Surgery

A 35-year-old electrical lineman is brought to the emergency department after sustaining a high-voltage electrical injury from a power transformer. The accident occurred exactly 2 hours prior to his arrival due to extrication difficulties. He is awake but confused. His blood pressure is 140/85 mm Hg and his heart rate is 112/min. A Foley catheter is placed and immediately drains dark, tea-colored urine. He weighs 90 kg. Physical examination reveals deep entry and exit wounds on his upper extremities, as well as associated full-thickness thermal burns covering exactly 20% of his total body surface area (TBSA).

According to the current Advanced Trauma Life Support (ATLS) guidelines for electrical burns, what should be the initial intravenous fluid infusion rate (in mL/hr) of lactated Ringer solution upon his arrival?

A 59-year-old woman arrives at the surgical triage unit complaining of excruciating, unremitting abdominal pain. She initially developed intermittent cramping, abdominal distension, and bilious vomiting three days ago, but states the pain acutely worsened and became continuous this morning. She has a history of an open appendectomy in childhood. Her temperature is 38.9°C (102.0°F), blood pressure is 88/54 mmHg, and pulse is 126/min. The abdomen is tensely distended and exquisitely tender to light palpation in all four quadrants, with marked rigidity and rebound tenderness. Bowel sounds are absent. Complete blood count shows a leukocyte count of 21,000/mm³ with a left shift. Serum chemistry reveals a lactate level of 5.2 mmol/L. Which of the following is the most appropriate next step in the management of this patient?

Match each clinical presentation in a patient who previously underwent bariatric surgery with the most likely diagnosis.

A 42-year-old construction worker is brought to the emergency department after a heavy steel beam fell on his left leg. His primary trauma survey is intact, and he is hemodynamically stable. Examination reveals a severely angulated left lower leg with a 5-cm laceration over the medial aspect, exposing fragmented tibial bone. There is moderate bleeding, but no pulsatile hemorrhage. Arrange the following steps in the most appropriate chronological order for the acute orthopedic management of this patient's injury.

An elderly gentleman, aged 74, is evaluated in the emergency department for severe, unremitting abdominal discomfort and multiple episodes of dark green emesis that began 14 hours ago. His surgical history is notable for a midline laparotomy performed a decade ago for a ruptured appendix. He has not passed stool or flatus since the symptoms began. Current vital signs include a temperature of 38.7°C (101.7°F), a heart rate of 122/min, a blood pressure of 92/58 mm Hg, and a respiratory rate of 24/min. Clinical examination reveals a tense, distended abdomen with marked rigidity and diffuse rebound tenderness. Laboratory analysis demonstrates a leukocyte count of 19,200/mm³ and a serum lactate concentration of 4.8 mmol/L. Upright abdominal radiography shows prominently dilated loops of small intestine with multiple air-fluid levels and an absence of distal colonic gas. What is the most appropriate next step in the clinical management of this patient?

A 71-year-old male is transported to the emergency room by ambulance due to profound weakness and severe abdominal distress that began abruptly 6 hours ago. His medical history includes ischemic cardiomyopathy and chronic atrial fibrillation. He was recently transitioned off oral anticoagulation prior to a planned invasive dental procedure. Currently, his temperature is 38.8°C (101.8°F), blood pressure is 76/42 mmHg, heart rate is 135/min and irregular, and respiratory rate is 28/min. Cardiopulmonary examination reveals a rapid, irregularly irregular rhythm. Abdominal examination demonstrates diffuse board-like rigidity, exquisite tenderness to light palpation in all four quadrants, and completely absent bowel sounds. Initial venous blood gas reveals a pH of 7.18 and a lactate level of 8.9 mmol/L. Arrange the following steps in the most appropriate sequential order for the management of this patient.

A 63-year-old male construction worker visits his primary care physician reporting a tight, aching pain in his left calf that consistently begins after walking two blocks. The pain completely resolves after 5 minutes of rest. He has a history of hypertension, hyperlipidemia, and a 40-pack-year smoking history. Physical examination reveals diminished dorsalis pedis and posterior tibial pulses on the left side. The skin is intact with no ulcerations, hair loss is noted on the distal leg, and there is no pain at rest. Vital signs show a blood pressure of 138/82 mmHg and a heart rate of 78/min.

Arrange the following steps in the most appropriate sequential order for the evaluation and management of this patient's condition, starting from the immediate next diagnostic step to the final intervention reserved for refractory symptoms.

A $6$-year-old girl is brought to the emergency department by her parents after falling from monkey bars onto her outstretched left hand $30$ minutes ago. She is crying and clutching her left arm. Vital signs show a temperature of $37.1^\circ$ C, blood pressure of $105/65$ mmHg, heart rate of $115$/min, and respiratory rate of $22$/min. Physical examination reveals a significantly swollen left elbow with a prominent S-shaped deformity. The overlying skin is intact. Neurovascular assessment of the left upper extremity demonstrates a pale hand with a capillary refill time of $4$ seconds. The radial pulse is not palpable but is faintly detectable via Doppler ultrasound. The patient is unable to make an "OK" sign with her left hand, but sensation over the palmar aspect of the first three digits is intact. Radiographs of the left elbow show a completely displaced, extension-type supracondylar fracture of the humerus. Which of the following is the most appropriate next step in management?

Emergency medical services bring a $69$-year-old man to the trauma bay after he experienced a sudden, agonizing tearing pain in his mid-abdomen that radiates to his lower back. He has a $45$-pack-year smoking history and a history of poorly controlled hypertension. Upon arrival, the patient is obtunded, pale, and diaphoretic. His vital signs show a temperature of $36.2^\circ\text{C}$ ($97.2^\circ\text{F}$), a blood pressure of $72/40\text{ mm Hg}$, and a regular heart rate of $124/\text{min}$. Abdominal examination reveals a prominent, expansile, and pulsatile mass extending just above the umbilicus. Arrange the following diagnostic and therapeutic interventions in the most appropriate chronological sequence for the standard management of this patient.

A 14-year-old boy with a BMI of $31 \text{ kg/m}^2$ is brought to the clinic by his mother due to a 3-week history of right knee pain and a progressive limp. He denies any recent trauma, fever, or weight loss. Vital signs are within normal limits. On physical examination, there is no effusion, erythema, or tenderness to palpation over the right knee. Ligamentous testing of the right knee is intact. When the patient's right hip is passively flexed to $90^\circ$, the right thigh obligatorily rotates externally. Internal rotation of the right hip is significantly limited and elicits pain. Which of the following is the most appropriate next step in management?

A $72$-year-old man is evaluated on postoperative day $3$ following a total hip arthroplasty due to progressive, painless abdominal distension. He has not passed flatus or stool for $48$ hours. He is currently receiving intravenous morphine for pain. Vital signs are within normal limits. Physical examination reveals a massively distended, tympanitic abdomen with high-pitched bowel sounds, but no focal tenderness, guarding, or rigidity. An abdominal radiograph demonstrates diffuse dilation of the entire colon, with a cecal diameter of $10.5$ cm, but no evidence of a mechanical transition point or pneumoperitoneum. Assuming the patient's condition fails to improve with each successive treatment modality and there are no specific contraindications, arrange the following management steps in the correct sequential order according to standard treatment algorithms for acute colonic pseudo-obstruction (Ogilvie syndrome).

A 52-year-old male with a history of poorly controlled type 2 diabetes mellitus presents to the emergency department with a 2-day history of severe right knee pain, swelling, and subjective fevers. His temperature is $38.9^\circ\text{C}$ ($102^\circ\text{F}$), blood pressure is $130/80\text{ mmHg}$, heart rate is $110/\text{min}$, and respiratory rate is $18/\text{min}$. Physical examination reveals a markedly swollen, erythematous, and warm right knee. The patient refuses to bear weight, and there is exquisite pain with even minimal passive range of motion. Blood cultures are drawn in the emergency department.

Arrange the following next steps in the most appropriate sequential order for the acute management of this patient.

A 65-year-old woman is evaluated in the cardiovascular intensive care unit on postoperative day 4 following a coronary artery bypass grafting (CABG) procedure. Over the past 45 minutes, she has become increasingly restless, confused, and short of breath. Her temperature is 37.8°C (100.0°F), blood pressure is 82/50 mmHg, pulse is 122/min, and respirations are 26/min. On physical examination, her jugular veins are distended to the angle of the mandible while she is seated upright. Auscultation of the chest reveals clear lung fields bilaterally, but heart sounds are distant and muffled. Her extremities are cool and clammy, with a capillary refill time of 4 seconds. The sternal incision is intact without erythema or purulent discharge. Electrocardiography demonstrates sinus tachycardia with low-voltage QRS complexes. Which of the following is the most appropriate next step in the management of this patient?

Match the following primary bone lesions with their most characteristic clinical presentation and radiographic features.

Correlate each of the following lower extremity vascular assessment findings with their most likely underlying surgical or vascular pathology.

A 34-year-old man is brought to the emergency department after a high-speed motorcycle collision. He was found 30 feet from his motorcycle and was unresponsive at the scene. Upon arrival, his temperature is 36.5°C (97.7°F), blood pressure is 76/40 mm Hg, pulse is 138/min, and respiratory rate is 28/min. He is immediately intubated for airway protection. A focused assessment with sonography for trauma (FAST) examination shows no intraperitoneal or pericardial fluid. The pelvis is mechanically stable to anteroposterior and lateral compression. A supine anteroposterior chest radiograph reveals a widened mediastinum, obliteration of the aortic knob, and depression of the left mainstem bronchus. Despite the rapid intravenous infusion of 2 liters of warmed crystalloid and 2 units of type O-negative packed red blood cells, his blood pressure remains 78/42 mm Hg. Which of the following is the most appropriate next step in management?

A 42-year-old man is brought to the emergency department following a high-speed motor vehicle collision. He was the restrained driver. Upon arrival, he is confused and diaphoretic. His temperature is 36.5°C (97.7°F), blood pressure is 78/50 mm Hg, pulse is 132/min, and respiratory rate is 24/min. Pulse oximetry shows 97% on room air. The airway is patent, and breath sounds are clear and equal bilaterally. A focused assessment with sonography for trauma (FAST) examination reveals no free fluid in the peritoneal cavity or pericardial sac. Physical examination demonstrates marked ecchymosis over the lower abdomen and perineum, with severe instability of the pelvic ring on gentle anteroposterior compression. There is blood at the urethral meatus. Bilateral lower extremity pulses are palpable but weak. Motor and sensory examinations of the lower extremities are limited due to patient confusion, but there are no gross deformities of the legs. Two large-bore intravenous lines are placed, and fluid resuscitation with isotonic crystalloid is initiated. Which of the following is the most appropriate next step in management?

Paramedics transport a male patient in his early forties to the trauma center following an industrial accident involving a crushed left lower extremity. Upon arrival, the patient exhibits altered sensorium and profound diaphoresis. Vital signs show a heart rate of 132 beats/min and a blood pressure reading of 78/42 mmHg. Physical assessment highlights a rapidly enlarging, pulsatile swelling in the medial aspect of the left thigh. The ipsilateral foot is pallid, cold, and lacks palpable or Doppler-identifiable pulses. Two large-bore peripheral venous catheters are placed, and fluid resuscitation begins. What is the most critical intervention to perform next for this individual?

A $65$-year-old woman is evaluated on postoperative day $7$ following a right total knee arthroplasty for severe osteoarthritis. She reports sudden, severe pain in the right knee that began yesterday and has progressively worsened. The patient has been compliant with prophylactic apixaban and routine postoperative physical therapy. Her temperature is $38.6^\circ\text{C}$ ($101.5^\circ\text{F}$), blood pressure is $130/80$ mmHg, pulse is $102$/min, and respirations are $16$/min. Physical examination reveals a right knee that is significantly swollen, erythematous, and warm to the touch. The surgical incision is closed and intact without any frank purulent drainage, but there is marked tenderness over the joint capsule. Passive range of motion is extremely limited due to severe pain. Laboratory studies show a leukocyte count of $14,000/\text{mm}^3$ and an erythrocyte sedimentation rate of $85\text{ mm/h}$. Which of the following is the most appropriate next step in management?

A 62-year-old man presents to the emergency department with sudden-onset, severe, tearing anterior chest pain that radiates to his back. His blood pressure is 185/110 mm Hg and heart rate is 112/min. Physical examination reveals a new early diastolic murmur at the right sternal border and a noticeable difference in pulse amplitude between the right and left radial arteries. An acute type A aortic dissection is highly suspected. Arrange the following management steps in the most appropriate chronological sequence for this patient.