Surgery

A 22-year-old woman is brought to the emergency department by paramedics after falling from a horse. The horse reportedly stepped directly on her mid-abdomen. She is groaning in pain and appears confused. Her temperature is 36.5°C (97.7°F), heart rate is 134/min, blood pressure is 82/50 mm Hg, and respiratory rate is 24/min. Pulse oximetry is 97% on room air. The patient is lethargic but is actively protecting her airway. Breath sounds are clear and equal bilaterally. The abdomen is visibly distended, tense, and diffusely tender to palpation with guarding. The pelvis is stable to gentle compression. Two large-bore intravenous lines are established, and a 1-liter bolus of warm crystalloid is rapidly administered. Reassessment reveals a heart rate of 128/min and a blood pressure of 84/52 mm Hg. Which of the following is the most appropriate next step in management?

A 45-year-old man presents to the emergency department with sudden-onset, excruciating, diffuse abdominal pain that began 2 hours ago. He has a history of untreated peptic ulcer disease and frequently uses over-the-counter nonsteroidal anti-inflammatory drugs. On physical examination, he appears acutely ill, is diaphoretic, and has a heart rate of 115/min. His abdomen is diffusely rigid with involuntary guarding and severe rebound tenderness. Arrange the following management steps in the most appropriate chronological sequence for this patient.

A $45$-year-old man is brought to the emergency department after a high-speed motorcycle collision. On arrival, he is confused and diaphoretic.

Temperature is $35.8^\circ\text{C}$ ($96.4^\circ\text{F}$), blood pressure is $78/40\text{ mmHg}$, heart rate is $135/\text{min}$, and respiratory rate is $28/\text{min}$. Primary survey reveals a patent airway and equal breath sounds bilaterally. The abdomen is distended with diffuse tenderness to palpation. Pelvic compression produces gross mechanical instability. Bilateral lower extremities are cool with weak dorsalis pedis pulses.

A pelvic binder is immediately applied, and massive transfusion protocol is initiated. Following the rapid administration of $2\text{ units}$ of uncrossmatched packed red blood cells and $2\text{ units}$ of fresh frozen plasma, his blood pressure is $82/45\text{ mmHg}$.

A focused assessment with sonography for trauma (FAST) exam demonstrates a moderate amount of anechoic fluid in the hepatorenal recess (Morison pouch). An anteroposterior pelvic radiograph shows a $4\text{ cm}$ diastasis of the pubic symphysis and widening of the right sacroiliac joint.

Arterial blood gas analysis reveals a $\text{pH}$ of $7.22$, $\text{pCO}_2$ of $29\text{ mmHg}$, and $\text{HCO}_3^-$ of $12\text{ mEq/L}$.

The patient's estranged brother arrives and demands that all life-saving procedures be halted, stating the patient 'would never want to be kept alive like this.' There is no formal advance directive on file, and the patient's wife is currently unreachable.

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

A $54$-year-old woman presents to the emergency department complaining of excruciating abdominal pain and bilious emesis for the past $24$ hours. The pain was initially intermittent and crampy but has become constant and diffuse over the last $4$ hours. She underwent an open myomectomy $8$ years ago. Vital signs show a temperature of $39.1^\circ\text{C}$ ($102.4^\circ\text{F}$), a pulse of $128/\text{min}$, and a blood pressure of $86/50 \text{ mm Hg}$. Physical examination reveals a markedly distended abdomen with board-like rigidity, diffuse involuntary guarding, and pronounced rebound tenderness. Laboratory evaluation shows a leukocyte count of $22,000/\text{mm}^3$ and a serum lactate concentration of $4.8 \text{ mmol/L}$. Which of the following is the most appropriate next step in management?

A $74$-year-old man is assessed in the surgical intensive care unit for a new-onset fever. He is currently on postoperative day $10$ following an emergency open repair of a ruptured abdominal aortic aneurysm. His postoperative course has been complicated by hemorrhagic shock requiring massive transfusion and acute kidney injury that is slowly resolving. He was successfully extubated two days ago. Today, his temperature is $39.1^\circ\text{C}$ ($102.4^\circ\text{F}$), blood pressure is $105/65\text{ mmHg}$, and heart rate is $112/\text{min}$. He is delirious and cannot accurately localize pain. Physical examination reveals mild scleral icterus. The abdomen is distended with absent bowel sounds; there is voluntary guarding in the right upper quadrant when deep palpation is performed. The midline surgical incision is clean and intact. Laboratory studies show:

Leukocyte count: $21,500/\text{mm}^3$
Total bilirubin: $2.8\text{ mg/dL}$
Direct bilirubin: $2.1\text{ mg/dL}$
Alkaline phosphatase: $320\text{ U/L}$
Aspartate aminotransferase (AST): $55\text{ U/L}$
Alanine aminotransferase (ALT): $62\text{ U/L}$
Blood urea nitrogen: $45\text{ mg/dL}$
Serum creatinine: $2.4\text{ mg/dL}$

Which of the following is the most appropriate initial diagnostic test?

A 72-year-old man with a 20-year history of poorly controlled type 2 diabetes mellitus and a 50-pack-year smoking history presents with a non-healing ulcer on his left great toe. He also reports severe, burning pain in his left foot that awakens him from sleep; the pain improves when he hangs his foot over the edge of the bed. Physical examination reveals a $1.5 \text{ cm}$ shallow, dry ulcer with an eschar on the left hallux. The left foot is cool to the touch with diminished capillary refill. Femoral pulses are palpable bilaterally, but the left popliteal, dorsalis pedis, and posterior tibial pulses are absent.

Arrange the following diagnostic and therapeutic steps in the most appropriate sequential order for the management of this patient's condition.

A $68$-year-old man is evaluated in the surgical ward for a fever on postoperative day $5$ following an uncomplicated right total knee arthroplasty. His temperature is $38.4^\circ\text{C}$ ($101.1^\circ\text{F}$), pulse is $98/\text{min}$, respirations are $16/\text{min}$, and blood pressure is $135/85\text{ mmHg}$. The patient reports a new, deep aching pain in his right calf that is distinct from his surgical site pain. He has a medical history of hypertension and type $2$ diabetes mellitus. Current medications include prophylactic subcutaneous enoxaparin, lisinopril, and metformin. Physical examination reveals a clean and dry surgical incision with mild, expected postoperative swelling around the knee, but no erythema, fluctuance, or purulent drainage. There is moderate, asymmetric swelling and tenderness in the right posterior calf. Passive dorsiflexion of the right foot elicits pain in the calf. Lungs are clear to auscultation bilaterally. A Foley catheter was removed on postoperative day $1$, and he has been voiding without dysuria. Which of the following is the most appropriate next step in management?

A $72$-year-old woman is evaluated in the surgical intensive care unit for new-onset fever and hypotension. She is currently on postoperative day $6$ following an exploratory laparotomy and small bowel resection for mesenteric ischemia. Her past medical history includes ischemic cardiomyopathy with a left ventricular ejection fraction of $35\%$, and type $2$ diabetes mellitus. She has been receiving parenteral nutrition via a right internal jugular central venous catheter that was placed prior to her surgery.

Over the past $6$ hours, her temperature has risen to $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$), heart rate to $122\text{/min}$, and blood pressure decreased to $85/50\text{ mm Hg}$. Her urine output has dropped to $10\text{ mL/h}$ over the last $4$ hours.

Physical examination reveals a lethargic patient. Jugular venous pressure is estimated at $3\text{ cm H}_2\text{O}$. The lungs are clear to auscultation bilaterally. The abdomen is mildly distended but non-tender, with a clean, intact midline surgical incision. Inspection of the right internal jugular catheter site reveals $2\text{ cm}$ of surrounding erythema and purulent exudate at the insertion site.

Laboratory studies:
Leukocyte count: $21,000\text{/mm}^3$ ($85\%$ neutrophils, $10\%$ bands)
Serum creatinine: $2.1\text{ mg/dL}$ (baseline $1.1\text{ mg/dL}$)
Blood lactic acid: $4.2\text{ mmol/L}$

Blood and urine cultures have been obtained. Which of the following are appropriate next steps in the management of this patient? (Select all that apply)

A $65$-year-old woman is evaluated in the surgical intensive care unit on postoperative day $7$ following a pancreaticoduodenectomy. She has been receiving total parenteral nutrition via a right internal jugular central venous catheter that was placed prior to surgery. Over the past $2$ hours, she has developed chills and altered mental status. Her temperature is $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$), blood pressure is $90/55\text{ mm Hg}$, pulse is $122/\text{min}$, and respirations are $24/\text{min}$. Physical examination of the central line insertion site reveals erythema, induration, and a small amount of purulent exudate.

Arrange the following management steps in the correct chronological order according to standard sepsis and central line-associated bloodstream infection (CLABSI) protocols.

A 5-year-old boy is brought to the emergency department after falling from a trampoline onto his outstretched right hand. He is crying and refuses to move his right arm. Physical examination reveals a gross, "S-shaped" deformity of the right elbow with significant soft tissue swelling. The right hand is pale and cool, and the radial pulse is absent on palpation. Radiographs show a completely displaced, extension-type supracondylar fracture of the humerus. The patient is immediately taken to the operating room, where closed reduction and percutaneous pinning are performed. Following stabilization of the fracture, the right hand remains pale and cool, and the radial pulse cannot be detected by Doppler ultrasound. Which of the following is the most appropriate next step in the management of this patient?

A 34-year-old woman is evaluated in the trauma bay after being struck by a fast-moving electric bicycle while crossing the street. She was thrown several feet and struck her abdomen against the edge of a sidewalk. On arrival, she is lethargic but responds to voice. Her temperature is $36.8^\circ C$ ($98.2^\circ F$), blood pressure is $82/50$ mm Hg, pulse is $128$/min, and respirations are $22$/min. Primary survey reveals a patent airway and clear, equal breath sounds bilaterally. The abdomen is visibly distended, firm, and diffusely tender to palpation with guarding. A focused assessment with sonography for trauma (FAST) shows a large amount of anechoic fluid in the hepatorenal recess (Morison's pouch) and the splenorenal recess. Two large-bore intravenous lines are placed, and fluid resuscitation is initiated. Which of the following is the most appropriate next step in management?

During morning rounds on the surgical ward, the team evaluates a female patient who underwent an uncomplicated left hemicolectomy three days ago for early-stage colon cancer. She is 68 years old and reports feeling progressively more short of breath since the previous evening. She also notes a new cough that produces thick, yellowish sputum, along with feeling hot and sweaty. Her past medical history includes hypertension and severe chronic obstructive pulmonary disease (COPD) managed with daily inhaled corticosteroids and long-acting bronchodilators.

Vital signs are:
Temperature: 38.8°C (101.8°F)
Blood pressure: 130/85 mm Hg
Pulse: 110/min
Respirations: 24/min
Oxygen saturation: 91% on room air

On physical examination, the patient appears in mild respiratory distress. Lung auscultation demonstrates crackles at the right lung base, a prolonged expiratory phase, and diffuse bilateral wheezing. The surgical incision is healing well without erythema or induration. The abdomen is soft and non-distended, with normoactive bowel sounds. There is no lower extremity edema or calf tenderness.

Laboratory results show a leukocyte count of 14,500/mm³. A chest radiograph demonstrates a new, patchy alveolar consolidation in the right lower lobe.

Which of the following interventions should be included in the immediate management of this patient? (Select all that apply)

A 48-year-old woman is admitted to the medical ward for the management of a partial small bowel obstruction. She initially presented with diffuse, colicky abdominal pain and bilious vomiting. Her surgical history is notable for a total abdominal hysterectomy 5 years ago. Upon admission, she was hemodynamically stable and managed with intravenous fluid resuscitation and nasogastric tube decompression.

Fourteen hours later, the nursing staff requests an urgent physician evaluation because the patient reports a sudden, drastic worsening of her abdominal pain, which has become severe and unremitting.

Vital signs are now:
Temperature: 38.8°C (101.8°F)
Pulse: 124/min
Blood pressure: 86/54 mm Hg

Physical examination reveals a markedly distended abdomen that is rigidly firm. There is severe, diffuse rebound tenderness and involuntary guarding present. Laboratory testing reveals a leukocyte count of 21,000/mm³ and a serum lactate of 4.8 mmol/L.

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

An emergency response team delivers a 69-year-old male to the trauma center following a syncopal episode at his residence. The patient's spouse reports that he complained of sudden, agonizing pain in his left flank radiating to his groin moments before collapsing. His medical records indicate a history of coronary artery disease and a 40-pack-year smoking history. On evaluation, he is lethargic, and his skin is cool, clammy, and mottled. His blood pressure is currently 74/42 mm Hg, heart rate is 128/min, and respiratory rate is 24/min. Palpation of the abdomen reveals a tender, prominently pulsatile central mass. Peripheral pulses in the lower extremities are diminished bilaterally. Two large-bore intravenous lines are placed. Which of the following is the most appropriate next step in the management of this patient?

A 31-year-old man is brought to the trauma center by helicopter after falling approximately 10 meters (33 feet) from a construction scaffold. His airway was secured by paramedics at the scene with an endotracheal tube. Large-bore intravenous access is established, and a massive transfusion protocol is initiated. Current vital signs are temperature 35.6°C (96.1°F), blood pressure 72/40 mm Hg, and heart rate 148/min. Breath sounds are equal bilaterally. The patient does not open his eyes or move his extremities to painful stimuli. His right pupil is 7 mm and nonreactive to light, while his left pupil is 3 mm and reactive. The abdomen is visibly distended and tense. Bedside sonography for trauma demonstrates a large volume of anechoic fluid in the hepatorenal and perisplenic spaces. Which of the following is the most appropriate next step in the management of this patient?

A 32-year-old man is brought to the emergency department via ambulance after being rescued from a house fire. He weighs 100 kg. The fire started at 13:00, and he was extricated shortly after. He arrives at the emergency department at 16:00. Physical examination reveals deep partial-thickness and full-thickness thermal burns involving his entire back, entire right arm, entire left arm, and the anterior surface of his right leg. During transport, emergency medical services administered 900 mL of intravenous Lactated Ringer's solution. Vital signs are blood pressure 110/70 mmHg, heart rate 115/min, and respiratory rate 22/min. Assuming adherence to the most current Advanced Trauma Life Support (ATLS) recommendations for adult thermal burn fluid resuscitation ($2 \text{ mL} \times \text{weight in kg} \times \%\text{TBSA}$), what should be the intravenous fluid infusion rate (in mL/hr) programmed on the pump for the remainder of the first 8-hour resuscitation window?

A 78-year-old man develops progressive abdominal distention over the past 48 hours. He is currently on postoperative day 4 following a right total knee arthroplasty. His medical history is significant for hypertension and osteoarthritis. Current medications include patient-controlled intravenous morphine. Vital signs are within normal limits. Physical examination reveals a massively distended, tympanitic abdomen with mild diffuse tenderness but no guarding or rebound. Bowel sounds are hypoactive. An upright abdominal radiograph demonstrates diffuse colonic dilation with a cecal diameter of 11.5 cm and no air-fluid levels or free air. The patient is diagnosed with acute colonic pseudo-obstruction (Ogilvie syndrome). Assuming the patient's condition does not resolve with each successive intervention and he remains hemodynamically stable without signs of perforation, arrange the following management options in the correct sequential order from initial step to most definitive last-resort therapy.

Match each acute gastrointestinal surgical condition with its most characteristic initial imaging finding.

Following a left total knee arthroplasty $48$ hours ago, a $75$-year-old man develops progressively worsening shortness of breath. His medical history includes severe chronic obstructive pulmonary disease, hypertension, and a myocardial infarction $4$ years prior. During the intraoperative and immediate postoperative periods, he received a total of $3.5$ L of intravenous crystalloid solution. Vital signs reveal a temperature of $38.1^\circ\text{C}$ ($100.6^\circ\text{F}$), a blood pressure of $162/94$ mm Hg, a pulse of $114$/min, and a respiratory rate of $26$/min. Pulse oximetry demonstrates an oxygen saturation of $88\%$ on room air. Physical examination shows visible engorgement of the jugular veins while sitting at a $45^\circ$ angle. Lung auscultation is notable for bilateral crackles in the lower and middle lung fields, along with scattered expiratory wheezes. He is coughing up pink-tinged, frothy sputum. The surgical site appears clean and intact without any signs of infection. Which of the following is the most appropriate initial step in management?

Match each clinical presentation of inflammatory bowel disease with the most appropriate definitive or initial surgical intervention.