in management of this patient? A. Computed tomography of the abdomen and pelvis with intravenous contrast B. Diagnostic peritoneal lavage C. Focused abdominal sonography for trauma (FAST) examination D. Exploratory laparoscopy E. Colonoscopy
C. Send the patient for percutaneous drainage of the fluid collection. Bile leak/biloma is a common complication of severe blunt hepatic injury, occurring in up to 30% of cases. If a biloma becomes infected, as in this case, source control via percutaneous drainage is the most important first step in management. ICU admission and initiation of antibiotics may be necessary, but removal of the infected fluid should be the clinician's primary concern.
A 53-year-old woman presents to the emergency department 4 weeks after undergoing non-operative management for a large hepatic laceration after a motor vehicle collision. She has a marked leukocytosis, tachycardia, and a fever. CT scan demonstrates an infected biloma in the area of previous injury. What is the best initial step in management? A. Place a central venous catheter, admit to the ICU, and start IV antibiotics. B. Send the patient for transarterial embolization of the fluid collection. C. Send the patient for percutaneous drainage of the fluid collection. D. Take the patient urgently to the operating room for open drainage. E. Discharge the patient from the emergency department and have them follow up in clinic the following week.
E. Exploratory laparotomy, debridement of devitalized tissue from the wound edges, and single-layer closure with permanent sutures The key steps to repairing a diaphragmatic injury include debridement of devitalized tissues from the diaphragm, eversion of the wound edges, and single- or double-layer closure with permanent sutures.
A 61-year-old farmer is brought in after being pinned between her truck and a cattle gate. She complains of abdominal pain and shortness of breath. Her blood pressure is 100/60 mm Hg, and her heart rate is 106 beats/min. Her chest x-ray is abnormal. Which of the following best describes appropriate repair of an acute diaphragmatic injury? A. Left posterolateral thoracotomy, debridement of devitalized tissue from the wound edges, and single-layer closure with absorbable sutures B. Left posterolateral thoracotomy, debridement of devitalized tissue from the wound edges, and single-layer closure with permanent sutures C. Right posterolateral thoracotomy, debridement of devitalized tissue from the wound edges, and triple-layer closure with absorbable sutures D. Exploratory laparotomy, debridement of devitalized tissue from the wound edges, and triple-layer closure with absorbable sutures E. Exploratory laparotomy, debridement of devitalized tissue from the wound edges, and single-layer closure with permanent sutures
E. cefotetan preoperatively and for 24 hours postoperatively Hollow viscus injury from penetrating trauma requires surgical repair, most commonly by laparotomy. Prior to surgery, broad-spectrum antibiotics should be given. If there is contamination from the intra-luminal spillage, peritoneal lavage should be used after repair of the injury and control of the spillage. There is good evidence to show that a preoperative dose of antibiotics followed by 24 hours of postoperative coverage should be sufficient treatment. If a history of tetanus immunization within the last 5 years cannot be confirmed, this should also be give to the patient.
A 63-year-old man sustained a stab wound to the left upper quadrant. At celiotomy, injuries to his transverse colon and stomach are identified and repaired primarily. Appropriate antibiotic coverage should consist of A. cefotetan preoperatively and for 48 hours postoperatively B. cefotetan preoperatively and for five days postoperatively C. ampicillin, gentamicin, and metronidazole on admission and for seven days postoperatively D. ceftazidime intravenously preoperatively and for 72 hours postoperatively E. cefotetan preoperatively and for 24 hours postoperatively
D. Perihepatic packing to achieve hemostasis and transfer of the patient to ICU for further resuscitation (damage control laparotomy) In this unstable patient who is likely acidotic, coagulopathic, and hypothermic, reversal of his metabolic derangements must be achieved as soon as possible. This is best performed in the ICU and not in the OR. As long as the bleeding can be stopped with perihepatic packing, repair of injured vasculature does not have to be performed at the time of the initial operation, and may not be necessary once the patient is adequately resuscitated.
A hypotensive patient with a large hepatic laceration is taken to the operating room for emergent laparotomy. In the OR, the laceration is noted to extend down to the hepatic veins, but the exact source of bleeding cannot be identified. A Pringle maneuver does not slow bleeding, but hemostasis can be obtained with manual compression. The patient continues to be hypotensive despite infusion of blood and FFP. What is the best next step in management? A. Suture hepatorrhaphy B. Divide the liver along the line of the laceration down to the hepatic veins to identify the source of bleeding. C. Total hepatic isolation with direct repair of the injured vessels D. Perihepatic packing to achieve hemostasis and transfer of the patient to ICU for further resuscitation (damage control laparotomy) E. Partial hepatectomy of the segment(s) including the laceration
C. Splenohepatic The spleen resides in the left upper quadrant of the peritoneal cavity. It is bound laterally by the rib cage and held in place by its many ligamentous attachments including the gastrosplenic, splenocolic, splenonephric, and splenophrenic ligaments. There is no splenohepatic ligament. Most notable of the ligaments is the gastrosplenic, which contains roughly 5-7 short gastric vessels. Special attention must be paid to these vessels during splenectomy. They should be taken close to the spleen and inspected very closely for hemostasis. The other ligamentous attachments tend to be avascular and are often disrupted by hematoma in the setting of splenic trauma. Finally, excessive caudal retraction of the colon may result in a capsular tear of the spleen and difficult-to-control hemorrhage. Special care must be taken during colonic mobilization and other procedures that require colonic retraction.
All of the following represent ligamentous attachments to the spleen EXCEPT: A. Gastrosplenic B. Splenocolic C. Splenohepatic D. Splenophrenic E. Splenonephric
D. antrectomy, gastrojejunostomy, and tube duodenostomy (duodenal diverticulization) A variety of operative procedures have been proposed for traumatic injuries of the duodenum. The criteria for selection of the operation are the site and extent of the duodenal injury as well as involvement of the surrounding structures. Duodenal injury severity has been graded as shown here. 102. The injury described here suggests that the duodenal wall cannot be closed primarily. Although pancreaticoduodenectomy is indicated for patients with unreconstructed duodenal injury and major ductal disruption in the pancreatic head (grade 5), and in those with uncontrolled bleeding posterior to the duodenum, antrectomy, gastrojejunostomy, and tube duodenostomy (duodenal diverticulization) are effective approaches to grade 4 injuries. This accomplishes vent depressurization of the repaired duodenum while diverting gastrointestinal contents from the area. If the duodenal wall can be satisfactorily closed, then pyloric exclusion is the preferred option.
At operation after blunt trauma, a 50-year-old man has a 75% circumferential duodenal tear proximal to the ampulla of Vater with 2 cm of devitalization to the anterior duodenal wall. The most appropriate treatment would be: A. primary closure with vagotomy and pyloroplasty B. primary closure and tube decompression C. primary closure with tube decompression and bile duct drainage D. antrectomy, gastrojejunostomy, and tube duodenostomy (duodenal diverticulization) E. pancreaticoduodenectomy
A. a history of chronic alcoholism A number of reviews of patients with penetrating abdominal injuries have consistently revealed increased infection rates in association with colon injury; blood transfusion requirement; hypotension; multiple intra-abdominal organs injuries; administration of antibiotics beginning after the initial corrective operation; administration of antibiotics without activity against anaerobic bacteria; administration of inadequate doses of antibiotics (especially aminoglycosides); and increasing age. An acute blood alcohol level above 200 mg/L is associated with an increased wound and intra-abdominal infection rate, whereas a history of chronic alcoholism is not.
In a patient with a gunshot wound to the abdomen, all of the following are associated with an increased risk of infection EXCEPT A. a history of chronic alcoholism B. requirement for blood transfusions C. colon injury D. an elevated blood alcohol level E. hypotension between injury and operation
A. Angiographic embolization Patients who become hemodynamically unstable should be taken immediately to the operating room for abdominal exploration. Arteriography with embolization should not be pursued under these circumstances given the time needed to set up the interventional radiology suite, get personnel in place, and perform the embolization procedure.
Which of the following techniques for hemorrhage control of the hemodynamically unstable patient with hepatic injury should be avoided? A. Angiographic embolization B. Pringle maneuver C. Manual compression D. Perihepatic packing E. Ligation of hepatic vessels
C. Laparotomy, reduction of herniated abdominal contents, watertight repair with 0 polypropylene suture using an interrupted horizontal mattress suture, and placement of a chest tube Acute diaphragmatic injuries should initially be approached through laparotomy. Primary repair with interrupted sutures is usually sufficient for diaphragmatic injuries that are recognized acutely. Interrupted closure of the diaphragm is preferred. Horizontal mattress sutures are favored.
Which of the following best describes the optimal approach to repair of an acute traumatic diaphragmatic laceration? A. Thoracotomy, reduction of herniated abdominal contents, watertight repair with 2-0 polypropylene suture using an interrupted horizontal mattress suture, and placement of a chest tube B. Laparotomy, reduction of herniated abdominal contents, watertight repair with 0 silk suture using an interrupted vertical mattress suture, and placement of a chest tube C. Laparotomy, reduction of herniated abdominal contents, watertight repair with 0 polypropylene suture using an interrupted horizontal mattress suture, and placement of a chest tube D. Thoracotomy, reduction of herniated abdominal contents, watertight repair with 0 polypropylene using a continuous running suture, and placement of a chest tube
B. Abdominal compartment syndrome Abdominal compartment syndrome can lead to increased abdominal pressure and decreased organ perfusion, which can worsen the outcome. Hence, this requires immediate surgery.
Which of the following complications of an hepatic injury requires immediate return to the operating room? A. Biloma B. Abdominal compartment syndrome C. Hemorrhage D. Hepatic abscess E. Intra-abdominal abscess
E. None of the above While A-D all increase the likelihood of failure of nonoperative management and are relative indications for operative intervention, only hemodynamic instability necessitates operative management in patients with blunt hepatic injury.
Which of the following findings or characteristics necessitates operative management in a patient with blunt hepatic injury? A. Age >55 B. Arterial blush on CT C. Grade IV or V injury D. Concomitant splenic injury E. None of the above
D. All of the above Higher grade liver injuries, large hemoperitoneum, and pancreatic/enteric injuries have all been demonstrated to increase the likelihood of failing non-operative management, which is somewhere around 15% for hemodynamically stable patients.
Which of the following has been demonstrated to increase the likelihood of failing non-operative management in patients with blunt hepatic injury? A. Grade IV or V liver injury B. Large hemoperitoneum (blood extending to pelvis) on CT C. Other associated intra-abdominal injuries D. All of the above E. None of the above
B. Hemodynamic instability Any sign of compromise of the patient's hemodynamic status-post hepatic injury requires an immediate operation.
Which of the following is an indication for immediate operation for a patient with a hepatic injury? A. Development of peritonitis B. Hemodynamic instability C. Transfusion of 8 units packed red blood cells over 3 days D. Tachycardia despite adequate fluid and blood product resuscitation. This may be due to other causes. E. Abnormal liver function tests
C. Sigmoidoscopy Penetrating wounds through the gluteal region can cause injury to organs of the pelvic abdomen. Therefore, adjunctive procedures such as bladder catheterization, urethrocystography, and sigmoidoscopy may be required to adequately assess the pelvic anatomic structures and avoid missing injuries. Focust abdominal sonography for trauma (FAST) provides little utility in stable patients with gluteal penetrating wounds.
Which of the following is important to evaluate a stable 28-year-old woman with gunshot wounds to the left gluteal region? A. Transvaginal ultrasound B. Urine pregnancy test C. Sigmoidoscopy D. Focused abdominal sonography for trauma (FAST) examination E. Diagnostic peritoneal lavage (DPL)
B. Hemorrhage The correct answer is hemorrhage—most commonly occurring from either the short-gastric vessels or the splenic artery. This is manifested by clinical signs of hypovolemia and hemorrhage such as progressive tachycardia, hypotension, low urine output, and a decreasing hemoglobin. A pancreatic leak typically manifests in the subacute postoperative phase and is less common than hemorrhage. A pancreatic leak is more common in traumatic settings when there is an associated pancreatic contusion or injury. This is often managed with drainage and dietary modification. Overwhelming postsplenectomy infection (OPSI) typically manifests weeks-to-years after splenectomy. Mortality rates are highest in patients with splenectomy for non-trauma etiology. Postoperative vaccination should be provided to cover Haemophilus, Streptococcus, and Meningococcus infection. Ventral hernia from an open splenectomy is typically a late complication with higher incidence in obese, malnourished patients and smokers.
Which of the following is the most common early postsplenectomy complication? A. Pancreatic leak B. Hemorrhage C. Overwhelming postsplenectomy infection D. Ventral hernia
C. General anesthesia Nonoperative management avoids general anesthesia, effectively eliminating its side effects.
Which of the following risks can be avoided with nonoperative management of hepatic injuries? A. Hollow viscus injury B. Transfusion-related illness C. General anesthesia D. Embolization techniques E. Hypotension secondary to bleeding
B. The most significant signs and symptoms associated with diaphragmatic injury are related to concomitant injuries. Both blunt and penetrating diaphragmatic injuries carry a high degree of morbidity due to their associated injuries. The amount of blunt force required to cause rupture of the diaphragm frequently results in additional injuries. Diaphragmatic injuries have a high association with solid organ injuries, hollow viscus injuries, rib fractures, and lung injuries.
Which of the following statements best characterizes the epidemiology and clinical presentation of diaphragmatic injuries? A. Blunt diaphragmatic injuries are more common than penetrating injuries. B. The most significant signs and symptoms associated with diaphragmatic injury are related to concomitant injuries. C. Blunt diaphragmatic injury is a common occurrence after high-speed motor vehicle crashes. D. Penetrating diaphragmatic injuries occur most commonly on the right. E. Patients with isolated diaphragmatic injury after blunt trauma commonly present with respiratory insufficiency.
C. Place a left-sided chest tube. A simple pneumothorax can be aggravated to a tension pneumothorax during the positive pressure ventilation given with general anesthesia for a diagnostic laparoscopy if a chest tube is not placed prior to intubation.
You are the junior resident on call when a 23-year-old male college student is brought by his friends to the emergency department. He has a stab wound to the left thoracoabdominal region. A chest x-ray shows a small left pneumothorax—less than 10%. Your chief resident and attending are in the operating room with another patient and ask you to prepare the patient for a diagnostic laparoscopy. In addition to obtaining an informed consent and placing a Foley catheter and a nasogastric tube, what other step must you take to ensure that the procedure is performed safely? A. Order a computed tomography of the abdomen and pelvis with oral and intravenous contrast to identify any potential intra-abdominal organ injury. B. Place a central venous line using the left internal jugular vein. C. Place a left-sided chest tube. D. Place an arterial line to monitor the patient's hemodynamics during the surgery. E. Perform a bronchoscopy to quickly evaluate the tracheobronchial tree.