Examkin

Surgery

1344 questions

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Question 41Question →

A 68-year-old woman with a history of permanent atrial fibrillation and hypertension presents to the emergency department with a 3-hour history of sudden-onset, severe right leg pain. She admits to running out of her oral anticoagulant medication a week ago. On physical examination, the right foot and distal calf are pale and cool to the touch. Sensation to light touch is intact, and she can move all her toes without difficulty. Capillary refill is delayed. Palpation reveals a normal femoral pulse, but popliteal and pedal pulses are absent.

Arrange the following steps in the most appropriate sequential order for the evidence-based management of this patient's condition.

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Answer

The correct sequence is: (1) Doppler ultrasonography, (2) Intravenous heparin, (3) Computed tomography angiography, (4) Definitive revascularization.
Acute limb ischemia requires rapid evaluation and intervention. The patient presents with a viable limb (Rutherford Category I) as she has intact sensory and motor function. The immediate first step after physical examination is to objectively assess blood flow using bedside continuous-wave Doppler. Once ischemia is confirmed, systemic anticoagulation with intravenous unfractionated heparin is initiated immediately to halt thrombus propagation. Because the limb is not immediately threatened (no neurological deficit), it is safe and appropriate to obtain a CTA to map the vascular anatomy. Finally, definitive revascularization is performed based on the detailed imaging findings.

Step-by-Step Solution

1
Identify the degree of limb ischemia
The patient has a viable limb (Rutherford Category I) based on intact sensation and motor function.
Determining the category of ischemia dictates the urgency of intervention and whether time permits imaging.
2
Confirm absent flow and establish a baseline
Bedside continuous-wave Doppler ultrasonography is selected as the initial objective diagnostic test.
Clinical palpation is subjective; Doppler provides immediate objective evidence of arterial and venous flow.
3
Halt the progression of the pathology
Intravenous unfractionated heparin is administered immediately.
Systemic anticoagulation prevents the clot from propagating into the microcirculation while awaiting further imaging or surgery.
4
Plan the definitive intervention
Computed tomography angiography (CTA) is performed.
Because the limb is viable and not immediately threatened, CTA is safely obtained to map the vascular anatomy and plan the best revascularization approach.
5
Perform definitive treatment
Catheter-directed thrombolysis or surgical embolectomy is executed.
Removal or lysis of the thrombus is required to restore perfusion and salvage the limb.

Key Concept

Sequential management of acute limb ischemia based on Rutherford classification

Alternative Method

In centers without rapid access to CTA, conventional digital subtraction angiography (DSA) in the operating room can be performed simultaneously with the revascularization intervention.
Estimated Time:1m 30s
Question 42Question →

A 72-year-old man is brought to the emergency department after experiencing a sudden onset of severe, tearing pain in his lower back and left flank. His wife states that he briefly lost consciousness at home. His medical history includes hypertension, hyperlipidemia, type 2 diabetes mellitus, and a 45-pack-year smoking history. He does not take any anticoagulant medications. On arrival, he is lethargic, pale, and diaphoretic. Vital signs are temperature 36.8°C (98.2°F), blood pressure 75/40 mmHg, heart rate 128/min, and respiratory rate 24/min. Physical examination reveals cold extremities with weak distal pulses. Abdominal examination demonstrates a tender, pulsatile mass in the periumbilical region. A bedside ultrasound confirms the presence of an infrarenal abdominal aortic dilation measuring 7.2 cm with an adjacent retroperitoneal hypoechoic fluid collection. Which of the following is the most appropriate next step in management?

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Answer: Immediate transfer to the operating room for surgical repair

Answer

The most appropriate next step is immediate transfer to the operating room for surgical repair.
This patient presents with the classic triad of a ruptured abdominal aortic aneurysm (AAA): severe back/flank pain, hypotension indicating hemorrhagic shock, and a pulsatile abdominal mass. The diagnosis is confirmed by bedside ultrasound showing a large aneurysm with retroperitoneal fluid. In a hemodynamically unstable patient with a known ruptured AAA, the absolute priority is immediate hemorrhage control. The correct action is emergent transfer to the operating room for either open surgical repair or endovascular aneurysm repair (EVAR), depending on the patient's anatomy and the facility's capabilities. Delaying surgery for any reason significantly increases mortality.

Step-by-Step Solution

1
Analyze the patient's clinical presentation and vital signs.
The patient is an elderly male smoker presenting with sudden severe back/flank pain, syncope, and profound hypotension (BP 75/40 mmHg) with tachycardia (128/min).
Identifying the classic triad of a ruptured abdominal aortic aneurysm (AAA): severe pain, hypotension/shock, and a pulsatile abdominal mass.
2
Interpret the bedside imaging findings.
Bedside ultrasound shows a 7.2 cm AAA with an adjacent hypoechoic collection.
The fluid collection adjacent to a large aneurysm in a hypotensive patient confirms retroperitoneal hemorrhage from a ruptured AAA.
3
Determine the management pathway based on hemodynamic stability.
Because the patient is hemodynamically unstable, diagnostic testing that requires moving the patient (like a CT scan) is contraindicated.
Unstable patients with a known ruptured AAA require emergent source control of the hemorrhage.
4
Select the definitive treatment.
Immediate transfer to the operating room for emergent open surgical or endovascular repair.
Definitive hemorrhage control is the only way to prevent fatal exsanguination.

Key Concept

Hemodynamically unstable patients with a ruptured abdominal aortic aneurysm (confirmed by bedside ultrasound) require immediate transfer to the operating room for emergent surgical repair, bypassing further imaging such as CT angiography.
Question 43Question →

A 64-year-old man is transported to the emergency department by ambulance following a sudden collapse at his residence. His spouse notes that prior to collapsing, he described an explosive pain in the back of his head, followed by severe vertigo, intractable emesis, and an inability to stand. His past medical history is significant for long-standing hypertension and medication nonadherence. On presentation, his blood pressure is 210/115 mm Hg, heart rate is 88/min, and respiratory rate is 16/min. He is immediately started on a continuous intravenous nicardipine infusion. Neurologic examination reveals a lethargic patient who arouses only to loud voice. He exhibits prominent left-sided finger-to-nose ataxia and horizontal nystagmus. A noncontrast CT scan of the head demonstrates a 4.2-cm hyperdense collection in the left cerebellar hemisphere with complete effacement of the fourth ventricle and marked enlargement of the lateral and third ventricles. Which of the following is the most appropriate definitive management for this patient?

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Answer: Suboccipital craniectomy and hematoma evacuation

Answer

Suboccipital craniectomy and hematoma evacuation
The correct answer is suboccipital craniectomy and hematoma evacuation. This patient has a large (4.2 cm) hypertensive cerebellar hemorrhage causing obstructive hydrocephalus and altered mental status. Because the posterior fossa is a small, rigid, and tightly confined space, expanding hematomas can rapidly cause fatal brainstem compression and tonsillar herniation. Neurosurgical guidelines dictate that cerebellar hemorrhages > 3 cm in diameter, or those associated with obstructive hydrocephalus, brainstem compression, or clinical deterioration, require urgent surgical evacuation rather than conservative medical management.

Step-by-Step Solution

1
Identify the primary pathology from the clinical and radiographic findings.
The patient has a hypertensive spontaneous cerebellar intracerebral hemorrhage, indicated by ataxia, vertigo, and a 4.2-cm hyperdense mass on the noncontrast CT scan.
Accurate diagnosis of the hemorrhage location and size is necessary to determine the surgical threshold.
2
Assess for secondary complications of the hemorrhage.
The hematoma is causing severe mass effect, evidenced by fourth ventricle effacement, obstructive hydrocephalus, and a depressed level of consciousness.
The presence of mass effect and hydrocephalus changes the management from medical to surgical.
3
Apply the neurosurgical intervention criteria for cerebellar hemorrhage.
Because the hematoma is > 3 cm and is causing brainstem compression and hydrocephalus, urgent surgical decompression is mandated.
The posterior fossa is a confined space; expanding lesions rapidly cause fatal brainstem compression if not evacuated.

Key Concept

Urgent surgical decompression (craniectomy and hematoma evacuation) is indicated for cerebellar hemorrhages greater than 3 cm in diameter, or those causing brainstem compression, hydrocephalus, or neurological deterioration.
Question 44Question →

A 45-year-old man is brought to the emergency department after a heavy concrete pipe rolled over his lower torso at a construction site. On arrival, his airway is patent, and breath sounds are equal bilaterally. His blood pressure is 78/45 mmHg and his pulse is 132/min. There is no visible external hemorrhage. Physical examination reveals ecchymosis over the perineum and severe instability of the pelvic ring upon gentle lateral compression. A focused assessment with sonography for trauma (FAST) examination reveals no intraperitoneal free fluid. Which of the following is the most appropriate next step in management?

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Answer: Application of a circumferential pelvic binder

Answer

Application of a circumferential pelvic binder
The correct answer is the application of a circumferential pelvic binder. This patient presents with class III/IV hemorrhagic shock (hypotension, marked tachycardia) and signs of an unstable pelvic ring fracture following a crush injury. In the setting of blunt trauma, a negative focused assessment with sonography for trauma (FAST) examination indicates that there is no significant intraperitoneal free fluid. Therefore, the source of bleeding is most likely retroperitoneal, arising directly from the fractured cancellous bone and the disrupted presacral venous plexus. The immediate priority in managing a hemodynamically unstable patient with a pelvic fracture is mechanical stabilization. A circumferential pelvic binder (or a firmly wrapped sheet centered over the greater trochanters) reduces the internal volume of the pelvis. This volume reduction promotes the tamponade of venous bleeding and prevents the disruption of early hemostatic clots by limiting bone motion, effectively addressing the 'Circulation' component of the Advanced Trauma Life Support (ATLS) protocol.

Step-by-Step Solution

1
Assess the patient's hemodynamic status.
Blood pressure is 78/45 mmHg and pulse is 132/min, indicating class III/IV hemorrhagic shock.
Identifying shock prioritizes the 'Circulation' step in the primary trauma survey.
2
Identify the source of the hemorrhage.
Pelvic instability is present, and the FAST exam is negative.
A negative FAST makes intra-abdominal hemorrhage unlikely, localizing the life-threatening bleed to the retroperitoneal space due to the pelvic ring disruption.
3
Determine the appropriate initial intervention.
Application of a circumferential pelvic binder.
A pelvic binder quickly reduces the internal volume of the pelvis, which decreases venous bleeding from the presacral plexus and helps stabilize forming hemostatic clots.

Key Concept

Mechanical stabilization with a pelvic binder is the initial management step for hemodynamically unstable patients with unstable pelvic ring fractures.
Question 45Question →

A 65-year-old man is evaluated on postoperative day 4 following a robotic-assisted laparoscopic radical prostatectomy for localized prostate adenocarcinoma. A urethral catheter was left in place at the end of the procedure. On postoperative day 2, he developed a fever of 38.8°C (101.8°F), chills, and suprapubic discomfort. Blood and urine cultures were obtained, and empiric intravenous piperacillin-tazobactam was initiated. Today, the patient is afebrile, and his vital signs are within normal limits. He reports complete resolution of his chills and suprapubic pain. The abdomen is soft and non-tender, and the urethral catheter is draining clear yellow urine. The blood cultures show no growth. The urine culture from postoperative day 2 returns with the following results:

Organism>100,000 CFU/mL *Escherichia coli*
AntibioticSusceptibility
AmpicillinResistant
Piperacillin-tazobactamSusceptible
CefazolinSusceptible
CeftriaxoneSusceptible
Trimethoprim-sulfamethoxazoleSusceptible
CiprofloxacinResistant

Which of the following is the most appropriate next step in management?

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Answer: Transition to a targeted antibiotic and leave the urethral catheter in place

Answer

Transition to a targeted antibiotic and leave the urethral catheter in place
The most appropriate next step is to transition the patient to a targeted antibiotic (such as cefazolin or ceftriaxone) and leave the urethral catheter in place. This patient developed a catheter-associated urinary tract infection (CAUTI) following a radical prostatectomy. While the general principle for managing a CAUTI involves removing or exchanging the infected catheter, doing so is strictly contraindicated in the early postoperative period (typically the first 1-2 weeks) following a radical prostatectomy. The catheter serves as a critical stent to allow the delicate vesicourethral anastomosis to heal. Premature removal can lead to acute urinary retention, anastomotic disruption, and urinary extravasation. If the patient goes into retention, blind placement of a new catheter carries a high risk of anastomotic perforation. Because the patient is clinically improving on empiric therapy, the next step is to adhere to antimicrobial stewardship principles and narrow the antibiotic coverage based on the culture susceptibilities.

Step-by-Step Solution

1
Interpret the clinical presentation and culture results.
The patient has a resolving CAUTI (fever, chills, E. coli >100,000 CFU/mL) on postoperative day 4 after a radical prostatectomy.
Establishing the current clinical status is essential to determine if the empiric treatment is working.
2
Evaluate the need for antibiotic modification.
The patient should be transitioned from broad-spectrum piperacillin-tazobactam to a narrower-spectrum agent (e.g., cefazolin or ceftriaxone).
Antimicrobial stewardship dictates de-escalation to targeted therapy once susceptibilities are known to prevent resistance.
3
Determine the appropriate management of the urinary catheter.
The catheter must be left in place despite being the likely source of the infection.
Following radical prostatectomy, the catheter stents the vesicourethral anastomosis. Early removal risks anastomotic disruption and severe complications.

Key Concept

Following radical prostatectomy, the urethral catheter must remain in place for 1-2 weeks to protect the vesicourethral anastomosis, even in the setting of a catheter-associated urinary tract infection (CAUTI). Appropriate management involves targeted antimicrobial therapy without early catheter removal.
Question 46Question →

Match each brain herniation syndrome with its most characteristic clinical presentation or pathophysiologic consequence as seen in acute neurotrauma or expanding intracranial mass lesions.

Click a left item, then click its matching right item

Items

Uncal herniation
Subfalcine (cingulate) herniation
Tonsillar herniation
Central transtentorial herniation

Matches

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Answer

Uncal matches with ipsilateral fixed/dilated pupil; Subfalcine matches with ACA compression (leg weakness); Tonsillar matches with medullary compression (respiratory arrest); Central matches with rostrocaudal brainstem impairment.
Each specific herniation syndrome displaces brain tissue into distinct intracranial compartments, compressing predictable adjacent neural and vascular structures. Mapping the exact focal neurologic deficit or vascular territory affected accurately identifies the type of herniation.

Step-by-Step Solution

1
Analyze the anatomic pathway of an uncal herniation.
The uncus of the temporal lobe shifts medially and inferiorly over the tentorial edge, compressing the ipsilateral CN III (causing a blown pupil) and the ipsilateral cerebral peduncle (causing contralateral hemiparesis).
Understanding regional anatomy dictates the focal neurologic deficits seen in medial temporal lobe shifts.
2
Identify the primary vascular risk in subfalcine herniation.
The cingulate gyrus is forced under the rigid falx cerebri, often compressing the adjacent anterior cerebral arteries (ACA), which supply the motor cortex for the contralateral leg.
Subfalcine shifts are often clinically silent early on, but ACA territory infarction is the classic major complication.
3
Determine the consequence of tonsillar herniation.
The cerebellar tonsils are pushed downward through the foramen magnum, immediately compressing the medulla oblongata, leading to sudden respiratory and cardiovascular collapse.
The medulla controls vital autonomic functions.
4
Characterize central transtentorial herniation.
Diffuse downward pressure forces the diencephalon through the tentorial notch, resulting in a predictable rostrocaudal deterioration (thalamus to midbrain to pons to medulla).
This contrasts with the asymmetric presentation of uncal herniation, presenting instead with symmetric posturing and pupil changes.

Key Concept

Anatomic localization and clinical consequences of specific brain herniation syndromes.
Question 47Question →

Match each acute cardiothoracic or vascular surgical presentation with the most appropriate immediate next step in management.

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Items

Following a syncopal episode, an elderly male patient is brought in with profound hypotension. Physical examination reveals left-sided flank ecchymosis and a palpable, expansile mid-abdominal mass.
While resting at home, a middle-aged female patient experiences the abrupt onset of excruciating pain radiating between her scapulae. Vital signs are stable, but her left radial pulse is markedly diminished compared to the right.
During the first 24 hours after a multi-vessel coronary revascularization procedure, a patient experiences a sudden drop in blood pressure. The nursing staff notes distended neck veins, distant heart sounds, and a sudden lack of sanguineous drainage in the mediastinal tubes.
Shortly after extubation for a procedure removing atherosclerotic plaque from the cervical internal carotid artery, a patient demonstrates severe inspiratory stridor, progressive dyspnea, and a rapidly expanding subplatysmal swelling.

Matches

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Answer

The correct matches are: the unstable ruptured abdominal aortic aneurysm pairs with immediate surgical exploration; the stable aortic dissection pairs with computed tomography angiography; the post-cardiac surgery tamponade pairs with urgent bedside echocardiography; and the expanding post-carotid endarterectomy neck hematoma pairs with immediate bedside opening of the surgical wound.
Each of these presentations represents a distinct cardiothoracic or vascular surgical emergency with a highly specific algorithmic approach. The primary decision branch points involve recognizing imminent threats to life, such as hemodynamic instability or airway compromise, which dictate bypassing standard diagnostic imaging in favor of immediate therapeutic intervention.

Step-by-Step Solution

1
Identify the underlying cardiothoracic or vascular pathology based on the clinical signs provided in each vignette.
The presentations correspond to a ruptured abdominal aortic aneurysm, an acute aortic dissection, cardiac tamponade, and an expanding postoperative neck hematoma, respectively.
Accurate diagnosis is a prerequisite for selecting the correct emergency management algorithm.
2
Determine the most appropriate initial management step for each identified pathology, factoring in the patient's hemodynamic stability and airway status.
Unstable ruptured aneurysms require the operating room immediately; stable dissections require diagnostic imaging (CTA); tamponade requires bedside echocardiography confirmation; and airway compromise from a neck hematoma requires emergent bedside wound opening.
Standard surgical algorithms prioritize immediate life-saving interventions over diagnostics in unstable patients or those with imminent airway loss, while utilizing rapid imaging in stable scenarios.

Key Concept

Emergent management of cardiothoracic and vascular complications prioritizes immediate life-saving interventions (surgical exploration, bedside wound opening) for hemodynamically unstable patients or those with airway compromise, while relying on targeted imaging for stable patients.
Estimated Time:2m 0s
Question 48Question →

A 3232-year-old woman, gravida 22, para 11, at 1818 weeks gestation presents to the clinic after noticing a new mass in her right breast 22 weeks ago. She reports no breast pain, skin changes, or nipple discharge. She has no personal or family history of breast cancer. Vital signs are within normal limits. Physical examination reveals a 33-cm, firm, non-tender, and relatively fixed mass in the upper outer quadrant of the right breast. There is no overlying erythema, warmth, or peau d'orange. Palpation of the right axilla reveals a firm, mobile 1.51.5-cm lymph node. The left breast and axilla are normal. Which of the following is the most appropriate next step in the evaluation of this patient's breast mass?

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Answer: Targeted ultrasound of the right breast and axilla

Answer

The most appropriate next step is a targeted ultrasound of the right breast and axilla.
The correct answer is a targeted ultrasound of the right breast and axilla. Breast cancer during pregnancy is rare but can occur, and any dominant, firm, or fixed mass requires prompt evaluation. The physiologic hypertrophy and increased glandular density of the breast during pregnancy and lactation significantly reduce the sensitivity and predictive value of mammography. Therefore, ultrasound is the preferred initial imaging modality. It is highly sensitive, avoids ionizing radiation exposure to the fetus, and can effectively distinguish between simple cysts (e.g., galactoceles) and complex or solid masses. If the ultrasound is suspicious for malignancy, a core needle biopsy is the subsequent definitive step.

Step-by-Step Solution

1
Identify the primary clinical problem from the vignette.
The patient has a new, 33-cm, firm, fixed breast mass with ipsilateral axillary lymphadenopathy at 1818 weeks gestation.
Establishing the severity and characteristics of the clinical finding dictates the urgency of the workup.
2
Determine the appropriate diagnostic algorithm for a breast mass in pregnancy.
Initial evaluation requires an imaging modality that is safe for the fetus and highly sensitive in the setting of dense breast tissue.
Pregnancy induces physiologic breast hypertrophy, altering the diagnostic utility of standard imaging like mammography.
3
Select the optimal initial imaging modality.
Targeted ultrasound of the breast and axilla is selected as the first step.
Ultrasound provides excellent characterization of solid versus cystic masses in dense breasts without exposing the fetus to ionizing radiation.

Key Concept

The initial imaging modality of choice for a palpable breast mass during pregnancy or lactation is a targeted ultrasound.
Question 49Question →

Match each clinical presentation to the most likely pediatric orthopedic diagnosis.

Click a left item, then click its matching right item

Items

A 13-year-old boy with a body mass index of 32 presents with an atraumatic limp and left knee pain. Examination shows the left hip is obligately externally rotated when actively flexed.
A 6-year-old boy presents with an insidious onset of a painless limp. Examination shows limited abduction and internal rotation of the hip. Radiographs reveal sclerosis and flattening of the proximal femoral epiphysis.
A 14-year-old basketball player presents with anterior knee pain worsened by jumping. Examination reveals localized tenderness and a bony prominence directly over the tibial tuberosity.
A 2-year-old girl refuses to use her right arm after being swung by her hands. The right upper extremity is held closely to her body in a pronated and extended position.
A 5-year-old boy presents with an acute onset limp and hip pain following a recent viral upper respiratory infection. He is afebrile, and his serum inflammatory markers are within normal limits.

Matches

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Answer

The correct pairings accurately match the clinical vignette of common pediatric musculoskeletal conditions to their respective diagnoses based on age, demographics, and key physical exam findings.
Each vignette represents the archetypal presentation of a pediatric orthopedic pathology. Recognition of defining features—such as obesity and referred knee pain in SCFE, or avascular necrosis changes in Legg-Calvé-Perthes—is required to form the correct matches.

Step-by-Step Solution

1
Analyze the presentation of the 13-year-old obese boy with knee pain and external hip rotation.
Matches with Slipped capital femoral epiphysis (SCFE).
SCFE predominantly affects overweight adolescents and frequently presents with referred knee pain and a pathognomonic loss of internal hip rotation.
2
Analyze the presentation of the 6-year-old boy with a painless limp and radiographic femoral head flattening.
Matches with Legg-Calvé-Perthes disease.
The age of onset (4 to 10 years), insidious progression, and avascular necrosis changes on x-ray are classic hallmarks of Legg-Calvé-Perthes disease.
3
Analyze the presentation of the 14-year-old athlete with tibial tubercle tenderness.
Matches with Osgood-Schlatter disease.
Mechanical overuse at the patellar tendon insertion site in growing athletes leads to Osgood-Schlatter disease.
4
Analyze the presentation of the 2-year-old girl with an immobile, pronated arm after being swung.
Matches with Radial head subluxation.
The mechanism of injury (axial traction) and the characteristic posture of the arm clearly indicate a nursemaid's elbow.
5
Analyze the presentation of the 5-year-old boy with acute hip pain following a viral illness and normal lab results.
Matches with Transient synovitis of the hip.
A benign, self-limiting inflammation of the hip joint following a recent viral infection without signs of septic arthritis points to transient synovitis.

Key Concept

Accurate diagnosis of pediatric orthopedic conditions relies heavily on the patient's age, mechanism of injury, associated demographics (e.g., obesity), and characteristic physical examination findings.
Estimated Time:1m 30s
Question 50Question →

A 28-year-old male is brought to the emergency department after a severe crush injury to his pelvis at a construction site. He is hemodynamically stable. Physical examination reveals a pelvic binder in place, blood at the urethral meatus, and a high-riding prostate on digital rectal examination. A FAST exam is negative. He has a palpable, distended bladder and reports a strong urge to urinate. Arrange the following diagnostic and therapeutic steps in the most appropriate chronological order for the urologic management of this patient.

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Answer

The correct sequence is to first perform retrograde urethrography, followed by placement of a suprapubic catheter, then computed tomography cystography, and finally, delayed surgical urethroplasty.
The management of posterior urethral injuries follows a strict protocol to prevent exacerbation of the injury and associated long-term complications. The presentation of blood at the meatus, a high-riding prostate, and a pelvic fracture suggests a posterior urethral disruption. The immediate first step is retrograde urethrography (RUG) to visualize the urethra and confirm the diagnosis. Once confirmed, urethral catheterization is strictly contraindicated, making the placement of a suprapubic catheter the next necessary step to drain the distended bladder safely. After securing bladder drainage, the bladder itself must be evaluated for rupture using CT cystography (or a conventional cystogram), as bladder injuries frequently co-occur with pelvic ring fractures. Finally, definitive surgical repair (open urethroplasty) is delayed for 3 to 6 months. This delay allows the pelvic hematoma to organize and inflammation to subside, which significantly decreases the risk of postoperative erectile dysfunction and urinary incontinence.

Step-by-Step Solution

1
Identify the suspected injury from clinical signs
The triad of blood at the urethral meatus, a high-riding prostate, and a pelvic fracture strongly indicates a posterior urethral injury.
Recognizing these classic signs is crucial to strictly avoid blind urethral catheterization, which can convert a partial tear into a complete transection.
2
Determine the first diagnostic intervention
Retrograde urethrography (RUG) must be performed immediately.
RUG is the gold standard for diagnosing and localizing urethral injuries prior to any further manipulation.
3
Determine the appropriate method of urinary diversion
Placement of a suprapubic catheter is required.
Once a significant urethral disruption is confirmed and a Foley catheter cannot be safely passed, a suprapubic tube provides the necessary bladder drainage for the patient.
4
Evaluate for concomitant injuries
Computed tomography (CT) cystography is performed through the newly placed suprapubic tube.
Pelvic fractures have a high association with bladder rupture. Securing a suprapubic tube allows for the retrograde instillation of contrast to safely evaluate the bladder.
5
Plan definitive management
Delayed surgical urethroplasty is scheduled.
Definitive repair is deferred for 3 to 6 months to allow the pelvic hematoma to organize, minimizing the severe risks of impotence and incontinence.

Key Concept

Sequential management of suspected posterior urethral injury in the setting of acute pelvic trauma.
Estimated Time:1m 30s
Question 51Question →

An emergency medical services team brings a 6868-year-old male to the trauma bay following an episode of syncope at home. His wife reports that he complained of sudden, excruciating pain in his left flank and lower abdomen just before collapsing. His past medical history is significant for chronic obstructive pulmonary disease, hypertension, and a 4545-pack-year smoking habit. On arrival, he is lethargic, pale, and diaphoretic. Vital signs include a temperature of 36.8∘C36.8^\circ\text{C} (98.2∘F98.2^\circ\text{F}), blood pressure of 72/45 mm Hg72/45\text{ mm Hg}, heart rate of 128/min128/\text{min}, and respiratory rate of 26/min26/\text{min}. Palpation of the abdomen reveals significant distention and a tender, pulsatile mass just above the umbilicus. A point-of-care ultrasound performed immediately demonstrates a 6.8 cm6.8\text{ cm} infrarenal aortic dilation with surrounding retroperitoneal free fluid. Which of the following is the most appropriate next step in management?

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Answer: Emergent transfer to the operating room for vascular repair

Answer

The most appropriate next step is emergent transfer to the operating room for vascular repair.
This patient presents with the classic triad of a ruptured abdominal aortic aneurysm (AAA): severe flank or abdominal pain, hypotension, and a pulsatile abdominal mass. His presentation of hypovolemic shock (blood pressure 72/45 mm Hg72/45\text{ mm Hg}, tachycardia, lethargy) combined with bedside ultrasound confirmation of a 6.8 cm6.8\text{ cm} AAA with retroperitoneal fluid demands immediate life-saving intervention. Hemodynamically unstable patients with a ruptured AAA must be transferred emergently to the operating room for either open surgical repair or endovascular aneurysm repair (EVAR). Any delay, including obtaining advanced imaging, significantly increases mortality.

Step-by-Step Solution

1
Analyze the patient's vital signs and physical presentation.
The patient is in severe hypovolemic shock (72/45 mm Hg72/45\text{ mm Hg}, 128/min128/\text{min}, lethargy, diaphoresis).
To determine hemodynamic stability, which dictates the urgency and safety of diagnostic modalities.
2
Synthesize the clinical triad and ultrasound findings.
Sudden flank pain, hypotension, and a pulsatile mass confirmed by ultrasound as a 6.8 cm6.8\text{ cm} AAA with free fluid indicates a ruptured AAA.
To establish the primary diagnosis responsible for the patient's shock.
3
Select the appropriate management based on stability and diagnosis.
Immediate transfer to the operating room for surgical or endovascular repair.
A ruptured AAA in an unstable patient is a surgical emergency requiring immediate hemorrhage control; delaying for CT imaging is contraindicated.

Key Concept

Management of a ruptured abdominal aortic aneurysm in a hemodynamically unstable patient
Question 52Question →

Match each clinical trauma presentation with the most appropriate immediate diagnostic or therapeutic intervention.

Click a left item, then click its matching right item

Items

A 22-year-old man presents with a stab wound to zone II of the neck, accompanied by an expanding hematoma, stridor, and altered mental status.
A 41-year-old woman is hypotensive and tachycardic following a motorcycle collision. She has distended neck veins, tracheal deviation to the left, and absent breath sounds on the right.
A 55-year-old man has a blood pressure of 78/40 mm Hg despite receiving 2 liters of isotonic crystalloid after a high fall. FAST examination demonstrates free fluid in the hepatorenal recess.
A 30-year-old woman is hemodynamically stable after a high-speed frontal motor vehicle crash. An anteroposterior chest radiograph reveals a widened mediastinum and an obscured aortic knob.

Matches

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Answer

Penetrating neck trauma with hard signs requires immediate surgical exploration. Tension pneumothorax requires needle decompression. Unstable abdominal trauma with a positive FAST requires an exploratory laparotomy. A stable patient with suspected blunt aortic injury requires CT angiography.
Each matching pair aligns precisely with established ATLS protocols. Patients with signs of impending airway collapse or exsanguinating hemorrhage (e.g., hard signs of neck trauma, unresuscitatable shock with a positive FAST, or tension pneumothorax) require immediate manual or operative intervention. Conversely, stable patients with concerning mechanisms or plain film findings (e.g., widened mediastinum) require high-resolution imaging such as CT angiography to define the precise nature and extent of the injury prior to management.

Step-by-Step Solution

1
Evaluate the hemodynamic status and primary survey findings of each patient.
Identify patients who are hemodynamically unstable or have hard signs of immediate life-threatening injuries versus those who are stable.
Hemodynamic stability is the primary decision point in Advanced Trauma Life Support (ATLS) algorithms, dictating whether a patient goes to the operating room or the CT scanner.
2
Match clinical findings to classic trauma diagnoses and their algorithmic pathways.
Recognize expanding hematoma/stridor as hard signs of neck injury, hypotension/JVD/absent breath sounds as a tension pneumothorax, hypotension/positive FAST as intra-abdominal hemorrhage, and widened mediastinum in a stable patient as requiring aortic evaluation.
Classic clinical presentations allow for immediate life-saving procedures (surgical exploration, thoracostomy, laparotomy) or appropriate advanced imaging (CT angiography).

Key Concept

Advanced Trauma Life Support (ATLS) algorithms dictate that hemodynamically unstable patients or those with 'hard signs' of vascular/airway injury require immediate therapeutic intervention or surgery, whereas stable patients should undergo advanced diagnostic imaging.
Estimated Time:2m 0s
Question 53Question →

A 45-year-old woman is brought to the emergency department after being thrown from a horse. She was wearing a helmet but landed forcefully on her back. Upon arrival, she is immobilized on a rigid backboard with a cervical collar. She is conscious and alert but reports an inability to move her legs and a lack of sensation below her chest. Vital signs reveal a blood pressure of 78/4278/42 mmHg, a heart rate of 5454/min, and a respiratory rate of 1616/min. Oxygen saturation is 98%98\% on room air. Physical examination demonstrates warm, flushed skin in the upper and lower extremities. Pulses are bounding. Which of the following is the most likely etiology of this patient's hemodynamic findings?

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Answer: Disruption of descending sympathetic pathways

Answer

Disruption of descending sympathetic pathways
This patient's presentation of hypotension, bradycardia, and warm extremities following significant spinal trauma (paraplegia, loss of sensation) is classic for neurogenic shock. Spinal cord injury above the level of T1-T4 can disrupt descending sympathetic pathways. This leads to a loss of sympathetic vascular tone, resulting in massive peripheral vasodilation (causing hypotension and warm, flushed skin). Furthermore, the loss of sympathetic innervation to the heart leaves parasympathetic (vagal) tone unopposed, preventing the expected compensatory tachycardia and instead causing bradycardia.

Step-by-Step Solution

1
Analyze the patient's vital signs and physical examination findings.
The patient is hypotensive (78/4278/42 mmHg), bradycardic (5454/min), and has warm, flushed skin.
Identifying the specific pattern of hemodynamic derangement is essential to determine the type of shock.
2
Correlate the hemodynamic pattern with the mechanism of injury.
The patient suffered blunt spinal trauma resulting in paraplegia and sensory loss below the chest. The combination of acute spinal cord injury, hypotension, and bradycardia defines neurogenic shock.
Trauma patients frequently experience hypovolemic shock, but the presence of bradycardia and warm extremities points directly to a neurogenic etiology.
3
Identify the pathophysiologic mechanism of neurogenic shock.
Neurogenic shock occurs due to the interruption of autonomic descending sympathetic tracts in the spinal cord, leading to unopposed parasympathetic (vagal) tone.
Loss of sympathetic tone causes peripheral vasodilation (producing warm skin and hypotension) and prevents the expected compensatory tachycardia, resulting in bradycardia.

Key Concept

Neurogenic shock is characterized by hypotension, bradycardia, and warm extremities due to the loss of sympathetic vascular tone following a spinal cord injury.
Estimated Time:1m 0s
Question 54Question →

A 25-year-old man is brought to the emergency department after a high-speed motor vehicle collision. He is unresponsive and has sustained multiple injuries. According to the Advanced Trauma Life Support (ATLS) protocol, arrange the following initial management steps of the primary survey in the correct chronological order.

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Answer

The correct sequence is: Airway and C-spine control, Breathing and ventilation, Circulation and hemorrhage control, Disability (neurologic exam), and Exposure/environmental control.
The Advanced Trauma Life Support (ATLS) protocol utilizes the ABCDE algorithm for the primary survey to systematically identify and treat the most immediately life-threatening conditions. The mandatory chronological order is: Airway maintenance with cervical spine protection, Breathing and ventilation, Circulation with hemorrhage control, Disability (rapid neurologic evaluation), and Exposure/environmental control.

Step-by-Step Solution

1
Identify the standard protocol for initial trauma assessment.
The scenario requires the ATLS primary survey approach.
ATLS provides a structured algorithm to identify and treat the most immediately life-threatening injuries first.
2
Apply the ABCDE mnemonic to the given clinical actions.
A = Airway, B = Breathing, C = Circulation, D = Disability, E = Exposure.
This mnemonic dictates the strict chronological order of the primary survey.
3
Arrange the steps according to the ABCDE sequence.
The airway must be secured first, followed by ventilation, then circulation/shock assessment, then neurologic status, and finally complete exposure.
Failure to follow this order can lead to preventable mortality, as an unprotected airway will quickly result in fatal hypoxia regardless of other interventions.

Key Concept

ATLS Primary Survey (ABCDE Algorithm)
Question 55Question →

Match the following classic patterns of abdominal pain to the most likely acute intra-abdominal diagnosis.

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Items

Periumbilical pain that subsequently migrates to the right lower quadrant, often accompanied by anorexia.
Constant right upper quadrant pain that radiates to the right shoulder or scapula.
Gradual onset of left lower quadrant abdominal pain, accompanied by fever and a recent change in bowel habits.
Sudden-onset, severe epigastric pain that radiates straight through to the back.

Matches

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Answer

Periumbilical to RLQ matches Acute appendicitis; RUQ to shoulder matches Acute cholecystitis; LLQ matches Acute diverticulitis; Epigastric to back matches Acute pancreatitis.
Each clinical presentation perfectly aligns with the classic anatomical and pathophysiological pain patterns of the respective acute surgical or gastrointestinal conditions.

Step-by-Step Solution

1
Analyze the anatomical location and migration of the pain.
Each pain pattern corresponds to a specific embryological or anatomical localization.
Pain characteristics are the primary clinical clues for diagnosing acute abdominal conditions.
2
Correlate associated symptoms and radiation.
Radiation to the back points to retroperitoneal structures, while radiation to the scapula indicates diaphragmatic irritation.
Associated features confirm the specific organ involvement and refine the diagnosis.

Key Concept

Clinical presentation and anatomical localization of acute abdominal surgical conditions.
Question 56Question →

Match each postoperative clinical presentation to the anatomical structure most likely injured during the cardiothoracic procedure.

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Items

Hoarseness and left vocal cord paralysis after repair of a distal aortic arch aneurysm
Ipsilateral ptosis, miosis, and anhidrosis following surgical resection of an apical lung tumor
Drainage of opaque, milky pleural fluid rich in triglycerides on postoperative day 3 following esophagectomy
Paradoxical upward movement of the right hemidiaphragm during inspiration after a right pneumonectomy

Matches

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Answer

The correct matches correlate each iatrogenic clinical syndrome with its respective anatomical structure: hoarseness to the left recurrent laryngeal nerve, Horner syndrome to the sympathetic chain, chylothorax to the thoracic duct, and diaphragmatic paralysis to the phrenic nerve.
Each matching pair represents a classic iatrogenic injury in cardiothoracic surgery governed by regional anatomy. The left recurrent laryngeal nerve is vulnerable during aortic arch surgery, leading to hoarseness. The sympathetic chain (stellate ganglion) is vulnerable during apical lung resections, leading to Horner syndrome. The thoracic duct is at risk during esophageal surgery, causing a chylothorax. The phrenic nerve is at risk during hilar dissections, causing diaphragmatic paralysis.

Step-by-Step Solution

1
Analyze the vocal cord paralysis presentation.
Matches to the left recurrent laryngeal nerve.
The anatomical course of the left recurrent laryngeal nerve makes it vulnerable during aortic arch interventions.
2
Analyze the ptosis, miosis, and anhidrosis presentation.
Matches to the sympathetic chain.
These are the classic signs of Horner syndrome, caused by disruption of the sympathetic ganglion at the lung apex (e.g., Pancoast tumor resection).
3
Analyze the milky, high-triglyceride pleural effusion presentation.
Matches to the thoracic duct.
This presentation describes a chylothorax, commonly caused by injury to the thoracic duct during esophageal surgery.
4
Analyze the paradoxical hemidiaphragm movement presentation.
Matches to the phrenic nerve.
The phrenic nerve provides motor innervation to the diaphragm and is at risk during hilar dissections such as a pneumonectomy.

Key Concept

Iatrogenic anatomic injuries in cardiothoracic surgery
Question 57Question →

Paramedics bring a 35-year-old male to the emergency department after he was rescued from a residential fire. The patient weighs 75 kg. According to the paramedics, the burn injury occurred exactly 2 hours prior to arrival. Physical examination reveals deep partial-thickness and full-thickness burns covering his entire posterior trunk and both of his entire upper extremities. The remainder of his skin is intact. Two large-bore intravenous lines are established.

Using the traditional Parkland formula (44 mL/kg/% total body surface area), what should be the intravenous fluid administration rate (in mL/hr) prescribed for the remaining time to complete the first 8-hour post-injury resuscitation goal?

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Answer: 900

Answer

900
The traditional Parkland formula is calculated as 44 mL of crystalloid per kg of body weight per percentage of TBSA burned. For this 75 kg patient with 36% TBSA burns (18% for the entire posterior trunk + 9% for each upper extremity), the total 24-hour fluid requirement is 4×75×36=10,8004 \times 75 \times 36 = 10,800 mL. Half of this volume (5,4005,400 mL) must be administered within the first 8 hours from the time of the burn. Because the injury occurred 2 hours prior to arrival, only 6 hours remain in this initial window. Therefore, the 5,4005,400 mL must be infused over 6 hours, requiring a rate of 900900 mL/hr.

Step-by-Step Solution

1
Calculate the burned Total Body Surface Area (TBSA) using the Rule of Nines.
18% (posterior trunk) + 9% (right arm) + 9% (left arm) = 36% TBSA.
The Parkland formula requires an accurate estimation of the total burn surface area.
2
Calculate the total 24-hour fluid resuscitation volume using the traditional Parkland formula.
4 mL/kg × 75 kg × 36% = 10,800 mL.
This establishes the total volume of Lactated Ringer's needed for the first 24 hours after the injury.
3
Determine the fluid volume required for the first 8 hours.
10,800 mL / 2 = 5,400 mL.
Standard burn resuscitation guidelines dictate that 50% of the calculated 24-hour volume is given in the first 8 hours post-injury.
4
Calculate the intravenous fluid rate based on the elapsed time since the injury.
5,400 mL / (8 hours - 2 hours) = 5,400 mL / 6 hours = 900 mL/hr.
The first 8-hour window begins at the time of injury, not at the time of hospital admission. Because 2 hours have already elapsed, the fluid must be infused over the remaining 6 hours.

Key Concept

Burn fluid resuscitation calculations must account for the time elapsed since the injury when setting the infusion rate for the first 8 hours.
Question 58Question →

A 5858-year-old man is brought to the emergency department by emergency medical services due to the sudden onset of severe, 'tearing' chest pain that radiates to his back between the scapulae. The pain started abruptly 4545 minutes ago while he was doing yard work. He has a history of poorly controlled essential hypertension. On arrival, he is diaphoretic and appears in acute distress. His temperature is 37.1∘37.1^\circ C (98.8∘98.8^\circ F), blood pressure is 195/110195/110 mmHg in the right arm and 180/105180/105 mmHg in the left arm, heart rate is 108108/min, and respiratory rate is 2222/min. Oxygen saturation is 96%96\% on room air. A bedside chest radiograph reveals a widened mediastinum. Arrange the following management steps in the most appropriate chronological order for this patient.

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Answer

The correct sequence is: 1. Perform primary assessment (ABCs), 2. Administer an intravenous beta-blocker, 3. Administer an intravenous vasodilator, 4. Obtain CT angiography, 5. Proceed to emergent open surgical repair.
The correct sequence for managing a suspected acute aortic dissection prioritizes immediate hemodynamic stabilization to prevent catastrophic rupture. After basic ABCs, heart rate must be controlled FIRST with negative inotropes (beta-blockers) to reduce aortic wall shear stress (dP/dtdP/dt). Vasodilators are then added if blood pressure remains elevated. Only after the patient's hemodynamics are stabilized should they be transported for definitive imaging (CTA). Finally, if imaging confirms a Type A dissection, emergent open surgical repair is required.

Step-by-Step Solution

1
Recognize the clinical presentation of an acute aortic dissection.
The patient's tearing chest pain, asymmetric blood pressures, and widened mediastinum strongly suggest an acute aortic syndrome.
Identifying the highly probable diagnosis dictates the immediate need for aggressive anti-impulse therapy before definitive imaging is obtained.
2
Prioritize initial stabilization and sequential anti-impulse medical therapy.
After ABCs, a short-acting beta-blocker (esmolol) is given to lower heart rate to <60<60/min, followed by a vasodilator (nitroprusside) to lower systolic blood pressure to 100−120100-120 mmHg.
Reducing the heart rate first prevents the reflex tachycardia that would occur if vasodilators were given alone. This minimizes aortic wall shear stress (dP/dtdP/dt) and the risk of catastrophic rupture.
3
Obtain definitive diagnostic imaging.
A CT angiography of the aorta is safely performed once the patient is hemodynamically stabilized.
Imaging is necessary to confirm the diagnosis and classify the dissection (Stanford Type A vs. Type B) to guide definitive surgical versus medical management.
4
Determine the definitive treatment based on dissection anatomy.
Assuming imaging confirms involvement of the ascending aorta (Stanford Type A), emergent open surgical repair is indicated.
Type A dissections have a high risk of retrograde progression causing cardiac tamponade, severe aortic regurgitation, or coronary artery occlusion, requiring immediate surgical intervention.

Key Concept

In the management of suspected acute aortic dissection, initial stabilization is followed immediately by anti-impulse therapy (beta-blockers FIRST, then vasodilators) prior to obtaining definitive imaging, which subsequently dictates the need for emergent surgery.
Question 59Question →

Match each thoracic trauma clinical presentation to the most appropriate next step in diagnosis or definitive management based on Advanced Trauma Life Support (ATLS) principles.

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Items

Stab wound to the left parasternal area accompanied by hypotension, distended neck veins, and muffled heart sounds
Severe blunt chest trauma resulting in hypoxia and paradoxical inward movement of a lateral chest wall segment during inspiration
High-speed deceleration injury with a persistent pneumothorax and a massive, continuous air leak despite adequate thoracostomy tube placement
Penetrating chest trauma with an immediate return of 1,600 mL of bright red blood upon insertion of a thoracostomy tube

Matches

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Answer

The presentations map to their respective ATLS interventions: cardiac tamponade requires pericardial decompression, flail chest requires pain management and positive pressure ventilation, tracheobronchial injury requires fiberoptic bronchoscopy, and massive hemothorax requires an emergent thoracotomy.
Each clinical scenario corresponds to a classic 'lethal six' thoracic injury that requires prompt recognition and targeted management. Cardiac tamponade is managed with immediate pericardial decompression. Flail chest relies on excellent analgesia and ventilatory support to correct hypoxia without surgical fixation in the acute setting. Tracheobronchial injuries manifest with massive air leaks, making bronchoscopy essential for localization. Finally, a massive hemothorax (>1,500 mL initially) mandates emergent exploratory thoracotomy to surgically arrest the hemorrhage.

Step-by-Step Solution

1
Analyze the first clinical presentation: left parasternal stab wound with Beck's triad.
Identified as cardiac tamponade.
Hypotension, jugular venous distention, and muffled heart sounds after penetrating chest trauma classically denote pericardial fluid accumulation.
2
Analyze the second presentation: blunt trauma with paradoxical chest wall movement.
Identified as flail chest.
Paradoxical motion occurs when a segment of the rib cage fractures in multiple places and detaches from the bony thorax.
3
Analyze the third presentation: blunt trauma with massive continuous air leak.
Identified as a tracheobronchial tree injury.
A persistent air leak failing to resolve with a chest tube indicates a major breach in the large airways.
4
Analyze the fourth presentation: penetrating trauma with 1,600 mL initial chest tube output.
Identified as massive hemothorax.
Initial chest tube drainage exceeding 1,500 mL of blood strictly meets the definition for a massive hemothorax.
5
Map each identified condition to its definitive ATLS management guideline.
Cardiac tamponade to decompression, flail chest to pain control/ventilation, tracheobronchial injury to bronchoscopy, and massive hemothorax to thoracotomy.
Applying standard trauma algorithms ensures immediate stabilization of life-threatening thoracic injuries.

Key Concept

Advanced Trauma Life Support (ATLS) diagnostic and therapeutic algorithms for life-threatening thoracic injuries.
Question 60Question →

A 58-year-old female patient is evaluated in the emergency room due to a 22-day history of severe right upper quadrant abdominal pain, shaking chills, and progressively worsening yellowing of her skin. Her temperature is 39.4∘C39.4^\circ\text{C} (102.9∘F102.9^\circ\text{F}), blood pressure is 98/6098/60 mm Hg, pulse is 112112/min, and respirations are 2020/min. Physical examination reveals marked scleral icterus and significant right upper quadrant tenderness, but no rebound or guarding.

Laboratory studies show:
Leukocyte count: 18,500/mm318,500/\text{mm}^3
Total bilirubin: 6.4 mg/dL6.4 \text{ mg/dL}
Alkaline phosphatase: 480 U/L480 \text{ U/L}
Aspartate aminotransferase (AST): 150 U/L150 \text{ U/L}
Alanine aminotransferase (ALT): 165 U/L165 \text{ U/L}
Amylase: 85 U/L85 \text{ U/L}

Arrange the following interventions in the most appropriate chronological sequence for the management of this patient's condition.

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Answer

The correct sequence for managing acute ascending cholangitis is: 1) Hemodynamic stabilization with intravenous fluids and antibiotics, 2) Diagnostic confirmation with a right upper quadrant ultrasound, 3) Biliary decompression via ERCP, and 4) Definitive management with an elective laparoscopic cholecystectomy.
The management of acute ascending cholangitis must follow a strict step-wise approach prioritized by immediate life threats. Because the patient presents with sepsis (hypotension, tachycardia, fever, leukocytosis), the immediate first step must be fluid resuscitation and broad-spectrum intravenous antibiotics. Only after initiating medical stabilization should imaging (right upper quadrant ultrasound) be obtained to confirm biliary dilation and stones. Once confirmed, the infected and obstructed biliary tree must be decompressed urgently, most commonly via ERCP. Finally, to prevent future recurrences, a laparoscopic cholecystectomy is performed later in the admission once the acute infection has resolved.

Step-by-Step Solution

1
Identify the clinical syndrome of acute ascending cholangitis based on Charcot's triad (fever, jaundice, right upper quadrant pain) and signs of sepsis.
The primary immediate threat to life is recognized as biliary sepsis.
Systemic infection and hemodynamic instability dictate the absolute first priority in clinical management.
2
Administer intravenous crystalloid fluids and broad-spectrum antibiotics.
Restores intravascular volume and initiates antimicrobial therapy against enteric organisms.
Medical stabilization must precede any invasive diagnostic or therapeutic procedures to prevent cardiovascular collapse.
3
Obtain a transabdominal right upper quadrant ultrasound.
Visualizes common bile duct dilation and identifies gallstones as the likely etiology of the obstruction.
Ultrasound is the optimal, non-invasive initial imaging modality to confirm the suspected diagnosis of biliary obstruction.
4
Perform endoscopic retrograde cholangiopancreatography (ERCP).
Decompresses the biliary tree and removes the obstructing common bile duct stone.
Once the patient is stabilized and diagnosed, urgent biliary drainage is required to definitively treat the source of the infection.
5
Perform a laparoscopic cholecystectomy.
Removes the gallbladder and any remaining stones.
This is performed electively or semi-electively after resolution of the acute illness to prevent recurrent choledocholithiasis and subsequent bouts of cholangitis.

Key Concept

Chronological management of acute ascending cholangitis (Resuscitation -> Imaging -> Decompression -> Cholecystectomy)
Estimated Time:1m 30s
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