Surgery

A 52-year-old man is transported to the trauma center by helicopter after a high-speed head-on motor vehicle collision. On arrival, he is confused and diaphoretic. His blood pressure is 82/54 mm Hg, heart rate is 128/min, and respiratory rate is 22/min. Oxygen saturation is 97% on a nonrebreather mask. The airway is secure, and breath sounds are present and equal bilaterally. The abdomen is grossly distended and rigid to palpation. Pelvic compression does not elicit instability. Intravenous access is established, and rapid fluid resuscitation with warmed crystalloid is initiated. A focused assessment with sonography for trauma (FAST) examination reveals an anechoic stripe in the hepatorenal recess. Which of the following is the most appropriate next step in management?

A 29-year-old woman is evaluated in the post-anesthesia care unit (PACU) due to severe agitation and a rapidly rising temperature. She just underwent an emergency laparoscopic appendectomy for a perforated appendix. Her medical history is significant for major depressive disorder, for which she takes sertraline daily. Intraoperative medications included propofol, succinylcholine, desflurane, fentanyl, and ondansetron. Reversal of neuromuscular blockade was achieved with sugammadex. Her temperature is $39.6^\circ\text{C}$ ($103.3^\circ\text{F}$), blood pressure is $168/96\text{ mmHg}$, pulse is $138/\text{min}$, and respiratory rate is $24/\text{min}$. On physical examination, she is diaphoretic, flushed, and disoriented. Neurologic examination reveals marked hyperreflexia in the bilateral lower extremities, spontaneous myoclonus, and inducible ocular clonus. Her muscle tone is increased, particularly in the lower extremities, but there is no "lead-pipe" rigidity. An arterial blood gas analysis shows a normal partial pressure of carbon dioxide ($PaCO_2$). Administration of a medication with which of the following mechanisms of action is the most appropriate targeted therapy for this patient's current condition?

Correlate the following classic clinical findings in blunt trauma patients with their most likely associated underlying injury.

A 78-year-old woman is evaluated in the emergency department for a 3-day history of progressively worsening abdominal distension, nausea, and vomiting of brown, foul-smelling fluid. She has not had a bowel movement or passed flatus for 48 hours. Her medical history includes hypertension, diet-controlled type 2 diabetes mellitus, and multiple episodes of right upper quadrant pain after meals over the past year. Her temperature is 37.8°C (100.0°F), blood pressure is 105/65 mmHg, pulse is 112/min, and respirations are 20/min. Physical examination shows a significantly distended, tympanitic abdomen with high-pitched, tinkling bowel sounds. There is diffuse tenderness to palpation but no guarding or rebound tenderness.

A non-contrast computed tomography scan of the abdomen demonstrates dilated small bowel loops up to the distal ileum, air in the biliary tree, and a 3.5-cm radiopaque structure in the right lower quadrant. Which of the following is the most appropriate next step in management?

A 31-year-old woman is brought to the emergency department after a high-speed motor vehicle collision. She was an unrestrained front-seat passenger, and her knees forcibly struck the dashboard during the impact. She is in severe distress and complains of excruciating right hip pain. Vital signs are temperature 37.1°C (98.8°F), pulse 105/min, blood pressure 122/78 mm Hg, and respirations 18/min. On physical examination, the right lower extremity is shortened, adducted, and internally rotated. Peripheral pulses are 2+ and symmetric. Neurologic examination reveals decreased sensation to pinprick over the dorsum of the right foot and an inability to actively dorsiflex the right ankle. Anteroposterior radiographs of the pelvis demonstrate a posterior dislocation of the right femoral head with no obvious displaced acetabular or femoral neck fractures. Which of the following is the most appropriate next step in management?

During morning rounds, a 74-year-old male is evaluated in the surgical intensive care unit due to progressive dyspnea and mild confusion. The patient is 72 hours status post an uncomplicated Billroth II subtotal gastrectomy for a refractory peptic ulcer. His past medical history is significant for essential hypertension and osteoarthritis. He has received a total of $7.5\text{ L}$ of isotonic crystalloid since the operation and has had a cumulative urine output of $1.8\text{ L}$. Vital signs demonstrate a temperature of $37.9^\circ\text{C}$ ($100.2^\circ\text{F}$), blood pressure of $162/94\text{ mm Hg}$, pulse of $118/\text{min}$, and respiratory rate of $28/\text{min}$. Pulse oximetry shows an oxygen saturation of $87\%$ on room air. Physical examination reveals elevated jugular venous pressure. Lung auscultation demonstrates bilateral basilar crackles and diffuse expiratory wheezing. The abdomen is soft, mildly tender at the incision site, and non-distended, with intact surgical dressings and no erythema. Which of the following are the most appropriate immediate steps in the management of this patient? (Select exactly two options)

A 45-year-old woman is brought to the emergency department due to progressively worsening abdominal pain. Two days ago, she developed diffuse, crampy abdominal pain associated with nausea and bilious vomiting. Over the past 4 hours, the pain has become severe and constant. She has not passed flatus or stool for 24 hours. Her past medical history is notable for an open abdominal hysterectomy performed four years ago. Her temperature is 38.9°C (102°F), blood pressure is 85/50 mmHg, pulse is 125/min, and respirations are 22/min. Physical examination reveals a distended abdomen that is rigid, with diffuse rebound tenderness and involuntary guarding. Laboratory studies show a leukocyte count of 19,500/mm³ and a serum lactate level of 4.8 mmol/L. Which of the following is the most appropriate next step in management?

Match each clinical trauma presentation with the most appropriate next step in definitive diagnosis or management.

In the emergency trauma setting, acute musculoskeletal injuries frequently compromise adjacent anatomical structures. Match each acute orthopedic injury pattern with its most commonly associated critical neurovascular consequence or expected physical examination finding.

A 25-year-old male is brought to the emergency department after falling 20 feet from a roof. He is unconscious, hypotensive, and has obvious facial trauma. Arrange the following steps of his initial assessment and management in the correct chronological order according to Advanced Trauma Life Support (ATLS) protocols.

A 34-year-old woman is brought to the emergency department after falling approximately 15 feet from a roof. Upon arrival, she is lethargic but responsive to painful stimuli. Her blood pressure is 78/45 mmHg, and her heart rate is 132/min. Oxygen saturation is 96% on room air. Her airway is clear, and breath sounds are present and equal bilaterally. The abdomen appears distended and is tense on palpation. A bedside focused assessment with sonography in trauma (FAST) reveals a significant amount of anechoic fluid surrounding the spleen and liver. Which of the following is the most appropriate next step in management?

A 41-year-old man is evaluated on the surgical floor due to a new-onset fever and abdominal discomfort. He is currently on postoperative day 7 following an emergency laparoscopic appendectomy for ruptured appendicitis. The patient was tolerating a regular diet until yesterday, when he developed anorexia, nausea, and a progressively worsening ache in his right lower quadrant. His temperature is $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), pulse is $112/\text{min}$, respirations are $18/\text{min}$, and blood pressure is $118/76\text{ mm Hg}$. Physical examination reveals a mildly distended abdomen with focal deep tenderness in the right lower quadrant. There is no rebound tenderness or guarding. Bowel sounds are hypoactive. The laparoscopic port incisions are clean, dry, and intact with no surrounding erythema, induration, or purulent drainage. 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 management?

Match the following complex trauma patient presentations with the most appropriate definitive next step in their diagnostic or therapeutic management. Assume all patients have established, secure airways and are receiving appropriate initial fluid resuscitation.

A 62-year-old man presents to the emergency department with a 3-day history of progressively worsening left lower quadrant abdominal pain, subjective fevers, and nausea. He has a history of diet-controlled type 2 diabetes and hypertension. His temperature is $38.6^\circ\text{C}$ ($101.5^\circ\text{F}$), blood pressure is $128/82\text{ mm Hg}$, pulse is $98/\text{min}$, and respirations are $18/\text{min}$. Physical examination demonstrates marked tenderness to palpation in the left lower quadrant with localized guarding, but no diffuse rigidity or generalized rebound tenderness. Bowel sounds are hypoactive. Laboratory results show a leukocyte count of $16,500/\text{mm}^3$ with a left shift.

Arrange the following management steps in the most appropriate chronological order for this patient's anticipated clinical course.

A 52-year-old male with a surgical history of an open appendectomy 10 years ago presents with severe, colicky abdominal pain, intractable vomiting, and failure to pass flatus for the past 24 hours. Vital signs reveal a heart rate of 105/min and blood pressure of 115/75 mmHg. Examination shows a distended, tympanitic abdomen without rebound tenderness or guarding. Arrange the following interventions in the most appropriate chronological order for his initial evaluation and management.

A 41-year-old factory worker is evaluated in the resuscitation bay following an industrial explosion inside an enclosed warehouse. Physical examination reveals singed facial hair, hoarseness, carbonaceous sputum, and extensive blistering over the anterior chest and both upper extremities.

Arrange the following acute management steps in the correct chronological sequence according to standard trauma life support protocols.

A 64-year-old man is evaluated on the surgical ward due to a change in his clinical status. He was admitted 24 hours ago for a small bowel obstruction secondary to adhesions from a prior open sigmoidectomy. On admission, he reported intermittent, crampy abdominal pain. He was placed on nil per os (NPO) status, and treatment with intravenous fluid resuscitation and nasogastric tube decompression was initiated. Over the past 4 hours, the patient reports that his abdominal pain has worsened, becoming severe and continuous rather than colicky. His temperature is 38.6°C (101.5°F), blood pressure is 105/65 mm Hg, and pulse is 118/min. Physical examination reveals a distended abdomen with focal rigidity, guarding, and marked rebound tenderness in the periumbilical region. Bowel sounds are absent. Laboratory studies show a leukocyte count of $17,500/mm^3$ with 15% bands, and a serum lactate level of $4.2 \text{ mmol/L}$. Which of the following is the most appropriate next step in the management of this patient?

During bedside rounds in the surgical intensive care unit, a 68-year-old female patient suddenly develops severe shortness of breath and lightheadedness. Her surgical history is significant for a frontotemporal craniotomy performed three days ago to resect a large meningioma. Current vital signs show a temperature of 37.2°C, blood pressure of 76/44 mmHg, pulse of 132/min, and respirations of 28/min. Oxygen saturation is 85% on room air. Physical examination reveals clear lung fields bilaterally and an elevated jugular venous pressure. A stat electrocardiogram demonstrates sinus tachycardia with new-onset T-wave inversions in leads $V_1-V_4$. Arrange the following management steps in the most appropriate chronological order.

A 31-year-old woman is evaluated in the emergency department after a paragliding collision with a mountain ridge. Upon arrival, she is lethargic and diaphoretic. Her temperature is 36.4°C (97.5°F), blood pressure is 78/42 mm Hg, pulse is 134/min, and respiratory rate is 24/min. Oxygen saturation is 96% on 15 L/min via non-rebreather mask. The airway is unobstructed, and breath sounds are clear and symmetric bilaterally. There is no active external bleeding. Physical examination reveals a large ecchymosis over the left flank. The abdomen is markedly distended, rigid, and diffusely tender with guarding. A focused assessment with sonography for trauma (FAST) demonstrates a large volume of anechoic fluid in the hepatorenal space (Morison pouch) and splenorenal recess. Intravenous access is rapidly secured and fluid resuscitation is initiated. Which of the following is the most appropriate next step in the management of this patient?

A 13-year-old boy is brought to the pediatric orthopedic clinic by his parents due to a two-month history of a persistent left-sided limp and intermittent, dull pain in his left knee. The pain is worse after walking long distances and improves with rest. He denies any history of trauma, recent illnesses, fevers, or night sweats. He is at the 95th percentile for weight and 60th percentile for height. Vital signs are within normal limits.

On physical examination, the patient has an antalgic gait. Inspection of the left knee reveals no swelling, erythema, or deformity. Palpation of the left knee and thigh elicits no tenderness, and knee range of motion is full and painless. However, when the examiner passively flexes the patient's left hip to 90 degrees, the thigh obligatorily rotates outward. Internal rotation of the left hip is limited compared to the right and elicits mild discomfort. Distal pulses are 2+ bilaterally, and sensation is intact throughout both lower extremities.

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