Surgery

During morning rounds, the surgical team evaluates a $61$-year-old female who reports increasing lower pelvic discomfort and a sense of general malaise. She is currently on her fifth day of recovery following an elective sigmoid resection for complicated diverticular disease. Her recovery had been progressing appropriately; her bowel function returned on the third day, and she was successfully transitioned to a soft diet. However, this morning she felt nauseous and refused breakfast.

Her temperature is $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), blood pressure is $118/74\text{ mmHg}$, pulse is $114/\text{min}$, and respiratory rate is $18/\text{min}$. Physical examination reveals a well-approximated midline abdominal incision with no surrounding erythema, induration, or purulent drainage. However, there is moderate deep tenderness in the left lower quadrant with mild voluntary guarding. Pulmonary auscultation is clear bilaterally. Laboratory studies show a leukocyte count of $17,500/\text{mm}^3$ with $85\%$ neutrophils.

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

A $29$-year-old man with a history of ileocolonic Crohn's disease presents to the emergency department with a $24$-hour history of severe, cramping abdominal pain and bilious vomiting. He reports not passing any flatus or stool since the pain began. Over the past $3$ hours, his pain has transitioned from colicky to constant and agonizing. His temperature is $38.7^\circ\text{C}$ ($101.7^\circ\text{F}$), blood pressure is $92/58 \text{ mm Hg}$, and heart rate is $118/\text{min}$. Physical examination reveals a distended abdomen that is exquisitely tender to palpation in all four quadrants, with marked rigidity and rebound tenderness. Laboratory studies show a leukocyte count of $18,500/\text{mm}^3$ and a serum lactate of $3.9 \text{ mmol/L}$. An abdominal radiograph demonstrates multiple dilated loops of small bowel with air-fluid levels and an absence of colonic gas. Which of the following is the most appropriate next step in management?

A 68-year-old man is evaluated in the surgical telemetry unit due to sudden-onset severe dyspnea. Two days ago, he underwent an open repair of a large, incarcerated ventral hernia. His medical history includes hypertension, obesity, and a 40-pack-year smoking history. Since the surgery, the patient has had severe incisional pain that has limited his mobility and deep breathing exercises despite the use of opioid analgesia. Vital signs show a temperature of 37.8°C (100.0°F), blood pressure of 138/86 mmHg, pulse of 118/min, and respiratory rate of 28/min. Pulse oximetry is 87% on room air. The patient appears anxious and is using accessory muscles of respiration. Neck examination reveals the trachea is deviated toward the right. Pulmonary examination demonstrates absent breath sounds and dullness to percussion over the entire right hemithorax. The cardiac apical impulse is palpated near the right sternal border. The surgical incision is clean and intact. Which of the following is the most appropriate next step in management?

Fourteen hours after undergoing an emergent exploratory laparotomy and small bowel resection for acute mesenteric ischemia, a $58$-year-old man develops severe oliguria and hypotension in the intensive care unit. His surgical procedure was complicated by massive intraoperative hemorrhage, requiring $8\text{ L}$ of crystalloid and $4$ units of packed red blood cells. The patient is currently intubated, deeply sedated, and receiving mechanical ventilation. Over the past $3$ hours, his urine output has been a total of $10\text{ mL}$.

His temperature is $38.2^\circ\text{C}$ ($100.8^\circ\text{F}$), blood pressure is $78/48\text{ mm Hg}$, and pulse is $132\text{/min}$. The ventilator is alarming for peak airway pressures of $45\text{ cm H}_2\text{O}$ (an increase from $22\text{ cm H}_2\text{O}$ postoperatively). Pulmonary artery catheterization reveals a central venous pressure of $24\text{ mm Hg}$, a pulmonary capillary wedge pressure of $26\text{ mm Hg}$, and a cardiac index of $1.6\text{ L/min/m}^2$. Physical examination shows a tensely distended abdomen with a clean, intact surgical dressing. Breath sounds are equal bilaterally but diminished at the lung bases.

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

A 71-year-old man is brought to the emergency department by his family due to confusion and fever. Over the past 48 hours, he has complained of progressively worsening right upper quadrant abdominal pain and yellowing of his skin. His medical history includes hypertension and symptomatic cholelithiasis, for which he has previously declined surgical intervention. On arrival, his temperature is $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$), blood pressure is $82/50\text{ mmHg}$, pulse is $128/\text{min}$, and respiratory rate is $22/\text{min}$. Physical examination reveals deep scleral icterus and marked right upper quadrant tenderness with involuntary guarding. He is lethargic and oriented only to person. Laboratory studies show a leukocyte count of $22,000/\text{mm}^3$, total bilirubin of $8.4\text{ mg/dL}$, and alkaline phosphatase of $450\text{ U/L}$.

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

A 45-year-old man presents to the triage desk of the emergency department complaining of severe, unremitting abdominal pain that began 12 hours ago. He has had three episodes of bilious vomiting and reports passing no flatus since the pain started. His surgical history is notable for an open appendectomy performed 10 years ago. On initial assessment, his temperature is 38.9°C (102.0°F), pulse is 125/min, and blood pressure is 88/58 mmHg. Physical examination reveals a markedly distended abdomen. Palpation elicits diffuse rigidity, significant rebound tenderness, and involuntary guarding across all quadrants. Laboratory analysis demonstrates a leukocyte count of 19,000/mm³ with 85% neutrophils, and an elevated serum lactate level. Which of the following is the most appropriate next step in the management of this patient?

A 38-year-old forestry worker is brought to the trauma center after a severe chainsaw accident followed by a fall down a steep ravine. On arrival, he is unresponsive with a Glasgow Coma Scale score of 5. He has a massive, spurting arterial laceration to his right thigh. He exhibits sonorous, gurgling respirations. Auscultation reveals absent breath sounds on the left hemithorax with jugular venous distention. His heart rate is 142/min and blood pressure is 65/30 mm Hg. Arrange the following critical interventions in the most appropriate sequential order based on current Advanced Trauma Life Support (ATLS) priorities.

A 35-year-old man is brought to the emergency department after sustaining injuries in a kitchen grease fire. On examination, he is alert and oriented. His blood pressure is 125/80 mm Hg, heart rate is 98/min, and respiratory rate is 16/min. Physical examination reveals deep partial-thickness burns involving the entire anterior surface of his chest and abdomen, as well as the entire anterior surface of both arms. His airway is patent with no signs of inhalational injury. Using the Rule of Nines, what is the estimated total body surface area (TBSA) percentage affected by these burns?

A 62-year-old man is evaluated on postoperative day 8 following an open bilateral inguinal hernia repair. Yesterday, he began experiencing progressive abdominal bloating, nausea, and bilious emesis. He has not passed flatus or stool for the past 48 hours. Two hours ago, his abdominal discomfort abruptly transitioned into severe, constant, and unremitting pain. Current vital signs show a temperature of 38.9°C (102.0°F), pulse of 122/min, respirations of 22/min, and blood pressure of 98/60 mm Hg. Physical examination reveals a markedly distended abdomen with diffuse rigidity, involuntary guarding, and rebound tenderness. Laboratory evaluation demonstrates a leukocyte count of 19,500/mm³ and a serum lactate of 4.5 mmol/L. An upright abdominal radiograph displays multiple dilated loops of small intestine with air-fluid levels and an absence of colonic gas. Which of the following is the most appropriate next step in the management of this patient?

A $45$-year-old man is evaluated in the surgical intensive care unit on postoperative day $1$ following a $14$-hour complex pelvic exenteration for an advanced rectal malignancy. His surgical history is significant only for this recent procedure. Over the past $6$ hours, his urine output has precipitously declined to $15 \text{ mL/hr}$, and the fluid in the Foley catheter tubing is noted to be dark reddish-brown. Vital signs are blood pressure $110/70 \text{ mmHg}$, heart rate $118 \text{ beats/min}$, respiratory rate $18 \text{ breaths/min}$, and temperature $37.4^\circ\text{C}$ ($99.3^\circ\text{F}$). Physical examination reveals diffuse muscle tenderness in the lower extremities, which were positioned in prolonged lithotomy during the surgery. Stat laboratory testing reveals a serum potassium level of $7.9 \text{ mEq/L}$, serum creatinine of $3.4 \text{ mg/dL}$, and a creatine kinase level of $52,000 \text{ U/L}$. An emergent $12$-lead electrocardiogram demonstrates peaked T waves, a widened QRS complex, and loss of P waves. Arrange the following interventions in the correct chronological sequence for the optimal management of this acute postoperative emergency.

A 64-year-old woman presents to the emergency department with a 6-hour history of sudden, severe, and continuous abdominal pain accompanied by two episodes of bilious vomiting. Her medical history includes hypertension, paroxysmal atrial fibrillation, and an open total abdominal hysterectomy performed 10 years ago. Her current medications are lisinopril and metoprolol; she is not taking anticoagulation. Temperature is $38.2^\circ\text{C}$ ($100.8^\circ\text{F}$), pulse is $122/\text{min}$ and irregularly irregular, blood pressure is $94/60\text{ mm Hg}$, and respirations are $24/\text{min}$. Physical examination shows a mildly distended abdomen. There is marked focal tenderness in the left lower quadrant with rigidity and rebound tenderness. Bowel sounds are absent. Laboratory studies show a leukocyte count of $17,500/\text{mm}^3$ and a serum lactate level of $4.2\text{ mmol/L}$. Computed tomography of the abdomen and pelvis with intravenous contrast reveals a high-grade small bowel obstruction with a radially distributed, U-shaped cluster of dilated small bowel loops. The mesenteric vessels converge toward a central point, and the wall of the affected bowel loop is thickened with diminished contrast enhancement. Which of the following is the most appropriate next step in management?

A 21-year-old male university student is rushed to the emergency department after a severe collision during a rugby game, where he was forcefully struck in the left flank by an opponent's shoulder. He reports intense left-sided abdominal pain with radiation to the top of his left shoulder. His temperature is $36.9^\circ\text{C}$ ($98.4^\circ\text{F}$), pulse is $132 \text{ beats/min}$, respirations are $24 \text{ breaths/min}$, and blood pressure is $80/46 \text{ mmHg}$. He is conscious but profusely diaphoretic and pale. Examination shows prominent guarding and rigidity over the left hemi-abdomen. The pelvis is mechanically stable, and chest auscultation is clear bilaterally. A bedside point-of-care ultrasound demonstrates significant free anechoic fluid in the splenorenal and hepatorenal spaces. Resuscitation with uncrossmatched blood products is initiated via two large-bore peripheral catheters. Which of the following is the most appropriate next step in this patient's management?

During an afternoon evaluation, the surgical team examines a $54$-year-old woman who underwent a laparoscopic Roux-en-Y gastric bypass $6$ days ago. The patient reports the recent onset of severe, unremitting left upper quadrant abdominal pain that radiates to her left shoulder. She has experienced significant nausea but no vomiting. Her temperature is $38.9^\circ\text{C}$ ($102.0^\circ\text{F}$), blood pressure is $112/70\text{ mmHg}$, pulse is $118/\text{min}$, and respiratory rate is $22/\text{min}$. Oxygen saturation is $96\%$ on room air. Physical examination reveals focal peritonitis in the left upper quadrant with voluntary guarding. The surgical incisions are well-approximated, clean, and dry. Bowel sounds are absent. A urinary catheter is in place, draining clear yellow urine. Which of the following is the most appropriate next step in the management of this patient?

A 58-year-old man is brought to the emergency department via ambulance due to severe, generalized abdominal pain and persistent bilious vomiting for the past 24 hours. He reports no bowel movements or passage of flatus during this time. His surgical history is significant for an open appendectomy performed 20 years ago. Current vital signs show a temperature of 39.2°C (102.6°F), blood pressure of 88/58 mmHg, heart rate of 124/min, and respiratory rate of 22/min. Physical examination demonstrates a markedly distended abdomen. Palpation reveals diffuse rigidity, severe rebound tenderness, and involuntary guarding. Bowel sounds are absent. Laboratory testing indicates a leukocyte count of 19,000/mm³ with a left shift and a serum lactate of 4.5 mmol/L. An upright abdominal radiograph displays multiple dilated loops of small intestine with prominent air-fluid levels. Which of the following is the most appropriate next step in management?

Match each acute thoracic trauma clinical presentation with the most appropriate immediate next step in management.

A 72-year-old man is brought to the emergency department from an assisted living facility due to worsening nausea, intense lower abdominal pain, and an inability to pass gas for the last 36 hours. His medical history includes hypertension, hyperlipidemia, and a large right groin bulge that he typically pushes back in himself. However, he states he has been unable to reduce the bulge since yesterday morning. His temperature is 38.8°C (101.8°F), blood pressure is 92/58 mmHg, and pulse is 118/min. Physical examination demonstrates dry oral mucosa. The abdomen is distended with high-pitched, hyperactive bowel sounds. Examination of the right groin reveals a 6-cm, tense, erythematous mass extending into the scrotum that is exquisitely tender to touch. Laboratory results show a leukocyte count of 19,000/mm³ and a venous lactate level of 4.8 mmol/L. Which of the following is the most appropriate next step in the management of this patient?

An 80-year-old female is evaluated in the surgical assessment unit for a 3-day history of intermittent, crampy abdominal pain and progressive nausea with bilious vomiting. She has a history of hypertension, type 2 diabetes mellitus, and symptomatic gallstones for which she declined surgery two years ago. Her temperature is 37.8°C (100.0°F), blood pressure is 112/68 mm Hg, and pulse is 95/min. On physical examination, the abdomen is distended and tympanitic to percussion, with high-pitched bowel sounds. There is mild, diffuse abdominal tenderness but no rebound or guarding. Laboratory studies show a leukocyte count of 11,200/mm³ and a normal serum amylase level. A plain abdominal radiograph reveals multiple dilated loops of small intestine with air-fluid levels, an absence of colonic gas, and branching radiolucencies over the central hepatic shadow. Which of the following is the most appropriate next step in the management of this patient?

An ambulance brings a 27-year-old female to the emergency department after she was thrown from a horse, landing forcefully on her left side. She is fully alert and complains of severe left-sided abdominal pain. Her temperature is 36.8°C (98.2°F), blood pressure is 78/42 mm Hg, pulse is 138/min, and respiratory rate is 22/min. Physical examination reveals guarding and rigidity in the left upper quadrant. Intravenous fluid resuscitation is initiated with 1 liter of warm crystalloid, but a repeat blood pressure reading is 80/45 mm Hg. A focused assessment with sonography for trauma (FAST) demonstrates a large amount of anechoic fluid in the splenorenal recess. Which of the following is the most appropriate next step in management?

A 45-year-old woman is evaluated on her second day of recovery following an uncomplicated open abdominal hysterectomy. Her temperature is $38.3^\circ C$ ($100.9^\circ F$), blood pressure is $122/78$ mmHg, heart rate is $88/min$, and respirations are $18/min$. Oxygen saturation is $95\%$ on room air. Physical examination reveals decreased breath sounds at the bilateral lung bases without crackles or wheezes. The surgical incision is clean, dry, and intact with no surrounding erythema or induration. The patient's calves are soft and non-tender. Which of the following are the most appropriate next steps in management? (Select two)

A 55-year-old man is evaluated 20 hours after undergoing an open partial colectomy for an obstructing colon mass. The surgical team is urgently called because the patient has developed sudden confusion and a high fever. His temperature is 39.8°C (103.6°F), blood pressure is 82/48 mm Hg, pulse is 132/min, and respirations are 28/min. The patient reports agonizing pain around his abdominal incision, which has rapidly worsened over the last few hours despite adequate opioid analgesia. Physical examination shows a confused, diaphoretic man. The abdominal dressing is removed, revealing significant edema, erythema, and purplish discoloration of the skin extending radially from the incision. Palpation of the abdominal wall elicits coarse crepitus. There is a small amount of thin, grayish, foul-smelling discharge at the wound edges. Intravenous fluids and broad-spectrum antibiotics are immediately ordered. Which of the following is the most appropriate next step in the management of this patient?