Surgery

A 28-year-old man is brought to the emergency department after a high-speed motorcycle collision. He is unresponsive and making gurgling respiratory sounds. His blood pressure is $72/40 \text{ mm Hg}$, pulse is $142\text{/min}$, and respiratory rate is $34\text{/min}$. Physical examination reveals severe maxillofacial crush injuries with active oropharyngeal hemorrhage. The trachea is deviated to the left, and breath sounds are absent over the right hemithorax. The pelvis is mechanically unstable on anteroposterior compression.

Arrange the following acute management steps in the correct chronological sequence according to standard trauma resuscitation protocols.

A $31$-year-old woman, G2P1, at $34$ weeks gestation is evaluated in the emergency department after a high-speed motor vehicle collision. She was an unrestrained driver. On arrival, she is unresponsive with a Glasgow Coma Scale score of $7$. She is rapidly intubated for airway protection. Vital signs are temperature $36.8^\circ\text{C}$ ($98.2^\circ\text{F}$), blood pressure $72/40\text{ mm Hg}$, and pulse $142/\text{min}$. Breath sounds are equal bilaterally. Her abdomen is gravid, tense, and diffusely tender. Uterine tone is markedly increased. A focused assessment with sonography for trauma exam demonstrates a large amount of free fluid in the hepatorenal and splenorenal recesses. External fetal monitoring reveals a baseline fetal heart rate of $105/\text{min}$ with recurrent late decelerations and absent variability. A massive transfusion protocol is initiated. Which of the following is the most appropriate next step in management?

A 38-year-old male motorcyclist is brought to the emergency department after colliding with a guardrail. On presentation, he is awake but groggy. His temperature is 36.2°C (97.1°F), blood pressure is 78/45 mm Hg, pulse is 132/min, and respirations are 22/min. Oxygen saturation is 97% on a nonrebreather mask. Airway is patent. Breath sounds are equal bilaterally, and the trachea is midline. The abdomen is soft and non-distended without guarding. There is a scrotal hematoma, and blood is noted at the urethral meatus. Anteroposterior compression of the iliac crests reveals mechanical instability. Intravenous access is established, and a 1-liter bolus of warmed lactated Ringer solution is rapidly infused, but the blood pressure remains 80/48 mm Hg. A bedside focused assessment with sonography for trauma (FAST) demonstrates no free intraperitoneal or pericardial fluid. A pelvic binder is immediately applied. Which of the following is the most appropriate next step in management?

Match each specific clinical presentation of thoracic trauma with its most appropriate immediate definitive intervention or diagnostic modality.

For each of the following acute gastrointestinal scenarios evaluated in the emergency department, identify the most appropriate next step in diagnosis or management.

Surgical team rounds are being conducted on a 71-year-old male patient who is currently recovering six days after an elective open abdominal aortic aneurysm repair. His past medical history is notable for diet-controlled type 2 diabetes and mild chronic obstructive pulmonary disease.

Seventy-two hours after his surgery, he experienced acute tachypnea, a productive cough, and a temperature spike to 38.7°C (101.7°F). Portable chest imaging confirmed a right lower lobe consolidation. The patient was promptly started on an empiric antimicrobial regimen of intravenous piperacillin-tazobactam and vancomycin for suspected hospital-acquired pneumonia.

Today, the patient feels much better, is breathing comfortably on ambient air, and his temperature has normalized to 37.1°C (98.8°F). Leukocyte counts have trended down from a peak of 16,500/mm³ to 8,500/mm³. The microbiology laboratory reports that respiratory cultures from the initial febrile episode have finalized, revealing a heavy growth of Haemophilus influenzae. The isolate demonstrates susceptibility to ceftriaxone, levofloxacin, and amoxicillin-clavulanate.

Which of the following represent the most appropriate management decisions at this time? (Select exactly 2 answers)

An inpatient surgical consult is requested for a 62-year-old male on the medical ward who was admitted two days ago for a small bowel obstruction. He has a history of an open appendectomy in childhood. Initially, his symptoms improved with bowel rest and nasogastric decompression. Over the past 4 hours, however, his clinical status has rapidly declined. Current vital signs show a temperature of 38.6°C (101.5°F), heart rate of 118/min, and blood pressure of 98/60 mm Hg. Physical examination reveals a distended abdomen with marked tenderness, guarding, and rebound in the right lower quadrant. Laboratory studies demonstrate a leukocyte count of 18,500/mm³ and a serum lactate of 4.2 mmol/L. Intravenous fluid resuscitation is immediately initiated. Which of the following is the most appropriate next step in management?

Match each patient presentation of hyperparathyroidism with the most appropriate surgical management strategy.

A 19-year-old male is brought to the emergency department after a skateboarding accident in which he struck the right side of his head on a concrete curb. Witnesses report that he lost consciousness for approximately one minute, then awoke and conversed normally. Over the past hour, however, he has become increasingly lethargic and complains of severe nausea. His temperature is 36.8°C (98.2°F), blood pressure is 175/95 mm Hg, pulse is 48/min, and respirations are 12/min. Physical examination shows a right pupil that is 7 mm and nonreactive to light, while the left pupil is 3 mm and reactive to light. A noncontrast CT scan of the head demonstrates a lens-shaped, hyperdense collection over the right frontoparietal convexity. Which of the following is the most appropriate next step in management?

A 24-year-old man is brought to the emergency department by paramedics following a street altercation where he sustained a stab wound to his left anteromedial thigh. On presentation, he appears pale, diaphoretic, and confused. His temperature is 36.5°C (97.7°F), blood pressure is 82/46 mmHg, heart rate is 128/min, and respiratory rate is 24/min. Pulse oximetry shows 97% on room air. Two large-bore intravenous lines are placed, and fluid resuscitation is initiated. Physical examination reveals a 4-cm laceration over the left medial thigh. There is a rapidly expanding hematoma around the wound and active pulsatile bleeding. The left foot is cold to the touch. Capillary refill is delayed in the left toes, and both the left dorsalis pedis and posterior tibial pulses are absent to palpation and Doppler ultrasound. The right lower extremity has normal pulses. Which of the following is the most appropriate next step in the management of this patient?

Following a head-on motor vehicle collision, a $34$-year-old female driver is evaluated in the trauma bay. She complains of worsening diffuse abdominal discomfort and pain radiating to her right shoulder. Her temperature is $37.3^\circ\text{C}$ ($99.1^\circ\text{F}$), blood pressure is $110/70$ mmHg, pulse is $112$/min, and respiratory rate is $18$/min. Physical examination reveals a lap-belt mark across the lower abdomen, generalized abdominal tenderness with guarding, and suprapubic rebound tenderness. After ensuring the urethral meatus is normal, a urinary catheter is inserted and immediately drains frankly bloody urine. A computed tomography (CT) cystography is performed and demonstrates contrast dye extravasation into the peritoneal cavity, outlining the loops of the small bowel. Based on the clinical and imaging findings, which of the following is the most appropriate next step in management?

Match each traumatic clinical presentation and its associated physical exam findings to the most likely specific vascular injury.

A 25-year-old man is brought to the emergency department via ambulance 20 minutes after being shot during an altercation. He sustained a single gunshot wound to the right anterior chest, located in the fifth intercostal space at the midclavicular line. There is no visible exit wound. The patient is pale, diaphoretic, and lethargic. Vital signs include a blood pressure of 76/40 mm Hg, heart rate of 132/min, and respiratory rate of 22/min. Oxygen saturation is 97% on high-flow oxygen. The trachea is midline, and neck veins are flat. Auscultation of the chest reveals clear and equal breath sounds bilaterally. The abdomen is visibly distended and demonstrates diffuse rigidity and guarding. Two large-bore intravenous lines are placed, and fluid resuscitation is initiated. Which of the following is the most appropriate next step in the management of this patient?

A series of patients arrive at the trauma bay following various traumatic incidents. Match each patient's clinical presentation with the most appropriate next step in management according to Advanced Trauma Life Support (ATLS) protocols.

A $45$-year-old man is brought to the emergency department by emergency medical services after a high-speed motor vehicle collision. He was an unrestrained driver and was ejected from the vehicle. On arrival, he is agitated, pale, and diaphoretic. His blood pressure is $76/40 \text{ mm Hg}$, heart rate is $138\text{/min}$, and respiratory rate is $24\text{/min}$. The airway is patent, and the trachea is midline. Breath sounds are present and equal bilaterally. Heart sounds are normal. The abdomen is distended and diffusely tender with mild rigidity. The pelvis is mechanically stable to anteroposterior and lateral compression. Intravenous access is established, and the mass transfusion protocol is initiated. Following the administration of $1 \text{ L}$ of warmed crystalloid and $1 \text{ unit}$ of uncrossmatched packed red blood cells, his blood pressure is $82/45 \text{ mm Hg}$. A focused assessment with sonography for trauma (FAST) reveals a large amount of anechoic fluid in the hepatorenal and splenorenal recesses; there is no fluid in the pericardial sac. A portable anteroposterior chest radiograph demonstrates clear lung fields but a noticeably widened mediastinum with blurring of the aortic knob. Which of the following is the most appropriate next step in the management of this patient?

Burn victims often present with complex, life-threatening complications that require immediate recognition and targeted intervention. Match each clinical presentation of a burn or inhalation injury to the most appropriate next step in management or specific antidote.

During morning rounds, the surgical team evaluates a 48-year-old male patient who is currently on his second day of recovery following an open cholecystectomy for acute gangrenous cholecystitis. The patient complains of new, mild shortness of breath and right-sided abdominal discomfort when attempting to take a deep breath. Vital signs show a temperature of 38.3°C (100.9°F), pulse of 98/min, blood pressure of 128/82 mmHg, and a respiratory rate of 20/min. Pulse oximetry displays 94% on room air. Auscultation of the chest demonstrates diminished breath sounds at both lung bases without crackles or wheezing. The surgical wound appears well-approximated without drainage, induration, or erythema. The abdomen is soft with expected mild tenderness at the incision site.

Which of the following interventions are the most appropriate next steps in managing this patient's clinical presentation? (Select 2 options)

A 42-year-old construction worker is transported to the trauma bay shortly after falling from a height of approximately 20 feet (6 meters). On arrival, his airway is secure, and breath sounds are present and equal bilaterally. His heart rate is 135/min, and blood pressure is 78/50 mm Hg. Oxygen saturation is 97% on ambient air. The patient is confused and appropriately localizes to painful stimuli. Two large-bore intravenous catheters are placed, and warmed isotonic crystalloid fluids are rapidly infused. Physical examination reveals a rigid, distended abdomen with diffuse tenderness. The pelvis is mechanically stable to anteroposterior and lateral compression. A focused assessment with sonography for trauma (FAST) reveals a significant collection of anechoic fluid in the hepatorenal recess. Which of the following is the most appropriate next step in the management of this patient?

A 52-year-old woman is brought to the emergency department by emergency medical services after being involved in a head-on motor vehicle collision. She is confused, tachypneic, and has blood on her face from a scalp laceration. Her vital signs show a blood pressure of 90/50 mmHg, a heart rate of 118/min, and a respiratory rate of 26/min. According to the Advanced Trauma Life Support (ATLS) protocol, arrange the following initial management steps in the correct chronological order.

Evaluate the following patients presenting to the emergency department with severe abdominal symptoms. Match each patient's clinical presentation with the most appropriate initial operative or non-operative management strategy.