Surgery

Match each patient's clinical presentation to the underlying surgical pathology or pathophysiologic mechanism that best explains their symptoms.

A $32$-year-old man is brought to the trauma bay via ambulance after being ejected from a vehicle during a high-speed rollover collision. On arrival, he is unresponsive. Vital signs show a blood pressure of $75/40$ mm Hg, a heart rate of $142$/min, and a respiratory rate of $6$/min with shallow, gurgling respirations. Paramedics report a large, deep laceration on his left mid-thigh that is actively spurting bright red blood. According to standard trauma resuscitation protocols, arrange the following initial management steps in the correct chronological order.

Match each trauma patient presentation with the most appropriate next step in acute management according to Advanced Trauma Life Support (ATLS) principles.

During the second day of hospitalization, a patient who suffered deep partial-thickness and full-thickness burns over $55\%$ of the total body surface area experiences sudden clinical deterioration. The thermal injuries predominantly involve the posterior torso and bilateral lower extremities. The patient is intubated, deeply sedated, and paralyzed with continuous neuromuscular blockade in the intensive care unit. An orogastric tube is in place and set to low continuous suction. Fluid resuscitation with isotonic crystalloids has been ongoing per standard burn protocols. Over the last three hours, urine output has decreased to $5\text{ mL/hr}$. Vital signs now show a blood pressure of $78/45\text{ mm Hg}$ and a heart rate of $138/\text{min}$. The abdomen is severely distended and tense to palpation. Mechanical ventilation parameters reveal a new increase in peak inspiratory pressures to $46\text{ cm H}_2\text{O}$. A transurethral bladder pressure measurement reveals a value of $32\text{ mm Hg}$. Which of the following is the most appropriate next step in the management of this patient?

A 68-year-old female is transferred from an inpatient rehabilitation facility to the acute care hospital due to severe, intractable abdominal discomfort. The patient reports that the pain began as intermittent cramping two days ago but has now become constant and severe. She has had multiple episodes of bilious emesis and has not passed stool or flatus in 48 hours. Her past medical history is significant for an open appendectomy and a total abdominal hysterectomy performed over a decade ago. Vital signs upon arrival include a temperature of 38.6°C (101.5°F), pulse of 124/min, respirations of 22/min, and blood pressure of 92/58 mm Hg. Physical examination reveals a markedly distended and tympanitic abdomen. Palpation elicits diffuse tenderness with severe focal guarding and rebound tenderness in the periumbilical region. Laboratory studies demonstrate a leukocyte count of 18,500/mm³ with a left shift, a serum bicarbonate level of 14 mEq/L, and a serum lactate concentration of 5.2 mmol/L. An upright abdominal radiograph displays multiple centrally located, dilated loops of intestine with air-fluid levels and an absence of distal colonic gas. Which of the following is the most appropriate next step in the management of this patient?

A 45-year-old woman is evaluated in the post-anesthesia care unit 2 hours after a total thyroidectomy for a large multinodular goiter. The nurse urgently calls for assistance because the patient has suddenly developed severe respiratory distress. Her temperature is 37.1°C (98.8°F), blood pressure is 155/92 mm Hg, pulse is 118/min, and respirations are 28/min. Pulse oximetry shows an oxygen saturation of 88% on room air. Physical examination reveals a tense, rapidly expanding swelling beneath the cervical incision and prominent inspiratory stridor. Arrange the following management steps in the most appropriate chronological order.

A 65-year-old man with a history of congestive heart failure is brought to the emergency department via ambulance after being involved in a high-speed motor vehicle collision. He was an unrestrained driver and required a prolonged extrication from the vehicle. Upon arrival, he is lethargic and confused. Vital signs show a heart rate of 142/min, blood pressure of 72/40 mmHg, and a respiratory rate of 28/min. The airway is patent, and breath sounds are clear and equal bilaterally. A Focused Assessment with Sonography in Trauma (FAST) examination reveals no intraperitoneal free fluid or pericardial effusion. Inspection of the perineum demonstrates severe scrotal ecchymosis and a drop of blood at the urethral meatus. Gentle inward compression of the iliac crests reveals profound mechanical instability of the pelvic ring. Dorsalis pedis pulses are faint bilaterally, and the lower extremities are cool to the touch. Which of the following is the most appropriate next step in management?

A 27-year-old collegiate athlete is evaluated on the surgical ward twelve hours after undergoing closed reduction and circumferential casting of a right tibial shaft fracture. The injury was sustained during a rugby match. Over the past two hours, he reports agonizing, unrelenting pain in his right leg that has progressively worsened despite receiving scheduled doses of intravenous hydromorphone. He states the pain feels like a "bursting pressure" and is entirely different from his initial fracture pain. On physical examination, the patient appears visibly distressed. The right foot is pink, and the dorsalis pedis pulse is easily palpable. However, passive plantar flexion of the foot and toes produces excruciating, sharp pain in the anterior leg. Sensation to light touch is diminished over the dorsal aspect of the first web space of the foot. Which of the following is the most appropriate next step in management?

A 61-year-old male is evaluated in the emergency room following the acute onset of a painful bulge in his left groin region. He reports that he usually has a small swelling in this area when coughing or straining, but it became much larger and intensely painful four hours ago. He has had no bowel movements or flatus since the pain began. Vital signs show a heart rate of 118/min, blood pressure of 98/60 mm Hg, and a temperature of 38.6°C (101.5°F). Examination of the groin demonstrates a rigid, dark red, and exquisitely tender left inguinal mass. Bowel sounds are absent. Complete blood count reveals a marked leukocytosis. Which of the following is the most appropriate next intervention?

A 71-year-old man is brought to the emergency department by his daughter due to a 2-day history of progressively worsening abdominal pain, severe nausea, and multiple episodes of dark green emesis. He has not passed flatus or had a bowel movement since the symptoms began. His medical history is notable for hypertension, benign prostatic hyperplasia, and a myocardial infarction 5 years ago. His temperature is 38.3°C (100.9°F), blood pressure is 105/65 mmHg, pulse is 112/min, and respirations are 20/min. Physical examination reveals a significantly distended abdomen with high-pitched, tinkling bowel sounds. Inspection of the groin reveals a 5-cm, exquisitely tender, firm, and erythematous mass in the right inguinal region that extends into the scrotum. Laboratory studies show a leukocyte count of 16,500/mm³ and a serum lactate of 4.1 mmol/L. Which of the following is the most appropriate next step in management?

A 68-year-old man with a history of poorly controlled diabetes mellitus and chronic obstructive pulmonary disease is evaluated on postoperative day 6 following an emergent open cholecystectomy for gangrenous cholecystitis. While attempting to transfer from his bed to a chair, he experiences a sudden, severe fit of coughing followed by a "tearing" sensation in his abdomen. On examination, his surgical dressing is saturated with serosanguinous fluid. Removal of the dressing reveals that the fascial edges of his midline incision have separated, and loops of small bowel are protruding onto the abdominal wall.

Arrange the following management steps in the most appropriate chronological sequence for this acute postoperative complication.

Following a physical altercation outside a local venue, a previously healthy adult male is rushed to the trauma bay by bystanders. He has sustained a single penetrating injury to the left parasternal region at the level of the fourth intercostal space. Upon arrival, the patient is restless, diaphoretic, and visibly confused. Vital signs demonstrate a blood pressure of $72/45 \text{ mm Hg}$, a heart rate of $134/\text{min}$, and a respiratory rate of $22/\text{min}$. Oxygen saturation is $94\%$ on ambient air. Physical examination is notable for prominent engorgement of the jugular veins. Pulmonary auscultation reveals clear breath sounds bilaterally. The cardiac point of maximal impulse is impalpable, and heart sounds are markedly muffled. His distal extremities are cool with delayed capillary refill. Which of the following is the most appropriate next step in the management of this patient?

A $28$-year-old male is brought to the trauma bay after a high-speed motorcycle collision. Emergency medical services report a prolonged scene time. On arrival, the patient is unresponsive. There is active, pulsatile bleeding from a traumatic partial amputation of the left lower leg. He has severe maxillofacial smash injuries with pooling of blood and vomitus in the oropharynx. Breath sounds are absent on the right side, and the trachea is deviated to the left. His blood pressure is $70/40$ mm Hg, and his heart rate is $145$/min. Arrange the following initial management steps in the correct chronological sequence according to the current Advanced Trauma Life Support (ATLS) primary survey protocol.

A 72-year-old man is evaluated on postoperative day 2 following an uncomplicated open right hemicolectomy for stage II colon cancer. He reports mild pain at the surgical incision site but is otherwise feeling well. His medical history includes hypertension, diet-controlled type 2 diabetes mellitus, chronic obstructive pulmonary disease (COPD), and heart failure with preserved ejection fraction. His current temperature is 38.2°C (100.8°F), blood pressure is 135/85 mmHg, pulse is 92/min, and respiratory rate is 16/min. Oxygen saturation is 96% on room air. On physical examination, the abdomen is soft and mildly tender around the incision, which shows no purulent drainage, induration, or surrounding erythema. Bowel sounds are hypoactive. Pulmonary auscultation reveals decreased breath sounds at both lung bases and scattered mild expiratory wheezes, but no crackles. Jugular venous pressure is normal at 6 cm H2O. Cardiac examination shows a regular rate and rhythm with no murmurs. His urine output via Foley catheter has been 45 mL/hour over the past 12 hours. Which of the following are the most appropriate next steps in management? (Select 2)

A 29-year-old woman, primigravida at 34 weeks gestation, is brought to the emergency department after a high-speed motor vehicle collision. She was the unrestrained driver. Upon arrival, her blood pressure is 78/42 mm Hg, pulse is 138/min, and respirations are 26/min. The airway is patent, and the trachea is midline. Breath sounds are vesicular and equal bilaterally. The patient is lethargic and pale. Abdominal examination reveals a gravid uterus, diffuse abdominal rigidity, and severe rebound tenderness. A Focused Assessment with Sonography for Trauma (FAST) exam reveals a large anechoic stripe in the hepatorenal space. After the rapid administration of 2 liters of intravenous crystalloid, her blood pressure is 82/46 mm Hg. Fetal heart rate monitoring shows a baseline of 105/min with recurrent late decelerations. The patient's husband, who was a restrained passenger and sustained no significant injuries, frantically demands that the surgical team perform an emergency Cesarean delivery immediately to save the baby. Which of the following is the most appropriate next step in management?

A 62-year-old man presents to the emergency department with a 1-day history of fever, severe right upper quadrant abdominal pain, and confusion. His temperature is 39.2°C (102.6°F), blood pressure is 88/56 mmHg, and heart rate is 118/min. Physical examination reveals pronounced scleral icterus and right upper quadrant tenderness without rebound or guarding. Laboratory studies show a leukocyte count of 18,000/mm³, total bilirubin of 6.8 mg/dL, and alkaline phosphatase of 480 U/L.

Arrange the following management steps in the most appropriate sequential order for this patient, from immediate priority to definitive long-term treatment.

A 32-year-old recreational skier is admitted after sustaining a closed diaphyseal fracture of the right tibia. Following closed reduction and immobilization in a circumferential long-leg cast, he is monitored on the orthopedic ward. Fourteen hours later, he develops excruciating leg pain that worsens with passive movement and is entirely refractory to high-dose intravenous analgesia. Arrange the following clinical steps in the appropriate chronological sequence for the definitive management of this patient's evolving condition.

A $45$-year-old man is brought to the emergency department by ambulance following an industrial boiler explosion. The injury occurred exactly $2$ hours prior to his arrival. He sustained deep partial-thickness and full-thickness thermal burns to his entire anterior trunk and his entire left lower extremity. His airway is intact without signs of inhalation injury, and there is no evidence of electrical injury. The patient weighs $80\text{ kg}$ ($176\text{ lbs}$). No intravenous fluids were administered in the prehospital setting. According to current Advanced Trauma Life Support (ATLS) guidelines for adult thermal burns, the medical team initiates resuscitation with lactated Ringer solution. What is the appropriate initial rate of intravenous fluid administration in $\text{mL/hr}$ for this patient?

A 32-year-old male is brought to the emergency department via ambulance after being involved in a high-speed motor vehicle collision. Primary and secondary trauma surveys reveal that he is hemodynamically stable with no life-threatening injuries. The patient reports excruciating left hip pain and is unable to move his left leg. On physical examination, the left lower extremity is shortened, internally rotated, and adducted. The skin is intact. Initial assessment reveals palpable dorsalis pedis and posterior tibial pulses, as well as normal sensation over the dorsum and plantar aspects of the left foot.

Arrange the following interventions in the most appropriate chronological sequence for the definitive evaluation and management of this patient's orthopedic injury.

A 68-year-old woman with a history of atrial fibrillation presents to the emergency department with a 3-hour history of sudden, severe right leg pain. On physical examination, her right lower extremity is pale and cold. Femoral pulses are palpable bilaterally, but right popliteal and pedal pulses are absent. Bedside Doppler evaluation reveals absent arterial signals but audible venous signals in the right foot. Motor function is intact, and there is mild sensory loss in the toes. Arrange the following management steps in the most appropriate chronological sequence for this patient.