Trauma and Burns

283 questions

All types283 Multiple choice148 Numeric38 Matching52 Ordering45

A 29-year-old man arrives at the trauma center via ambulance following an altercation where he sustained a stab wound to the periumbilical region. En route, he received $1$ L of intravenous crystalloid. Upon arrival, he appears pale and confused. Vital signs show a temperature of $36.6^\circ\text{C}$ ( $97.9^\circ\text{F}$ ), blood pressure of $78/45\text{ mm Hg}$ , heart rate of $138\text{/min}$ , and respiratory rate of $28\text{/min}$ . The airway is clear, and bilateral breath sounds are normal. Examination of the abdomen reveals a $4$ -cm transverse laceration $2\text{ cm}$ to the left of the umbilicus. The abdomen is rigid with severe diffuse tenderness and rebound. Intravenous access is secured with two large-bore peripheral catheters, and uncrossmatched blood transfusions are initiated. Which of the following is the most appropriate next step in management?

Emergent celiotomy

Point-of-care ultrasound of the abdomen

Multidetector CT scan of the abdomen and pelvis

Local wound exploration at the bedside

Diagnostic peritoneal lavage

Show answer & explanation

Answer: Emergent celiotomy

Answer

Emergent celiotomy

The correct approach for this patient is immediate surgical exploration. In the setting of penetrating abdominal trauma, absolute indications for emergent celiotomy (laparotomy) include hemodynamic instability (e.g., systolic blood pressure <

90\text{ mm Hg}

), generalized peritonitis (e.g., rigidity, rebound tenderness), evisceration, and blood from a nasogastric tube or on rectal examination. This patient presents in hemorrhagic shock and has classic signs of peritonitis, mandating prompt transfer to the operating room to control bleeding and hollow viscus injury.

Step-by-Step Solution

Identify the mechanism of injury and the patient's hemodynamic status.

The patient has penetrating abdominal trauma (stab wound) and is hemodynamically unstable (hypotensive, tachycardic, confused).

Hemodynamic status determines whether a patient can safely undergo imaging or requires immediate operative intervention.

Evaluate the physical examination findings.

The patient exhibits a rigid abdomen with diffuse tenderness and rebound, indicating peritonitis.

Peritonitis following penetrating trauma strongly suggests bowel perforation or significant intra-abdominal bleeding.

Determine the appropriate management pathway according to ATLS guidelines.

The combination of penetrating trauma, hemodynamic instability, and peritonitis dictates immediate surgical exploration.

Any delay for diagnostic imaging in this clinical scenario increases mortality risk.

Key Concept

Indications for immediate laparotomy (celiotomy) in penetrating abdominal trauma include hemodynamic instability, peritonitis, or evisceration.

Question 222Question →

An emergency medical crew transports a 35-year-old female equestrian to the trauma bay after she was violently thrown from her horse and trampled. She arrives fully immobilized on a backboard with a cervical collar. Her airway is patent and self-maintained. Initial vital signs demonstrate a heart rate of 142/min, blood pressure of 72/38 mm Hg, and a respiratory rate of 26/min. Both lungs are clear to auscultation bilaterally, and heart sounds are crisp and normal. There is extensive ecchymosis across her anterior chest wall and lower abdomen. Pelvic compression elicits no crepitus or mechanical instability. A portable supine anteroposterior chest radiograph reveals a widened mediastinal silhouette and deviation of the trachea to the right, with no evidence of hemothorax or pneumothorax. A bedside focused assessment with sonography for trauma (FAST) demonstrates a large volume of anechoic fluid in the hepatorenal space (Morison pouch) and the rectouterine pouch. Which of the following is the most appropriate next step in the management of this patient?

Computed tomography angiography of the chest and abdomen

Exploratory laparotomy

Diagnostic peritoneal lavage

Placement of a pelvic binder

Resuscitative left anterolateral thoracotomy

Show answer & explanation

Answer: Exploratory laparotomy

Answer

Exploratory laparotomy

Exploratory laparotomy is the correct next step because the patient is in profound hemorrhagic shock with clear evidence of intraperitoneal bleeding on the FAST exam. While the widened mediastinum on the chest radiograph is highly suspicious for a blunt thoracic aortic injury (BTAI), most patients who survive to reach the hospital with a BTAI have a temporarily contained hematoma. In contrast, the active intra-abdominal hemorrhage is the immediate driver of her shock and will be rapidly fatal if not addressed. ATLS guidelines mandate that the active, uncontained source of bleeding be controlled first in the operating room. Advanced imaging for the aorta can be pursued once the patient is hemodynamically stabilized post-laparotomy.

Step-by-Step Solution

Assess the patient's hemodynamic status.

The patient is in Class III/IV hemorrhagic shock (heart rate 142/min, blood pressure 72/38 mm Hg).

Hemodynamic instability dictates the urgency and location of the next intervention (operating room vs. imaging suite).

Analyze the primary survey and diagnostic adjuncts.

FAST is strongly positive for intraperitoneal hemorrhage. The chest x-ray suggests a blunt thoracic aortic injury (BTAI) due to the widened mediastinum.

Identifying all potential sources of life-threatening hemorrhage is necessary to prioritize surgical interventions.

Determine the priority of intervention based on ATLS protocols.

Active intra-abdominal bleeding takes precedence. The BTAI is likely contained by the adventitia as a pseudoaneurysm.

In polytrauma, the immediate cause of decompensation (free intra-abdominal hemorrhage) must be surgically controlled before evaluating or treating temporarily contained injuries.

Select the definitive management step.

The patient must be taken immediately for an exploratory laparotomy.

Laparotomy is the definitive treatment for uncontrolled intra-abdominal hemorrhage in an unstable patient.

Key Concept

In patients with multiple traumatic injuries, hemodynamic instability driven by active intra-abdominal hemorrhage (positive FAST) requires immediate exploratory laparotomy. Evaluation of suspected blunt thoracic aortic injury must be deferred until after the primary source of bleeding is surgically controlled.

Question 223Question →

A $45$ -year-old man is brought to the burn center via helicopter after an industrial explosion. The incident occurred exactly $3$ hours prior to his arrival. He weighs $100$ kg. Physical examination reveals deep partial-thickness burns over his entire anterior trunk, entire right arm, and entire left arm. His airway is secure, and he is hemodynamically stable. Two large-bore intravenous lines are placed. Based on current Advanced Trauma Life Support (ATLS) guidelines (using $2 \text{ mL/kg} \times \%\text{TBSA}$ for adult thermal burns), at what rate (in $\text{mL/hr}$ ) should the intravenous lactated Ringer's solution be administered for the remainder of the first $8$ -hour post-injury period?

Show answer & explanation

Answer: 720

Answer

720

The correct infusion rate is

720 \text{ mL/hr}

. To determine this, first calculate the TBSA using the Rule of Nines: the entire anterior trunk (

18\%

), right arm (

9\%

), and left arm (

9\%

) sum to

36\%

. Using the modern ATLS fluid resuscitation formula for adults with thermal burns (

2 \text{ mL} \times \text{weight in kg} \times \%\text{TBSA}

), the total 24-hour fluid requirement is

2 \times 100 \times 36 = 7200 \text{ mL}

. Exactly half of this volume (

3600 \text{ mL}

) must be administered in the first 8 hours from the time of the injury. Since the injury occurred

3

hours prior to arrival, there are only

5

hours remaining in this initial 8-hour window. Therefore, the rate is

3600 \text{ mL} / 5 \text{ hours} = 720 \text{ mL/hr}

Step-by-Step Solution

Calculate the estimated burn size using the Rule of Nines.

36\%

TBSA

Accurate estimation of Total Body Surface Area (TBSA) is required to calculate fluid needs. Anterior trunk =

18\%

, right arm =

9\%

, left arm =

9\%

Calculate the total 24-hour fluid requirement using the ATLS formula.

7200 \text{ mL}

The formula is

2 \text{ mL} \times \text{weight in kg} \times \%\text{TBSA}

. Therefore,

2 \times 100 \times 36 = 7200 \text{ mL}

Determine the fluid volume targeted for the first 8 hours post-injury.

3600 \text{ mL}

Half of the total 24-hour calculated volume must be administered during the first 8 hours following the time of the burn.

Calculate the infusion rate over the remaining time in the first 8-hour window.

720 \text{ mL/hr}

Because

3

hours have already passed since the injury, the

3600 \text{ mL}

must be delivered over the remaining

5

hours (

3600 / 5 = 720

Key Concept

Burn resuscitation fluid calculation requires assessing TBSA, using the

2 \text{ mL/kg/}\text{TBSA}

formula, providing half the total fluid in the first 8 hours, and subtracting any elapsed time from that 8-hour window to determine the current hourly rate.

Estimated Time:1m 30s

Question 224Question →

A 26-year-old man weighing 90 kg is brought to the emergency department 2 hours after being rescued from a house fire. On primary survey, his airway is patent, and he is breathing spontaneously on supplemental oxygen without evidence of inhalation injury. Vital signs include a blood pressure of 110/70 mm Hg, heart rate of 115/min, and respiratory rate of 18/min. Physical examination reveals deep partial-thickness burns with blistering over his entire anterior trunk, entire left arm, and the anterior surface of his left leg. The skin on his face is erythematous and highly sensitive to touch, but no blisters are present. Two large-bore intravenous catheters were placed at the scene, but no intravenous fluids have been administered yet.

Based on current Advanced Trauma Life Support (ATLS) guidelines for adult thermal burns, what is the appropriate targeted intravenous fluid administration rate (in mL/hour) for the remainder of the first 8-hour period following the burn?

Show answer & explanation

Answer: 540

Answer

540

The updated ATLS protocol for adult thermal burns dictates using 2 mL of lactated Ringer solution per kg of body weight per percentage of TBSA. TBSA calculations only include partial-thickness and full-thickness burns (anterior trunk 18% + left arm 9% + anterior left leg 9% = 36%). Superficial face burns are excluded. The 24-hour fluid total is 2 mL x 90 kg x 36% = 6,480 mL. Half of this volume (3,240 mL) is given in the first 8 hours from the time of injury. Since 2 hours have already passed, the 3,240 mL must be infused over the remaining 6 hours, resulting in a target rate of 540 mL/hour.

Step-by-Step Solution

Calculate the Total Body Surface Area (TBSA) affected by second- and third-degree burns using the Rule of Nines.

TBSA = 36%

The anterior trunk is 18%, the entire left arm is 9%, and the anterior left leg is 9%. Superficial (first-degree) burns, such as those on the patient's face, do not count toward TBSA for fluid resuscitation.

Calculate the total 24-hour resuscitation fluid requirement using the updated ATLS formula for adult thermal burns.

Total 24-hour fluid = 6,480 mL

The current standard is 2 mL x weight in kg x %TBSA. Therefore, 2 x 90 x 36 = 6,480 mL.

Determine the fluid volume required for the first 8-hour period post-injury.

First 8-hour volume = 3,240 mL

Exactly half of the total calculated 24-hour fluid must be administered within the first 8 hours following the exact time of the burn.

Calculate the appropriate hourly infusion rate based on the time elapsed since the injury.

Infusion rate = 540 mL/hour

The patient arrived 2 hours after the injury, leaving only 6 hours remaining in the initial 8-hour window. Dividing 3,240 mL by 6 hours yields 540 mL/hour.

Key Concept

Burn fluid resuscitation calculations must use the updated ATLS guidelines (2 mL/kg/%TBSA for adults), exclude superficial burns, and account for the time elapsed since the injury.

Alternative Method

An alternative mathematical shortcut is to calculate the initial 8-hour total directly as (1 mL x weight in kg x %TBSA), which yields 1 x 90 x 36 = 3,240 mL, and then divide by the remaining hours.

Estimated Time:2m 0s

Question 225Question →

Determine the most appropriate immediate surgical or procedural intervention for each of the following critically injured trauma patients.

Click a left item, then click its matching right item

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Answer

The correct pairings identify the immediate life-saving intervention for each specific traumatic presentation based on ATLS protocols: cardiac tamponade requires thoracotomy, retroperitoneal pelvic bleeding requires angiography or packing, unstable intraperitoneal bleeding requires laparotomy, a 'cannot intubate, cannot oxygenate' airway requires cricothyroidotomy, and hard signs of vascular injury require operative exploration.

Each clinical scenario presents a classic ATLS decision point. The neck stab wound patient has an impending airway disaster with failed intubation, necessitating a surgical cricothyroidotomy. The patient with the parasternal stab wound has cardiac tamponade and requires a thoracotomy. The blunt abdominal trauma patient is unstable with a positive FAST, mandating an exploratory laparotomy. The pelvic fracture patient is unstable with a negative FAST, meaning the bleeding is retroperitoneal and requires angioembolization or packing. Finally, the extremity trauma patient has hard signs of vascular injury, requiring immediate operative vascular exploration.

Step-by-Step Solution

Evaluate the airway and breathing status.

The patient with the neck stab wound and failed intubation has a definitively compromised airway.

Airway is the first priority in the ATLS primary survey, and a definitive surgical airway must be established when non-surgical methods fail.

Assess circulation and identify the anatomical source of shock.

Shock sources are localized to the pericardium (tamponade), retroperitoneum (pelvis), and intraperitoneal space (abdomen).

Interventions for shock are location-specific; misidentifying the bleeding source leads to incorrect and potentially fatal surgical approaches.

Match specific hard signs of vascular trauma to operative management.

The extremity gunshot wound exhibits hard signs (pulsatile hematoma, absent pulses).

Hard signs of vascular injury mandate immediate surgical exploration rather than further diagnostic imaging.

Key Concept

Advanced Trauma Life Support (ATLS) Primary Survey and Resuscitation Algorithms

Question 226Question →

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?

Computed tomography scan of the abdomen and pelvis

Diagnostic peritoneal lavage

Immediate exploratory laparotomy

Left-sided tube thoracostomy

Local wound exploration

Show answer & explanation

Answer: Immediate exploratory laparotomy

Answer

Immediate exploratory laparotomy

The correct answer is immediate exploratory laparotomy. This patient has sustained a penetrating stab wound to the thoracoabdominal region (the "box," extending from the

4\text{th}

intercostal space down to the costal margins), which carries a high risk of intra-abdominal injury due to diaphragmatic excursion. He presents in hemorrhagic shock that is unresponsive to initial fluid and blood resuscitation. The primary survey and normal portable chest radiograph effectively rule out a massive hemothorax or tension pneumothorax as the cause of his shock. Concurrently, the Focused Assessment with Sonography for Trauma (FAST) examination confirms the presence of intraperitoneal hemorrhage. According to standard trauma protocols, any patient with penetrating trauma who is hemodynamically unstable and has evidence of intraperitoneal bleeding (e.g., a positive FAST) or peritonitis must bypass further diagnostic testing and proceed directly to the operating room for an immediate exploratory laparotomy to surgically control the hemorrhage.

Step-by-Step Solution

Evaluate the patient's hemodynamic status and mechanism of injury.

The patient has a penetrating stab wound to the left

7\text{th}

intercostal space and is in hemorrhagic shock (BP

75/45\text{ mmHg}

, HR

132/\text{min}

) that is unresponsive to initial fluid and blood resuscitation.

Hemodynamic instability determines the urgency of intervention and strictly precludes time-consuming diagnostic tests like CT scans.

Assess the primary survey and imaging adjuncts to localize the source of bleeding.

Clear breath sounds and a normal chest radiograph effectively rule out life-threatening intrathoracic bleeding. The FAST examination is positive for free fluid in the splenorenal recess.

Stab wounds below the

4\text{th}

intercostal space can involve the abdomen due to diaphragmatic excursion. The positive FAST confirms an intraperitoneal source for the hemorrhagic shock.

Determine the next best step in management based on the algorithmic approach to trauma.

Proceed directly to immediate exploratory laparotomy.

Any hemodynamically unstable patient with penetrating thoracoabdominal trauma and evidence of intraperitoneal bleeding requires immediate surgical exploration for hemorrhage control.

Key Concept

Hemodynamically unstable patients with penetrating thoracoabdominal trauma and a positive FAST examination require immediate exploratory laparotomy.

Question 227Question →

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.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is: 1) Apply a proximal right lower extremity tourniquet, 2) Perform endotracheal intubation with in-line cervical stabilization, 3) Perform a right-sided tube thoracostomy, 4) Initiate massive transfusion with uncrossmatched blood products, 5) Remove all clothing and apply external warming devices.

The Advanced Trauma Life Support (ATLS) primary survey protocol utilizes the <C>ABCDE algorithm to identify and treat the most immediate life-threatening injuries first. '<C>' stands for Catastrophic hemorrhage, which must be controlled instantly (e.g., via tourniquet for an amputation). Next is 'A' for Airway with cervical spine protection (intubation for GCS < 8). This is followed by 'B' for Breathing (tube thoracostomy for tension pneumothorax). Then 'C' for Circulation (massive transfusion for profound shock). The survey concludes with 'D' for Disability (neurologic exam) and 'E' for Exposure and environmental control (completely undressing the patient while preventing hypothermia).

Step-by-Step Solution

Address Catastrophic Hemorrhage (<C>)

Apply a proximal right lower extremity tourniquet.

Exsanguinating external hemorrhage will lead to death more rapidly than any other injury. Modern ATLS protocols prioritize catastrophic bleeding control before the airway.

Secure the Airway (A)

Perform endotracheal intubation with in-line cervical stabilization.

The patient is comatose (GCS 6) with sonorous respirations and maxillofacial trauma, indicating failure to protect the airway. A definitive airway must be established while restricting cervical spine motion.

Manage Breathing and Ventilation (B)

Perform a right-sided tube thoracostomy.

The patient has a right-sided tension pneumothorax (absent breath sounds, leftward tracheal deviation, hemodynamic instability) that must be decompressed immediately after the airway is secured.

Support Circulation (C)

Initiate massive transfusion with uncrossmatched blood products.

Following control of catastrophic bleeding and thoracic decompression, the patient's class IV hemorrhagic shock is resuscitated using balanced blood products rather than large volumes of crystalloid.

Perform Exposure/Environmental Control (E)

Remove all clothing and apply external warming devices.

The patient must be completely exposed to find all injuries, followed by immediate application of warm blankets to prevent the lethal triad of trauma (hypothermia, coagulopathy, acidosis).

Key Concept

The ATLS primary survey follows the <C>ABCDE sequence: Catastrophic hemorrhage control, Airway, Breathing, Circulation, Disability, and Exposure.

Question 228Question →

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.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct chronological sequence follows the standard primary survey and resuscitation guidelines: first secure the airway via endotracheal intubation, then establish large-bore intravenous access, initiate crystalloid fluid resuscitation, place a urinary catheter to monitor resuscitation adequacy, and finally apply topical wound dressings.

In accordance with standard trauma principles, management follows the ABCs (Airway, Breathing, Circulation). For this patient, clinical signs point to an inhalation injury (hoarseness, singed hair), making prophylactic intubation the absolute first priority (Airway). This is followed by establishing vascular access and initiating fluid resuscitation to combat distributive shock (Circulation). Monitoring adjuncts such as a urinary catheter are placed next to guide fluid rates. Finally, burn wound care is deferred until the primary survey is complete and the patient is stabilized.

Step-by-Step Solution

Assess and secure the airway.

Endotracheal intubation is performed.

Clinical signs of inhalation injury dictate immediate airway protection before progressive edema causes complete obstruction.

Ensure vascular access for resuscitation.

Large-bore peripheral intravenous access is established.

The patient is hypotensive and requires immediate access to the circulatory system for volume replacement.

Restore intravascular volume.

Calculated crystalloid fluid resuscitation is initiated.

Extensive burns cause massive fluid shifts; early and aggressive volume replacement is necessary to prevent burn shock.

Establish monitoring for resuscitation adequacy.

A urinary catheter is placed.

Urine output must be strictly monitored as it represents the most accurate clinical gauge of tissue perfusion during burn resuscitation.

Perform local wound care.

Topical antimicrobials and nonadherent dressings are applied.

Wound management is part of the secondary survey and is only performed after life-threatening systemic derangements are addressed.

Key Concept

Management of severe thermal and inhalation injuries strictly follows the standard trauma primary survey: prioritize early airway securement for impending obstruction, followed by circulation management and fluid resuscitation.

Question 229Question →

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?

Immediate exploratory laparotomy

Computed tomography of the head, cervical spine, and abdomen

Diagnostic peritoneal lavage

Endovascular angiography with targeted embolization

Defer operative intervention until next-of-kin provides informed consent

Show answer & explanation

Answer: Immediate exploratory laparotomy

Answer

Immediate exploratory laparotomy

The correct answer is immediate exploratory laparotomy. This patient is in class IV hemorrhagic shock, evidenced by profound hypotension and tachycardia that remain refractory to initial blood transfusion. The positive FAST exam localizes the source of this exsanguinating hemorrhage to the abdomen. According to Advanced Trauma Life Support (ATLS) principles, patients with hemodynamic instability and intraperitoneal fluid must undergo emergent exploratory laparotomy to surgically control the bleeding. While the patient has a fixed, dilated pupil indicating likely uncal herniation from a traumatic brain injury (TBI), the immediate threat to life is circulatory collapse. Definitive management of the C (Circulation) phase must precede the D (Disability) diagnostic workup. Neurosurgical interventions, such as placing an intracranial pressure monitor or performing a decompressive craniectomy, can be performed concurrently in the operating room, but the patient cannot safely go to the CT scanner while actively exsanguinating.

Step-by-Step Solution

Evaluate the patient's hemodynamic status and primary survey findings.

The patient is in profound hemorrhagic shock (BP 76/40 mmHg) that is unresponsive to initial fluid and blood resuscitation.

Determining hemodynamic stability is the critical branch point in trauma management algorithms.

Interpret the results of the FAST examination.

The FAST scan is grossly positive in multiple dependent intra-abdominal areas.

A positive FAST in the setting of instability localizes the source of exsanguinating hemorrhage to the peritoneal cavity.

Reconcile competing clinical priorities (intra-abdominal bleeding vs. traumatic brain injury signs).

Prioritize surgical control of the bleeding (Circulation) over definitive diagnostic imaging of the brain (Disability).

ATLS protocols mandate addressing imminent threats to life in alphabetical order; exsanguination will cause cardiac arrest before a head CT can alter neurological management.

Select the definitive intervention.

Immediate transfer to the operating room for an exploratory laparotomy.

Surgical hemostasis is the only definitive treatment for unstable intraperitoneal hemorrhage.

Key Concept

Hemodynamically unstable trauma patients with a positive FAST scan require immediate exploratory laparotomy, even in the presence of focal neurologic deficits indicating severe traumatic brain injury.

Question 230Question →

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?

Show answer & explanation

Answer: 1200

Answer

1200

The patient has a high-voltage electrical burn with clinical evidence of myoglobinuria (dark brown urine). Current ATLS guidelines mandate using 4 mL/kg/%TBSA for electrical burns to maintain high urine output and prevent pigment nephropathy. With a 45% TBSA burn (18% for each leg + 9% for the arm) and 80 kg weight, the 24-hour fluid need is 14,400 mL. Half of this total (7,200 mL) must be given in the first 8 hours from the time of injury. Since 2 hours have elapsed prior to arrival, the 7,200 mL must be infused over the remaining 6 hours, resulting in an infusion rate of 1,200 mL/hr.

Step-by-Step Solution

Select the correct resuscitation formula based on burn mechanism.

Use the ATLS electrical burn formula: 4 mL/kg/%TBSA.

High-voltage electrical burns cause deep muscle damage and rhabdomyolysis, leading to myoglobinuria (indicated by dark brown urine). Higher fluid volumes (4 mL vs standard 2 mL) are required to flush the kidneys and prevent acute kidney injury.

Calculate the Total Body Surface Area (TBSA) burned using the Rule of Nines.

TBSA = 18% (entire right leg) + 18% (entire left leg) + 9% (entire right arm) = 45%.

Accurate TBSA estimation is critical for the Parkland/ATLS fluid calculation.

Calculate the total 24-hour resuscitation volume.

4 mL × 80 kg × 45 = 14,400 mL.

This formula provides the estimated fluid requirement for the first 24 hours post-injury.

Determine the volume needed for the first 8 hours.

14,400 mL / 2 = 7,200 mL.

ATLS protocols require half of the total 24-hour calculated volume to be administered in the first 8 hours after the time of injury.

Calculate the remaining time for the first 8-hour infusion window.

8 hours - 2 hours (time since injury) = 6 hours remaining.

The 8-hour clock starts at the time of the burn, not the time of arrival at the hospital.

Calculate the hourly infusion rate.

7,200 mL / 6 hours = 1,200 mL/hr.

This is the continuous rate required to deliver the remaining first-half volume over the correct time period.

Key Concept

Fluid Resuscitation in Electrical Burns

Estimated Time:1m 30s

Question 231Question →

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?

Show answer & explanation

Answer: 510

Answer

510

The correct rate is

510\text{ mL/hr}

. First, the total body surface area (TBSA) is calculated using the Rule of Nines: the entire anterior trunk accounts for

18\%

, the entire right upper extremity is

9\%

, and the anterior surface of the left lower extremity is

9\%

, yielding a total of

36\%

TBSA. According to current ATLS guidelines for adult thermal burns, the total 24-hour fluid requirement is calculated as

2\text{ mL} \times 85\text{ kg} \times 36 = 6,120\text{ mL}

. Exactly half of this total (

3,060\text{ mL}

) is mandated to be administered within the first 8 hours from the time of injury. Because 2 hours have already elapsed prior to emergency department arrival, the required

3,060\text{ mL}

must be infused over the remaining 6 hours. Therefore, the hourly rate is

3,060\text{ mL} / 6\text{ hours} = 510\text{ mL/hr}

Step-by-Step Solution

Calculate the burned Total Body Surface Area (TBSA) using the Rule of Nines.

Anterior trunk (

18\%

) + right arm (

9\%

) + anterior left leg (

9\%

) =

36\%

TBSA.

Accurate estimation of TBSA is required to determine total fluid needs.

Calculate the total 24-hour fluid requirement using the current ATLS multiplier for adult thermal burns.

2\text{ mL} \times 85\text{ kg} \times 36\% = 6,120\text{ mL}

Current ATLS guidelines recommend

2\text{ mL/kg/\%TBSA}

for adult thermal burns to prevent fluid creep and over-resuscitation.

Determine the fluid volume that must be given in the first phase of resuscitation.

6,120\text{ mL} / 2 = 3,060\text{ mL}

Half of the calculated 24-hour total must be administered within the first 8 hours from the time of injury.

Adjust the remaining time for the first phase based on the pre-hospital delay.

8\text{ hours} - 2\text{ hours elapsed} = 6\text{ hours remaining}

The 8-hour window begins at the time of injury, not at the time of arrival to the hospital.

Calculate the hourly infusion rate.

3,060\text{ mL} / 6\text{ hours} = 510\text{ mL/hr}

This rate ensures the patient receives the correct first-half volume precisely within the 8-hour post-injury window.

Key Concept

Burn fluid resuscitation calculations require applying the Rule of Nines for TBSA, using the

2\text{ mL/kg}

multiplier for adult thermal burns, and subtracting pre-hospital elapsed time from the initial 8-hour administration window.

Question 232Question →

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?

Emergent celiotomy

Non-contrast computed tomography of the brain and abdomen

Bedside peritoneal aspiration and lavage

Intravenous administration of hypertonic saline

Pelvic angiography with embolization

Show answer & explanation

Answer: Emergent celiotomy

Answer

Emergent celiotomy

The correct answer is emergent celiotomy. This patient presents with multiple severe injuries, including traumatic brain injury with signs of uncal herniation (anisocoria) and profound hemorrhagic shock. According to Advanced Trauma Life Support (ATLS) protocols, airway and breathing are secured first (he is intubated with clear breath sounds). The next priority is circulation. He has class IV shock, and the positive FAST scan localizes the hemorrhage to the peritoneal cavity. When a patient with blunt abdominal trauma is hemodynamically unstable and has a positive FAST, the absolute next step is immediate surgical exploration (celiotomy/laparotomy) to achieve source control. Taking this patient to the CT scanner to evaluate the head injury would result in death from exsanguination.

Step-by-Step Solution

Identify the patient's hemodynamic status.

The patient is in class IV hemorrhagic shock with a blood pressure of

74/42

mm Hg and a heart rate of

144

/min.

Hemodynamic instability dictates the treatment algorithm in trauma, overriding diagnostic imaging that requires transporting the patient.

Locate the source of the shock using the primary survey and adjuncts.

The chest is clear, the pelvis is stable, but the abdomen is distended and the FAST scan is positive for fluid.

A positive FAST in a hypotensive patient confirms intra-abdominal hemorrhage as the cause of shock.

Determine the priority of interventions given the competing injuries.

Despite signs of severe traumatic brain injury (anisocoria, depressed consciousness), the immediate cause of death is exsanguination.

Advanced Trauma Life Support (ATLS) principles require that circulation (C) and severe hemorrhage be addressed immediately; thus, source control in the operating room takes precedence over CT imaging of the brain.

Key Concept

In patients with multiple traumatic injuries, life-threatening hemorrhagic shock from an intra-abdominal source (indicated by a positive FAST) requires immediate emergent celiotomy (exploratory laparotomy), which takes precedence over diagnostic imaging for traumatic brain injury.

Question 233Question →

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?

Computed tomography angiography of the abdomen and pelvis

Immediate exploratory laparotomy

Diagnostic peritoneal lavage

Local wound exploration

Diagnostic laparoscopy

Show answer & explanation

Answer: Immediate exploratory laparotomy

Answer

Immediate exploratory laparotomy

The most appropriate next step for this patient is immediate exploratory laparotomy. She has a penetrating wound to the flank and is exhibiting signs of severe hemorrhagic shock (hypotension, tachycardia, altered mental status) that has not improved following initial fluid resuscitation. In trauma management, any penetrating injury to the torso (anterior abdomen, flank, or back) accompanied by hemodynamic instability is an absolute indication for emergency surgical exploration. While the FAST exam is negative, this imaging modality primarily evaluates the intraperitoneal and pericardial spaces. It is highly insensitive for detecting retroperitoneal hemorrhage, which is a major concern with flank stab wounds (e.g., injuries to the kidney or retroperitoneal vasculature). Because the patient is unstable, further diagnostic workup must be bypassed in favor of immediate operative hemorrhage control.

Step-by-Step Solution

Assess the patient's hemodynamic status and response to initial resuscitation.

The patient is in hemorrhagic shock (hypotensive, tachycardic, lethargic) and is a non-responder to initial crystalloid fluid resuscitation.

Determining hemodynamic stability is the most critical initial branch point in trauma management algorithms.

Evaluate the mechanism and anatomical location of the injury.

The patient has a penetrating wound to the left flank, which is considered part of the torso and poses a high risk to retroperitoneal structures (e.g., kidney, descending colon, major vasculature).

Mechanism (blunt vs. penetrating) and location dictate specific operative or diagnostic indications.

Interpret the adjunct imaging (FAST) within the clinical context.

FAST is negative, indicating no significant intraperitoneal or pericardial fluid. However, flank wounds frequently injure retroperitoneal structures.

FAST is highly insensitive for detecting retroperitoneal hemorrhage. A negative FAST does not rule out massive bleeding in this compartment.

Determine the definitive management step based on stability and mechanism.

Immediate exploratory laparotomy is indicated.

Any patient with a penetrating torso injury and persistent hemodynamic instability requires emergency surgical exploration to identify and control the source of bleeding.

Key Concept

Hemodynamically unstable patients with penetrating trauma to the torso (including the anterior abdomen, back, and flank) require immediate exploratory laparotomy. A negative FAST exam does not rule out massive retroperitoneal hemorrhage.

Question 234Question →

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.

Click a left item, then click its matching right item

Show answer & explanation

Answer

The scenarios pair as follows: left thoracoabdominal stab wound matches with diagnostic laparoscopy; widened mediastinum matches with CT angiography; massive hemothorax matches with emergent operative thoracotomy; flail chest with respiratory failure matches with endotracheal intubation.

Each clinical presentation tests a distinct node in the Advanced Trauma Life Support (ATLS) algorithm. Hemodynamically stable patients with specific occult injury risks (like blunt aortic injury or diaphragmatic penetration) require targeted evaluation with CT angiography or diagnostic laparoscopy, respectively. In contrast, life-threatening derangements like massive hemothorax (>1,500 mL blood) or flail chest with respiratory failure demand immediate, definitive intervention such as emergent thoracotomy or intubation with positive pressure ventilation.

Step-by-Step Solution

Analyze the stab wound scenario.

Stable patient with a left-sided wound in the 'thoracoabdominal box' (T4-T12). FAST and CXR are negative.

Occult diaphragmatic injuries are easily missed by initial imaging. Laparoscopy is required to prevent delayed diaphragmatic hernia.

Analyze the high-speed collision scenario.

Stable patient with a widened mediastinum.

Suspicion for blunt aortic injury is high. A stable patient can safely undergo CT angiography for definitive diagnosis.

Analyze the gunshot wound scenario.

Unstable patient with 1,600 mL of immediate blood output from a chest tube.

This meets criteria for a massive hemothorax (> 1,500 mL initial, or > 200 mL/hr for 2-4 hours), requiring immediate surgical control via thoracotomy.

Analyze the fall scenario.

Patient with paradoxical chest wall movement and refractory hypoxemia.

Flail chest complicated by respiratory failure necessitates positive pressure ventilation to internally splint the chest and ensure adequate oxygenation.

Key Concept

Appropriate trauma management relies on mechanism of injury and hemodynamic stability to differentiate between immediate surgical intervention, procedural stabilization, advanced imaging, or operative evaluation of occult injuries.

Question 235Question →

A $28$ -year-old man is brought to the emergency department by ambulance after being struck by a motor vehicle while crossing the street. On arrival, he is moaning in pain. His temperature is $36.5^\circ\text{C}$ ( $97.7^\circ\text{F}$ ), pulse is $132/\text{min}$ , respirations are $22/\text{min}$ , and blood pressure is $78/40\text{ mm Hg}$ . Pulse oximetry shows $97\%$ on room air. The patient's airway is patent, and breath sounds are equal bilaterally. A rigid cervical collar is in place. Physical examination reveals ecchymosis over the lower abdomen and perineum, as well as blood at the urethral meatus. Gentle anteroposterior compression of the iliac crests reveals mechanical instability of the pelvis. Intravenous access is established, and a massive transfusion protocol is initiated. A pelvic binder is applied in the emergency department, but the patient's blood pressure remains $80/42\text{ mm Hg}$ . A focused assessment with sonography for trauma (FAST) examination shows no free fluid in the pericardial, perihepatic, perisplenic, or pelvic spaces. Which of the following is the most appropriate next step in management?

Pelvic angiography

Computed tomography of the abdomen and pelvis

Exploratory laparotomy

Retrograde urethrography

Diagnostic peritoneal lavage

Show answer & explanation

Answer: Pelvic angiography

Answer

Pelvic angiography

In a hemodynamically unstable patient with a mechanically unstable pelvic fracture and a negative FAST examination, the primary source of hemorrhage is most likely retroperitoneal (from the presacral venous plexus or branches of the internal iliac artery). Because the FAST is negative, an exploratory laparotomy is contraindicated; opening the peritoneum will release the tamponade effect holding the retroperitoneal hematoma in check, potentially causing catastrophic exsanguination. The most appropriate next step is to address the pelvic bleeding directly via pelvic angiography with embolization (or preperitoneal pelvic packing).

Step-by-Step Solution

Evaluate the patient's hemodynamic status and mechanism of injury.

The patient is in class III/IV hemorrhagic shock (hypotension, marked tachycardia) following high-energy blunt trauma.

Identifying shock dictates the urgency and subsequent pathway of the ATLS algorithm.

Assess the source of hemorrhage based on physical exam and primary adjuncts.

The mechanically unstable pelvis indicates a pelvic fracture, while the negative FAST suggests the bleeding is not intraperitoneal.

A negative FAST in the setting of severe pelvic trauma implies that the life-threatening hemorrhage is retroperitoneal (typically from the presacral venous plexus or branches of the internal iliac artery).

Determine the definitive management for the identified source of shock.

Select pelvic angiography with embolization (or preperitoneal pelvic packing) as the next definitive intervention.

These interventions directly address retroperitoneal pelvic bleeding. Exploratory laparotomy is strictly contraindicated as it releases the natural retroperitoneal tamponade effect.

Key Concept

Management algorithm for hemodynamically unstable pelvic trauma

Question 236Question →

A 40-year-old man is brought to the emergency department after being rescued from a house fire. He has full-thickness burns involving his entire anterior chest, abdomen, and both upper extremities (approximately 36% total body surface area). He is awake but agitated. On primary survey, he has singed nasal hairs, a hoarse voice, and carbonaceous sputum. Vital signs are temperature 37.0°C (98.6°F), blood pressure 110/70 mmHg, heart rate 115/min, and respiratory rate 24/min. Arrange the following management steps in the optimal chronological order according to standard Advanced Trauma Life Support (ATLS) and burn protocols.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct order is: Endotracheal intubation -> Placement of large-bore peripheral intravenous lines and initiation of crystalloid fluid resuscitation -> Insertion of an indwelling urinary catheter to monitor output -> Cleansing of burn wounds and application of topical antimicrobial dressings -> Tangential excision of the burn eschar and split-thickness skin grafting.

The correct sequence strictly adheres to the Advanced Trauma Life Support (ATLS) protocol. The primary survey always prioritizes the airway (A). This patient has clear clinical indicators of inhalation injury (singed nasal hairs, hoarseness, carbonaceous sputum), which carries a high risk of rapid airway obstruction from edema; thus, endotracheal intubation is the immediate first step. Next, circulation (C) must be supported. Severe burns cause massive fluid shifts, requiring large-bore intravenous access and aggressive crystalloid fluid resuscitation. Once resuscitation is initiated, adjuncts to the primary survey are placed, notably an indwelling urinary catheter, to monitor urine output and titrate fluid administration. After the patient is hemodynamically stable and the primary and secondary surveys are complete, initial wound care is performed, consisting of cleansing and applying topical antimicrobial dressings to prevent sepsis. Finally, the definitive surgical management for full-thickness burns is tangential excision and skin grafting, which is typically scheduled within the first week after injury.

Step-by-Step Solution

Assess and secure the airway (Primary Survey - A).

Endotracheal intubation.

The patient's clinical signs (hoarseness, singed nasal hairs, carbonaceous sputum) strongly suggest inhalation injury and impending airway edema, mandating immediate airway protection.

Support circulation and address hypovolemia (Primary Survey - C).

Placement of large-bore peripheral intravenous lines and initiation of crystalloid fluid resuscitation.

Following airway control, fluid resuscitation must be initiated to address the massive third-spacing and intravascular volume depletion caused by severe thermal injury.

Place monitoring adjuncts.

Insertion of an indwelling urinary catheter to monitor output.

An indwelling urinary catheter is essential to accurately measure hourly urine output, which is the most reliable indicator of adequate end-organ perfusion and guides the ongoing titration of fluid resuscitation.

Perform secondary survey and initial wound care.

Cleansing of burn wounds and application of topical antimicrobial dressings.

After the patient is hemodynamically stable and life threats are managed, burn wounds are cleansed and topical antimicrobial dressings are applied to prevent early infection.

Plan definitive surgical care.

Tangential excision of the burn eschar and split-thickness skin grafting.

Early tangential excision and skin grafting is the standard definitive management for full-thickness burns, typically performed in the operating room within a few days of the initial injury.

Key Concept

The chronological management of severe burns prioritizes securing the airway (especially with signs of inhalation injury), followed by fluid resuscitation, monitoring adjuncts, local wound care, and ultimately definitive surgical excision.

Question 237Question →

A 45-year-old man is brought to the emergency department after being ejected from a vehicle during a high-speed rollover collision. On arrival, he is unresponsive. His blood pressure is 65/40 mm Hg, heart rate is 142/min, and respiratory rate is 8/min. Examination reveals active, pulsatile arterial bleeding from a severe crush injury to the right thigh. The patient has snoring respirations and significant maxillofacial trauma. Breath sounds are markedly decreased over the left hemithorax, and the trachea is deviated to the right. The pelvis is mechanically unstable on physical examination. Arrange the following steps in the most appropriate chronological sequence of management according to current Advanced Trauma Life Support (ATLS) principles.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence follows the ATLS algorithm: apply a tourniquet (Catastrophic hemorrhage), secure the airway with endotracheal intubation (Airway), perform a thoracostomy (Breathing), apply a pelvic binder and administer blood (Circulation), and assess the Glasgow Coma Scale score (Disability).

Current Advanced Trauma Life Support (ATLS) guidelines emphasize the <C>ABCDE algorithm for the primary survey. <C> stands for Catastrophic hemorrhage control, which is the absolute first priority and is addressed by applying a tourniquet to the pulsatile thigh injury. Next is A (Airway with cervical spine protection), addressed via intubation for this unresponsive patient. B (Breathing) follows, managed by thoracostomy for the suspected tension pneumothorax. C (Circulation) involves pelvic binding and transfusion for hemorrhagic shock. Finally, D (Disability) involves assessing the GCS and pupillary reflexes.

Step-by-Step Solution

Identify the most immediate threat to life.

The patient has active, pulsatile arterial bleeding from a crush injury to the thigh.

Catastrophic hemorrhage (<C>) causes exsanguination within minutes and supersedes airway management in the initial trauma survey.

Assess and secure the airway with cervical spine precautions.

The patient is unresponsive with snoring respirations and facial trauma, requiring endotracheal intubation.

Airway (A) obstruction is the next most rapid cause of preventable death in trauma patients.

Evaluate breathing and ventilation.

Decreased breath sounds and tracheal deviation indicate a tension pneumothorax, necessitating a decompression thoracostomy.

Breathing (B) compromise must be rapidly identified and relieved after the airway is secured.

Assess circulation and treat hemorrhagic shock.

Profound hypotension and an unstable pelvis indicate massive internal bleeding, requiring a pelvic binder and blood products.

Circulation (C) must be supported with definitive mechanical hemorrhage control and volume resuscitation.

Perform a focused neurologic evaluation.

The patient requires a formal Glasgow Coma Scale and pupillary assessment.

Disability (D) is formally assessed only after establishing adequate oxygen delivery to the brain to prevent secondary brain injury.

Key Concept

The Advanced Trauma Life Support (ATLS) primary survey follows the <C>ABCDE sequence: Catastrophic hemorrhage control, Airway, Breathing, Circulation, Disability, and Exposure.

Question 238Question →

Emergency medical services bring a 31-year-old female equestrian to the trauma center after her horse tripped and rolled over her torso during a jumping event. The patient is pale, diaphoretic, and lethargic. Vital signs are temperature 36.8°C (98.2°F), blood pressure 82/45 mm Hg, pulse 128/min, and respirations 22/min. Pulse oximetry shows 96% on high-flow oxygen. Primary survey reveals a patent airway and equal bilateral breath sounds. The abdomen is markedly distended with diffuse guarding and rebound tenderness. Bedside ultrasound evaluation of the abdomen demonstrates a significant amount of anechoic fluid in Morison pouch. Which of the following is the most appropriate next step in the management of this patient?

Immediate transfer to the operating room for surgical exploration

Contrast-enhanced multidetector CT scan

Performance of diagnostic peritoneal lavage

Gastric decompression and serial abdominal examinations

Empiric initiation of broad-spectrum antimicrobial therapy

Show answer & explanation

Answer: Immediate transfer to the operating room for surgical exploration

Answer

Immediate transfer to the operating room for surgical exploration

This patient presents with signs of profound hemorrhagic shock (hypotension, tachycardia, diaphoresis, lethargy) following blunt torso trauma. The rigid abdomen and positive focused assessment with sonography for trauma (FAST) examination, specifically showing fluid in Morison pouch, confirm the presence of significant intraperitoneal hemorrhage. The standard of care for a hemodynamically unstable patient with blunt abdominal trauma and a positive FAST is immediate surgical exploration to control the source of bleeding. Any delay for further diagnostic testing can be fatal.

Step-by-Step Solution

Evaluate hemodynamic status and primary survey.

The patient is in hemorrhagic shock, evidenced by hypotension (82/45 mm Hg), tachycardia (128/min), and altered mental status, with an intact airway.

To identify immediate life-threatening physiologic derangements.

Analyze abdominal exam and bedside imaging.

The patient has a rigid, distended abdomen and a positive FAST exam showing fluid in Morison pouch (hepatorenal recess).

To locate the source of the hemorrhagic shock.

Determine the appropriate intervention.

An unstable trauma patient with confirmed intra-abdominal hemorrhage requires emergent surgical control.

Delaying surgery for further imaging in an unstable patient significantly increases mortality.

Key Concept

In a hemodynamically unstable patient with blunt abdominal trauma, a positive FAST examination mandates immediate surgical exploration to achieve hemorrhage control.

Question 239Question →

A 62-year-old male with a history of chronic obstructive pulmonary disease and ischemic heart disease is brought to the trauma center after being struck by a forklift. He is lethargic and complains of severe abdominal pain. Vital signs show a temperature of $36.5^\circ$ C ( $97.7^\circ$ F), a blood pressure of $76/40$ mm Hg, a pulse of $128$ /min, and a respiratory rate of $26$ /min. Examination reveals large ecchymoses over the left lower ribs and severe diffuse abdominal tenderness with involuntary guarding. A focused assessment with sonography for trauma (FAST) demonstrates a substantial anechoic fluid collection in the splenorenal recess. A portable chest radiograph shows fractures of the left eighth, ninth, and tenth ribs with no pneumothorax. Which of the following is the most appropriate next step in the management of this patient?

Transfer to the operating room for an abdominal celiotomy

Multidetector computed tomography imaging of the torso

Nasogastric tube decompression and admission for serial examinations

Intravenous administration of furosemide and noninvasive ventilation

Intravenous administration of sodium bicarbonate

Show answer & explanation

Answer: Transfer to the operating room for an abdominal celiotomy

Answer

Transfer to the operating room for an abdominal celiotomy

The correct management for a hemodynamically unstable patient (hypotension, tachycardia) following blunt abdominal trauma with evidence of intra-abdominal hemorrhage on a FAST exam is immediate surgical exploration. The patient's left lower rib fractures and fluid in the splenorenal recess strongly suggest a splenic injury. Delaying surgery for imaging or attempting conservative management in the setting of shock is contraindicated.

Step-by-Step Solution

Assess the patient's hemodynamic status.

The patient has a blood pressure of

76/40

mm Hg and a pulse of

128

/min, indicating hemodynamic instability and class III/IV shock.

Hemodynamic status determines whether the patient can safely undergo advanced imaging or requires immediate intervention.

Evaluate the source of instability using bedside diagnostics.

A FAST exam reveals an anechoic fluid collection in the splenorenal recess, indicating hemoperitoneum (likely a splenic laceration due to overlying rib fractures).

Rapid identification of the bleeding source is required in the primary survey of trauma patients.

Determine the definitive management.

The patient requires immediate surgical exploration (celiotomy) to arrest the intra-abdominal hemorrhage.

According to ATLS protocols, hemodynamically unstable patients with intra-abdominal bleeding require emergent operative intervention.

Key Concept

Hemodynamically unstable patients with blunt abdominal trauma and a positive FAST exam require emergent surgical exploration (celiotomy).

Question 240Question →

Helicopter transport arrives at a regional burn center carrying a 30-year-old female who was trapped in a residential fire. She currently weighs $70\text{ kg}$ . The injury occurred exactly $2\text{ hours}$ prior to her arrival. Physical examination reveals full-thickness burns involving her entire anterior trunk, her entire right lower extremity, and her entire left upper extremity. The trauma team confirms this accounts for exactly $45\%$ of her total body surface area (TBSA). Large-bore intravenous access is established. Utilizing the classic Parkland formula ( $4\text{ mL/kg/\%TBSA}$ ), what is the targeted fluid administration rate in $\text{mL/hr}$ for the remainder of the first 8-hour post-burn period?

Show answer & explanation

Answer: 1050

Answer

1050

The correct infusion rate is found by calculating the total 24-hour fluid requirement (

12,600\text{ mL}

), allocating half of that volume to the first 8 hours post-injury (

6,300\text{ mL}

), and dividing that volume by the time remaining in that 8-hour window (

6\text{ hours}

). This yields a target rate of

1,050\text{ mL/hr}

Step-by-Step Solution

Identify the key variables required for the calculation.

Weight =

70\text{ kg}

, TBSA =

45\%

, Elapsed time =

2\text{ hours}

These values are strictly necessary to apply the formula and adjust for the pre-hospital delay.

Calculate the total 24-hour fluid volume.

4\text{ mL} \times 70\text{ kg} \times 45 = 12,600\text{ mL}

The classic Parkland formula estimates the total fluid deficit over the first 24 hours post-burn.

Determine the fluid volume required for the first resuscitation period.

12,600\text{ mL} / 2 = 6,300\text{ mL}

Standard burn resuscitation guidelines dictate that half of the total 24-hour volume must be administered in the first 8 hours.

Calculate the remaining time in the first 8-hour window.

8\text{ hours} - 2\text{ hours elapsed} = 6\text{ hours remaining}

The 8-hour clock begins precisely at the time of injury, not at the time of hospital arrival.

Calculate the target hourly infusion rate.

6,300\text{ mL} / 6\text{ hours} = 1,050\text{ mL/hr}

The remaining volume must be divided equally over the remaining hours of the first 8-hour period to catch up on fluid deficits safely.

Key Concept

Parkland formula fluid resuscitation and time-delay adjustment

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