Surgery

A $27$-year-old man is brought to the emergency department after sustaining a single stab wound during an altercation. The wound is located in the left $7\text{th}$ intercostal space at the midaxillary line. On arrival, he is lethargic and noticeably diaphoretic. His temperature is $36.8^\circ\text{C}$ ($98.2^\circ\text{F}$), heart rate is $132/\text{min}$, blood pressure is $75/45\text{ mmHg}$, and respiratory rate is $24/\text{min}$.

On primary survey, his airway is patent. Breath sounds are equal and clear bilaterally. A portable chest radiograph shows a normal mediastinal silhouette and no evidence of pneumothorax or hemothorax. The abdomen is moderately distended, but there is no evisceration. A Focused Assessment with Sonography for Trauma (FAST) examination reveals a significant amount of free fluid in the splenorenal recess.

The patient receives a rapid infusion of $1\text{ L}$ of warmed lactated Ringer solution and $1$ unit of emergency-release type O-negative blood. Reassessment reveals a blood pressure of $78/40\text{ mmHg}$ and a heart rate of $128/\text{min}$.

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

A $28$-year-old male is brought to the trauma bay via helicopter emergency medical services following a severe industrial explosion. On arrival, he is unresponsive. Vital signs are temperature $35.2^{\circ}\text{C}$ ($95.4^{\circ}\text{F}$), blood pressure $70/40\text{ mm Hg}$, heart rate $148/\text{min}$, and respiratory rate $34/\text{min}$. Physical examination reveals sonorous respirations and massive maxillofacial trauma. The trachea is deviated to the left, and breath sounds are absent over the right hemithorax. There is a traumatic amputation of the right mid-thigh with continuous, high-volume pulsatile bleeding. His Glasgow Coma Scale score is $6$. Based on current Advanced Trauma Life Support (ATLS) guidelines, arrange the following initial management steps in the correct chronological sequence.

A 58-year-old man is evaluated on postoperative day 5 following an elective left hemicolectomy for colon cancer. Over the past 12 hours, he has developed worsening left lower quadrant abdominal pain, nausea, and chills. His temperature is 39.2°C (102.5°F), heart rate is 115/min, respirations are 20/min, and blood pressure is 112/70 mmHg. Oxygen saturation is 96% on room air. Abdominal examination reveals localized tenderness and voluntary guarding in the left lower quadrant, but no generalized rigidity. Bowel sounds are hypoactive. The surgical incision is clean with no surrounding erythema or discharge.

Arrange the following management steps in the most appropriate chronological order for this patient.

A 35-year-old woman is brought to the emergency department after being rescued from a closed-space house fire. She has deep partial-thickness and full-thickness burns over 40% of her total body surface area. On examination, she has singed facial hair, carbonaceous sputum, and a noticeably hoarse voice. Her blood pressure is 90/60 mm Hg, and her heart rate is 120/min. Arrange the following management steps in the most appropriate chronological sequence for this patient according to standard trauma principles.

Emergency medical services bring a $72$-year-old female to the acute care facility following the acute onset of severe, unrelenting diffuse abdominal pain. The patient reports that the pain started roughly $6$ hours ago and has been associated with recurrent bilious emesis and absolute constipation. Her surgical history includes a laparotomy for a perforated appendix during childhood. Current vital signs include a temperature of $38.6^\circ\text{C}$ ($101.5^\circ\text{F}$), a heart rate of $118\text{/min}$, a blood pressure of $95/58\text{ mmHg}$, and a respiratory rate of $22\text{/min}$. On abdominal evaluation, the abdomen is tensely distended with high-pitched 'tinkling' sounds initially, which have now progressed to absent bowel sounds. Palpation elicits diffuse rigidity, marked rebound tenderness, and involuntary guarding. Laboratory results reveal a white blood cell count of $18,500/\text{mm}^3$ and a serum lactate concentration of $4.8\text{ mmol/L}$. Initial plain films of the abdomen display prominently dilated small bowel loops with differential air-fluid levels and an absence of gas in the distal colon. Which of the following represents the most appropriate definitive management for this patient?

A 45-year-old woman is evaluated on postoperative day 2 following an open myomectomy for symptomatic uterine fibroids. She reports diffuse abdominal fullness, mild cramping, and persistent nausea. She has not passed flatus or had a bowel movement since the procedure. Her pain is currently being managed with intravenous hydromorphone via patient-controlled analgesia.

Her temperature is $37.8^\circ\text{C}$ ($100.0^\circ\text{F}$), blood pressure is $118/76 \text{ mm Hg}$, pulse is $88/\text{min}$, and respirations are $14/\text{min}$. Pulse oximetry shows $98\%$ on room air. The abdomen is moderately distended and tympanic on percussion. Bowel sounds are hypoactive. There is mild, diffuse abdominal tenderness, but no guarding, rigidity, or rebound tenderness is present. The surgical incision is clean, dry, and intact. Laboratory evaluation shows a leukocyte count of $9,500/\text{mm}^3$ and a serum potassium level of $4.1 \text{ mEq/L}$.

Which of the following are the most appropriate next steps in the management of this patient? (Select two)

Emergency medical responders transport a 46-year-old pedestrian to the acute resuscitation area after he was struck by a sport utility vehicle. Upon arrival, the patient is unresponsive with a Glasgow Coma Scale score of 6. His blood pressure is 76/40 mmHg, heart rate is 138/min, and respiratory rate is 28/min. The right pupil is 6 mm and unreactive to light, while the left pupil is 3 mm and reactive. Physical examination reveals massive bruising over the left lower chest and a distended, tense abdomen. A portable chest radiograph shows left-sided rib fractures without pneumothorax or hemothorax. A focused assessment with sonography for trauma (FAST) demonstrates a large amount of anechoic fluid in the splenorenal and hepatorenal recesses. The patient is rapidly intubated and receives 1 unit of uncrossmatched type O-negative blood, after which his blood pressure remains 78/42 mmHg. Which of the following is the most appropriate next step in the management of this patient?

A 32-year-old male construction worker is brought to the emergency department after a high-voltage electrical injury. He was electrocuted by a live power line exactly 2 hours prior to arrival. On presentation, he is awake and reports severe pain. His vital signs show a blood pressure of 105/65 mm Hg, heart rate of 118/min, and respiratory rate of 20/min. Physical examination reveals deep, charred, full-thickness burns covering his entire right lower extremity, his entire left lower extremity, and his entire right upper extremity. His estimated body weight is 80 kg. A Foley catheter is placed, yielding dark brown urine.

Based on current Advanced Trauma Life Support (ATLS) guidelines for electrical burns, at what rate should the initial intravenous crystalloid infusion be set to deliver the appropriate resuscitation volume for the remainder of the first 8-hour period?

A 43-year-old gentleman arrives at the triage center reporting intermittent, cramping abdominal pain that started $24\text{ hours}$ ago. He has had multiple episodes of greenish vomiting and has not passed flatus since yesterday. His past surgical history is notable for an exploratory laparotomy for a gunshot wound a decade ago. Vital signs show a heart rate of $98/\text{min}$, blood pressure of $122/78\text{ mmHg}$, and temperature of $37.3^\circ\text{C}$ ($99.1^\circ\text{F}$). On physical examination, the abdomen is markedly distended with high-pitched 'tinkling' bowel sounds. There is generalized mild tenderness to palpation, but no rebound, rigidity, or guarding is elicited. Laboratory results reveal a leukocyte count of $8,500/\text{mm}^3$ and a normal basic metabolic panel. An abdominal CT scan with intravenous contrast demonstrates multiple dilated loops of small intestine with a distinct transition point in the mid-abdomen, decompressed colon, and normal bowel wall enhancement without free fluid or free air. Which of the following is the most appropriate next step in the management of this patient?

A 52-year-old man weighing $85\text{ kg}$ is brought to the emergency department after being trapped in a residential garage fire. The injury occurred exactly 2 hours prior to his arrival. On examination, he has deep partial-thickness and full-thickness burns involving the entire anterior trunk, the entire right upper extremity, and the anterior surface of the left lower extremity. He has no inhalation injury, and his airway is patent. Intravenous access is established. According to current Advanced Trauma Life Support (ATLS) guidelines for adult thermal burns, what should be the initial intravenous fluid infusion rate in $\text{mL/hr}$ to administer the first half of his calculated resuscitation volume?

Match each patient's clinical presentation with the most likely underlying postoperative or gastrointestinal complication.

A $62$-year-old man arrives at the emergency department via helicopter after falling approximately $20$ feet from a roof. The patient was intubated in the field due to a depressed level of consciousness. Upon arrival, his blood pressure is $74/42$ mm Hg and his heart rate is $144$/min. Breath sounds are symmetric and clear bilaterally. The pelvis is stable to anteroposterior compression. Physical examination reveals a large right-sided parietal scalp hematoma. The right pupil is $5$ mm and reacts sluggishly to light, while the left pupil is $3$ mm and briskly reactive. His abdomen is markedly distended and tense. Bedside focused assessment with sonography for trauma (FAST) demonstrates significant anechoic fluid in the hepatorenal and splenorenal recesses. What is the most appropriate next step in the management of this patient?

A 34-year-old woman is brought to the emergency department by paramedics after being assaulted at a local park. She sustained a single stab wound to her left flank with a pocket knife approximately 20 minutes ago. On arrival, she is lethargic and pale. Her temperature is 36.2°C (97.2°F), blood pressure is 82/40 mm Hg, pulse is 138/min, and respirations are 26/min. Pulse oximetry shows 96% on room air. The airway is patent, and breath sounds are clear and equal bilaterally. Physical examination reveals a 4-cm laceration located posterior to the left midaxillary line, midway between the 12th rib and the iliac crest. There is minimal active bleeding from the wound. A focused assessment with sonography for trauma (FAST) demonstrates no free fluid in the perihepatic, perisplenic, pelvic, or pericardial windows. Following the rapid intravenous infusion of 1 L of warmed lactated Ringer solution, her blood pressure is 84/42 mm Hg and pulse is 132/min. Which of the following is the most appropriate next step in management?

A 62-year-old woman is evaluated on postoperative day 6 following an open total abdominal hysterectomy and bilateral salpingo-oophorectomy for endometrial cancer. She reports the sudden onset of right-sided chest pain that worsens with deep inspiration, accompanied by mild shortness of breath. She has a medical history of chronic obstructive pulmonary disease, hypertension, and type 2 diabetes mellitus. Her current medications include inhaled tiotropium and subcutaneous prophylactic enoxaparin. Vital signs are:

Temperature: 37.8°C (100.0°F)
Blood pressure: 118/76 mmHg
Pulse: 114/min
Respirations: 22/min
Oxygen saturation: 90% on room air

Physical examination reveals a patient in mild respiratory distress. Jugular venous pressure is normal. Lung auscultation reveals clear breath sounds bilaterally without wheezes or crackles. Cardiac examination shows tachycardia with a regular rhythm; no murmurs, rubs, or gallops are heard. The abdominal incision is clean, dry, and well-approximated without erythema. Her right calf is visibly swollen, erythematous, and tender to palpation compared to the left.

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

A 56-year-old man is brought to the emergency department due to the sudden onset of severe, diffuse abdominal pain that began 2 hours ago. He has a history of osteoarthritis for which he takes naproxen daily. His temperature is $38.2^\circ\text{C}$ ($100.8^\circ\text{F}$), pulse is $122/\text{min}$, respirations are $24/\text{min}$, and blood pressure is $88/56\text{ mmHg}$. On physical examination, the patient is lying completely still on the stretcher. The abdomen is diffusely tender to palpation with board-like rigidity and pronounced rebound tenderness. Bowel sounds are absent. Intravenous fluid resuscitation and broad-spectrum antibiotics are initiated. An upright chest radiograph reveals a crescent of radiolucency between the liver and the right hemidiaphragm. Which of the following is the most appropriate next step in management?

A 62-year-old woman is admitted to the hospital with a 3-day history of severe left lower quadrant abdominal pain, fever, and nausea. Her temperature is $38.7^{\circ}\text{C}$ ($101.7^{\circ}\text{F}$), blood pressure is $118/76\text{ mmHg}$, and heart rate is $92/\text{min}$. Physical examination reveals marked tenderness in the left lower quadrant without diffuse rebound tenderness or guarding. Laboratory studies show a leukocyte count of $16,500/\text{mm}^3$. A computed tomography (CT) scan of the abdomen and pelvis with intravenous contrast reveals acute sigmoid diverticulitis complicated by a $5.5\text{ cm}$ peridiverticular abscess. Arrange the following management steps in the most appropriate chronological sequence for this patient.

Review the following descriptions of patients presenting to the emergency department following various traumatic events. Pair each specific clinical scenario with its unequivocally correct next step in diagnostic evaluation or acute management.

A $72$-year-old man is evaluated on the surgical ward for a new-onset fever. He is currently on postoperative day $3$ following an elective open lower anterior resection for rectal adenocarcinoma. His medical history is significant for hypertension and type $2$ diabetes mellitus. His temperature is $38.8^\circ\text{C}$ ($101.8^\circ\text{F}$), blood pressure is $132/82\text{ mm Hg}$, pulse is $94/\text{min}$, and respirations are $16/\text{min}$. Oxygen saturation is $97\%$ on room air. The patient reports mild, well-controlled pain at his surgical site but notes a new onset of burning with urination and a sensation of incomplete bladder emptying. His indwelling urinary catheter was removed $24$ hours ago. Physical examination shows a soft, non-distended abdomen with normal active bowel sounds. The surgical incision is clean, dry, and intact without erythema, induration, or purulent drainage. Lung fields are clear to auscultation bilaterally. The calves are soft and non-tender. Which of the following is the most appropriate next step in management?

A rapid response is called for a 67-year-old male inpatient recovering from an emergent open sigmoid colectomy performed 5 days ago for perforated diverticulitis. He has a history of severe chronic obstructive pulmonary disease and obesity (BMI $41 \text{ kg/m}^2$). His vital signs are temperature $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure $145/85 \text{ mmHg}$, heart rate $110/\text{min}$, and respiratory rate $22/\text{min}$. The nursing staff reports that while the patient was having a violent coughing fit, his abdominal binder became saturated with copious amounts of a pink, salmon-colored fluid. Upon removal of the binder and surgical dressings, it is immediately apparent that the midline abdominal incision has dehisced and multiple loops of small intestine are protruding outside the abdominal cavity onto the skin.

Arrange the following steps for the definitive management of this patient's surgical complication in the most appropriate chronological order.

A 31-year-old woman comes to the emergency department due to the sudden onset of severe, unremitting mid-abdominal pain that began 6 hours ago. The pain is associated with nausea and multiple episodes of non-bilious vomiting. Two years ago, she underwent a laparoscopic Roux-en-Y gastric bypass for morbid obesity, losing $45\text{ kg}$ ($99\text{ lb}$) since the procedure. Her temperature is $38.2^\circ\text{C}$ ($100.8^\circ\text{F}$), pulse is $126\text{/min}$, and blood pressure is $90/58\text{ mm Hg}$. Physical examination shows a significantly distended abdomen that is exquisitely tender to palpation, with involuntary guarding and rebound tenderness. Laboratory evaluation reveals a leukocyte count of $17,500\text{/mm}^3$ and a serum lactate level of $4.8\text{ mmol/L}$. A computed tomography scan of the abdomen demonstrates dilated loops of small intestine with a 'swirl sign' of the mesenteric vessels. Which of the following is the most appropriate next step in management?