Surgery

Match the following specific clinical trauma and burn presentations with their most appropriate immediate next step in management.

A 62-year-old man is evaluated on postoperative day 2 following an elective low anterior resection for rectal cancer. He reports severe, continuous pain at the abdominal incision site that has worsened over the past 6 hours and is disproportionate to his previous postoperative pain. His temperature is $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$), blood pressure is $88/58 \text{ mmHg}$, pulse is $122/\text{min}$, and respiratory rate is $22/\text{min}$. Physical examination reveals significant edema and violaceous discoloration of the skin surrounding the midline incision. Removal of the dressing reveals a thin, grayish fluid leaking from the wound edges. Palpation around the incision elicits exquisite tenderness, though sensation to light touch is decreased near the wound margins. Which of the following is the most appropriate next step in the management of this patient?

Paramedics arrive at the trauma bay with a $24$-year-old construction worker who sustained a stab wound to the left lower chest during an altercation at a job site. The injury occurred approximately $30$ minutes ago. On presentation, blood pressure is $82/45 \text{ mm Hg}$ and heart rate is $134 \text{/min}$. Pulse oximetry shows $96\%$ on supplemental oxygen. Primary survey reveals a $3\text{-cm}$ linear laceration in the left $6^{\text{th}}$ intercostal space at the midclavicular line. The airway is patent. Breath sounds are clear and symmetric bilaterally, and heart sounds are normal without muffling. Examination of the abdomen reveals diffuse rigidity, guarding, and severe tenderness to palpation in all four quadrants. Which of the following is the most appropriate next step in the management of this patient?

A $61$-year-old male is brought to the acute care clinic complaining of severe, unremitting abdominal pain that began suddenly $5$ hours ago. For the past three days, he had experienced mild, crampy abdominal discomfort and nausea, but the pain abruptly intensified today. His past medical history includes an appendectomy during childhood and a cholecystectomy a decade ago. Vital signs show a temperature of $38.9^\circ\text{C}$ ($102.0^\circ\text{F}$), a heart rate of $122\text{ /min}$, and a blood pressure of $92/58\text{ mmHg}$. Physical examination reveals a rigid, distended abdomen with profound guarding and generalized rebound tenderness. Complete blood count demonstrates a leukocyte count of $19,000/\text{mm}^3$. Arterial blood gas analysis reveals a pH of $7.28$, $\text{pCO}_2$ of $32\text{ mmHg}$, and $\text{HCO}_3^-$ of $15\text{ mEq/L}$. Serum lactate is markedly elevated at $5.4\text{ mmol/L}$. An initial plain radiograph reveals multiple dilated loops of small intestine with prominent air-fluid levels. Intravenous fluids and broad-spectrum antibiotics are immediately initiated. Which of the following is the most appropriate next step in the management of this patient?

A 40-year-old female is rescued from an enclosed house fire and brought to the emergency department. She has sustained deep partial-thickness and full-thickness burns over her trunk and extremities. Physical examination reveals soot in her oropharynx, singed nasal hairs, and hoarseness. Her right arm has a circumferential full-thickness burn, and the distal radial pulse is absent on Doppler ultrasound. Arrange the following clinical interventions in the most appropriate chronological sequence according to standard trauma and burn management protocols.

A 72-year-old man with a history of chronic constipation and Parkinson disease is brought to the emergency department with a 2-day history of progressive abdominal distension, obstipation, and crampy, lower abdominal pain. His temperature is 37.2°C (99.0°F), blood pressure is 135/85 mm Hg, pulse is 98/min, and respiratory rate is 16/min. Physical examination reveals a markedly distended, tympanitic abdomen with mild, diffuse tenderness but no guarding, rigidity, or rebound. Bowel sounds are high-pitched. Laboratory studies show mild leukocytosis (11,500/mm³) and a normal serum lactate level. Arrange the following management steps in the most appropriate chronological sequence for this patient.

While recovering in the surgical intensive care unit, a 76-year-old male patient develops acute respiratory distress. He underwent an extensive open bowel resection and anastomosis for mesenteric ischemia approximately four hours ago. The surgical log indicates an estimated blood loss of 1,200 mL, for which he was resuscitated with 3 units of packed red blood cells and 4 liters of lactated Ringer solution. The patient is conscious and complains of severe difficulty breathing. Vital signs reveal a temperature of 38.1°C (100.6°F), blood pressure of 175/98 mm Hg, heart rate of 115/min, and a respiratory rate of 28/min. Pulse oximetry displays an oxygen saturation of 85% on room air. Physical assessment is notable for engorged jugular veins and a prominent S3 heart sound. Auscultation of the chest demonstrates bilateral crackles extending to the mid-lung fields. A portable chest radiograph displays cardiomegaly and bilateral hazy alveolar opacities.

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

An emergency medical team evaluates a 34-year-old female in the emergency department who complains of severe, unrelenting abdominal pain and bilious vomiting for the past 24 hours. The patient underwent an uncomplicated appendectomy 15 years prior. Her temperature is $38.7^\circ\text{C}$ ($101.7^\circ\text{F}$), blood pressure is $88/54\text{ mmHg}$, pulse is $124/\text{min}$, and respiratory rate is $22/\text{min}$. On physical examination, the abdomen is significantly distended and diffusely tender to palpation. Board-like rigidity and rebound tenderness are present across all quadrants. Bowel sounds are absent. Laboratory results demonstrate a leukocyte count of $18,500/\text{mm}^3$ and a serum lactate level of $4.8\text{ mmol/L}$. A supine abdominal radiograph reveals multiple dilated loops of small intestine with prominent air-fluid levels and a paucity of gas in the colon. Which of the following is the most appropriate next step in the management of this patient?

On her sixth day of recovery following a pancreaticoduodenectomy (Whipple procedure) for a pancreatic head mass, a 65-year-old woman is urgently assessed by the rapid response team due to altered mental status. She has a right internal jugular central venous catheter that was placed prior to surgery for hemodynamic monitoring and administration of total parenteral nutrition. Over the past four hours, she has become progressively lethargic. Vital signs show a temperature of 39.2°C (102.6°F), blood pressure of 82/50 mmHg, pulse of 124/min, and respiratory rate of 24/min. Physical examination demonstrates marked erythema, induration, and purulent exudate at the insertion site of the central venous catheter. Her surgical abdominal incision is clean and intact without any drainage. Auscultation of the lungs reveals equal breath sounds bilaterally. A urinary catheter is draining clear, yellow urine. Which of the following are the most appropriate next steps in management? (Select all that apply)

A $27$-year-old male is brought to the emergency department $2$ hours after sustaining thermal injuries in an industrial flash fire. He is awake and alert. His airway is intact with no evidence of inhalational injury. Vital signs show a blood pressure of $115/75$ mm Hg, a heart rate of $108/min$, and a respiratory rate of $18/min$. Physical examination reveals deep partial-thickness burns over his entire anterior chest and abdomen, as well as his entire left upper extremity (circumferential). He weighs $80$ kg. Peripheral intravenous access is established.

Using the traditional Parkland formula ($4$ mL/kg/$\%$ total body surface area), what is the appropriate intravenous fluid administration rate (in mL/hr) for the remainder of the first $8$ hours following the injury?

A 55-year-old man arrives at the emergency department reporting three days of worsening, diffuse abdominal cramps associated with intractable bilious emesis and an inability to pass stool or gas. His medical history is significant for a ruptured appendix requiring an open appendectomy 20 years ago. He was initially evaluated at an urgent care center yesterday and discharged with antiemetics. Over the past 6 hours, his pain has transitioned from intermittent cramping to severe, relentless, and unyielding discomfort. His temperature is 38.9°C (102.0°F), pulse is 126/min, respirations are 24/min, and blood pressure is 92/58 mm Hg. On physical examination, the patient lies completely still. His abdomen is significantly distended, diffusely rigid, and exhibits profound rebound tenderness. Bowel sounds, which he noted were "rumbling" yesterday, are now absent. Laboratory investigations demonstrate a leukocyte count of 19,500/mm³ and a serum lactate level of 4.8 mmol/L. A plain radiograph of the abdomen reveals multiple dilated loops of small intestine with prominent air-fluid levels and an absence of distal colonic gas. No pneumoperitoneum is identified. Which of the following is the most appropriate next step in the management of this patient?

Following a high-velocity collision during a collegiate rugby match, an athlete is transported to the trauma center complaining of progressive lightheadedness and severe left-sided abdominal pain. On arrival, the patient appears pale and diaphoretic. Vital signs show a heart rate of 128/min and a blood pressure of 82/50 mmHg. Primary survey reveals a patent airway, clear breath sounds bilaterally, and a rigid, distended abdomen with significant guarding. After rapid intravenous infusion of 1 liter of warmed lactated Ringer's solution, the blood pressure transiently improves to 105/65 mmHg but subsequently drops to 85/45 mmHg within 10 minutes. A bedside focused assessment with sonography for trauma (FAST) reveals a large amount of anechoic fluid in the splenorenal recess. Which of the following is the most appropriate next step in the management of this patient?

A 78-year-old woman with a history of atrial fibrillation and a recent lapse in her anticoagulant medication presents to the emergency department with a 2-hour history of severe, acute-onset generalized abdominal pain. She reports nausea and one episode of vomiting. Her temperature is 37.2°C (99.0°F), pulse is 118/min and irregular, blood pressure is 138/86 mm Hg, and respirations are 20/min. Physical examination reveals a soft abdomen with minimal tenderness to palpation, which is strikingly disproportionate to the severity of her reported pain. Laboratory studies show a leukocyte count of 18,000/mm³ and a significantly elevated serum lactate level. Arrange the following management steps in the most appropriate sequential order for this patient.

A rapid response code is called for a $71$-year-old man on his fourth day in the hospital after an emergency bowel resection with primary anastomosis for acute mesenteric ischemia. The patient is suddenly experiencing severe, agonizing abdominal pain and difficulty breathing. Vital signs are temperature $39.0^\circ\text{C}$ ($102.2^\circ\text{F}$), blood pressure $84/52\text{ mmHg}$, pulse $138/\text{min}$, and respirations $28/\text{min}$. Oxygen saturation is $94\%$ on $4\text{ L/min}$ via nasal cannula. On physical examination, the patient appears ashen and diaphoretic. Lung auscultation reveals shallow breathing with bibasilar crackles. The abdomen is board-like with diffuse rigidity, severe tenderness to light palpation, and absent bowel sounds. Laboratory studies reveal a leukocyte count of $24,000/\text{mm}^3$ and a serum lactate level of $5.8\text{ mmol/L}$. Which of the following is the most appropriate next step in the management of this patient?

A 19-year-old man is rushed to the trauma center by emergency medical services after being struck by a fast-moving motor vehicle while crossing the street. On arrival, his blood pressure is 72/44 mmHg, heart rate is 140/min, and respiratory rate is 26/min. Pulse oximetry shows 96% on a non-rebreather mask. The airway is patent, and breath sounds are present and equal bilaterally. Trachea is midline. Peripheral pulses are rapid and thready. He immediately receives 1 L of intravenous Ringer's lactate and 1 unit of uncrossmatched packed red blood cells. Reassessment vital signs show a blood pressure of 78/48 mmHg and a heart rate of 130/min. Physical examination reveals a distended abdomen with diffuse guarding and rebound tenderness. The pelvis is mechanically stable to gentle compression. A focused assessment with sonography for trauma (FAST) exam demonstrates a prominent anechoic stripe in the right upper quadrant between the liver and kidney. Which of the following is the most appropriate next step in management?

An $84$-year-old woman is brought to the emergency department from her assisted living facility due to a $3$-day history of progressively worsening nausea, bilious vomiting, and colicky abdominal pain. She has not had a bowel movement or passed flatus for $36$ hours. Her medical history is significant for severe osteoporosis and dementia. Over the past year, she has unintentionally lost $10\text{ kg}$ ($22\text{ lb}$). Vital signs show a temperature of $38.2^\circ\text{C}$ ($100.8^\circ\text{F}$), blood pressure of $96/60\text{ mmHg}$, and pulse of $115/\text{min}$. On physical examination, the abdomen is distended, tympanic, and exhibits high-pitched, tinkling bowel sounds. There is diffuse abdominal tenderness but no overt rigidity. Passive extension and internal rotation of the right hip elicits sharp pain radiating down the medial aspect of the right thigh. Laboratory studies reveal a leukocyte count of $15,200/\text{mm}^3$ and a serum lactate of $3.4\text{ mmol/L}$. Computed tomography of the abdomen and pelvis with intravenous contrast demonstrates markedly dilated loops of small bowel with a transition point in the right pelvis. At the transition point, a small segment of bowel passes through the obturator foramen; this segment shows absent mucosal enhancement. Which of the following is the most appropriate next step in management?

A 68-year-old man is evaluated on postoperative day 5 following an exploratory laparotomy and colon resection for ischemic colitis. He has a medical history of obesity and severe chronic obstructive pulmonary disease. While being assisted out of bed by the nursing staff, he has a violent coughing fit and reports a sudden "tearing" sensation in his abdomen. His temperature is 37.2°C (99.0°F), blood pressure is 130/80 mm Hg, pulse is 98/min, and respirations are 18/min. Physical examination reveals that the lower half of the surgical incision has separated, and several loops of small bowel are visibly protruding through the fascial defect onto the abdominal wall. Arrange the following management steps in the most appropriate chronological order.

A 34-year-old industrial worker is brought to the trauma bay after being involved in an accident with heavy machinery. On arrival, he has a pulsatile, massive hemorrhage from a mangled right leg. He is making gurgling sounds, his respiratory rate is 8/min, and he has a weak radial pulse of 130/min.

Arrange the following acute management steps in the correct chronological sequence according to current Advanced Trauma Life Support (ATLS) principles.

Match each acute abdominal clinical presentation with its most appropriate initial definitive management strategy.

During morning rounds on his sixth postoperative day, a $60$-year-old male patient is noted to have a new-onset fever. Six days ago, he underwent an open sigmoid colectomy to treat complicated diverticulitis. His medical history is significant for obesity, type 2 diabetes mellitus, and chronic obstructive pulmonary disease. His temperature is $38.9^\circ\text{C}$ ($102.0^\circ\text{F}$), blood pressure is $132/84\text{ mm Hg}$, pulse is $102/\text{min}$, and respirations are $18/\text{min}$. Oxygen saturation is $94\%$ on room air. He reports generalized fatigue and worsening pain around his abdominal incision. Physical examination reveals mild bilateral basilar crackles that clear with coughing. The abdomen is non-distended. The midline laparotomy incision exhibits a $5\text{-cm}$ area of erythema, induration, and tenderness. Gentle pressure applied adjacent to the incision yields thick, purulent fluid from between two surgical staples. There is no calf tenderness or swelling. Which of the following is the most appropriate next step in management?