Surgery

A 30-year-old G1P0 woman at 35 weeks gestation is brought to the trauma center after being involved in a high-speed motor vehicle collision as the unrestrained driver. On arrival, she is lethargic but conversant and protecting her airway. She is placed on a backboard with left lateral tilt and receives 2 liters of warmed intravenous crystalloids. Reassessment reveals a blood pressure of 78/42 mm Hg and a heart rate of 135/min. Breath sounds are clear and equal bilaterally. Her abdomen is gravid, rigid, and diffusely tender with rebound and guarding. Bedside focused assessment with sonography for trauma (FAST) demonstrates a large volume of free fluid in the hepatorenal recess. Fetal monitoring shows a baseline heart rate of 115/min with recurrent late decelerations. Arterial blood gas analysis reveals a pH of 7.21, $pCO_2$ of 25 mm Hg, and $HCO_3^-$ of 10 mEq/L. Which of the following is the most appropriate next step in management?

A 71-year-old woman presents to the emergency department with 18 hours of worsening, colicky lower abdominal pain and repeated bilious vomiting. She has not had a bowel movement or passed flatus since the symptoms began. Her temperature is 38.6°C (101.5°F), blood pressure is 92/60 mm Hg, and pulse is 118/min. Cardiopulmonary examination is unremarkable. Abdominal examination reveals a distended abdomen with diffuse rebound tenderness and involuntary guarding. A tender, erythematous, non-reducible bulge is palpated in the right groin, located inferior to the inguinal ligament and medial to the femoral artery pulse. Laboratory studies demonstrate a leukocyte count of 18,500/mm³ and a serum lactate level of 4.2 mmol/L. Which of the following is the most appropriate next step in management?

A 68-year-old man is evaluated in the surgical intensive care unit for sudden-onset hypotension and altered mental status. He was admitted 3 days ago after a severe motor vehicle collision. His initial injuries included multiple left-sided rib fractures, bilateral pulmonary contusions, and a grade III liver laceration that was managed nonoperatively. His past medical history includes heart failure with preserved ejection fraction and chronic obstructive pulmonary disease (COPD).

Currently, his blood pressure is 76/45 mm Hg and his heart rate is 135/min. Oxygen saturation is 89% on 4 L/min via nasal cannula. His temperature is 38.3°C (100.9°F). Physical examination reveals a rigid, distended abdomen with involuntary guarding and rebound tenderness. Auscultation of the lungs reveals decreased breath sounds at the bases with scattered wheezes.

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

A 68-year-old man is evaluated for a new-onset fever on postoperative day 7 following an open anterior resection of the rectum for rectal adenocarcinoma. Over the past 12 hours, he has developed right-sided chest pain that worsens with deep inspiration, along with a mild, dry cough. His temperature is 38.9°C (102.0°F), blood pressure is 132/84 mm Hg, pulse is 114/min, and respirations are 22/min. Oxygen saturation is 93% on room air. His medical history includes heart failure with preserved ejection fraction and diet-controlled type 2 diabetes mellitus. Physical examination shows a normal jugular venous pressure. Lung auscultation is notable for a focal pleural friction rub in the right lower lung field, without crackles or wheezing. The abdomen is soft and non-distended; the midline surgical incision is well-approximated with no erythema, induration, or purulent drainage. The right calf is mildly edematous and tender to palpation compared to the left. Laboratory studies show a white blood cell count of 11,200/mm³. A chest radiograph demonstrates a peripheral, wedge-shaped opacity in the right lower lung zone and a small right-sided pleural effusion. There is no cardiomegaly. Which of the following is the most appropriate next step in management?

A 38-year-old woman is evaluated by the surgical team 24 hours after admission for a mechanical small bowel obstruction. Her initial management included intravenous fluid resuscitation, bowel rest, and nasogastric tube decompression. Over the last 3 hours, she has developed severe, constant abdominal pain that is distinctly different from the cramping pain she experienced on admission. She underwent a total abdominal hysterectomy for uterine fibroids 4 years ago. Her temperature is 38.8°C (101.8°F), blood pressure is 96/60 mmHg, pulse is 124/min, and respirations are 22/min. On physical examination, the abdomen is distended. There is marked right lower quadrant tenderness with guarding and rebound. The nasogastric tube has drained 400 mL of bilious fluid since placement. Laboratory results demonstrate a leukocyte count of 18,000/mm³ with 15% bands, and a serum lactate of 3.5 mmol/L. Which of the following is the most appropriate next step in management?

Match each classic imaging finding described below with its most likely gastrointestinal or surgical diagnosis.

Review the following trauma patient presentations and pair each one with its definitive diagnostic modality or most appropriate immediate intervention.

A 71-year-old man is evaluated in the cardiac intensive care unit for sudden-onset severe dyspnea and worsening confusion. He was admitted 4 days ago for a late-presenting anterior ST-segment elevation myocardial infarction that was treated with delayed percutaneous coronary intervention. His temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $76/40\text{ mm Hg}$, pulse is $122/\text{min}$, and respirations are $28/\text{min}$. Pulse oximetry shows $84\%$ on room air. Physical examination reveals cold, clammy extremities, distended neck veins, and diffuse bilateral pulmonary crackles. Cardiac auscultation demonstrates a new, loud, harsh holosystolic murmur that is heard best at the left lower sternal border, accompanied by a palpable thrill. Bedside echocardiography confirms a left-to-right intracardiac shunt. Which of the following is the most appropriate definitive management for this patient's current condition?

A 76-year-old woman is brought to the emergency department by her family with a 48-hour history of severe, colicky abdominal pain, intractable nausea, and bilious vomiting. She reports no passage of flatus or stool since the symptoms began. Her medical history includes hypertension and type 2 diabetes mellitus. She has never undergone abdominal surgery.

Her temperature is 38.6°C (101.5°F), blood pressure is 98/60 mm Hg, pulse is 115/min, and respiratory rate is 22/min. Physical examination reveals a distended, tympanic abdomen with high-pitched, hyperactive bowel sounds. There is mild, diffuse abdominal tenderness. Examination of the right groin reveals a 4-cm, firm, erythematous, and exquisitely tender mass located inferior to the inguinal ligament and medial to the femoral artery pulsation.

Laboratory studies demonstrate a leukocyte count of 17,200/mm³ and a serum lactate of 3.4 mmol/L (normal: 0.5-1.0 mmol/L).

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

A 62-year-old woman is brought to the emergency department due to a 2-day history of right upper quadrant abdominal pain, high fever, and new-onset confusion. Her temperature is $39.2^\circ C$, blood pressure is 88/54 mmHg, and heart rate is 118/min. Physical examination reveals scleral icterus and right upper quadrant tenderness with guarding. Laboratory studies show a leukocyte count of $18,500/mm^3$, total bilirubin of 6.5 mg/dL, and alkaline phosphatase of 450 U/L. Abdominal ultrasound demonstrates cholelithiasis and a dilated common bile duct measuring 12 mm with an obstructing echogenic focus. Arrange the following management steps in the most appropriate chronological sequence for this patient.

A 25-year-old man is brought to the emergency department after being involved in a chemical plant fire. The incident occurred exactly 3 hours prior to his arrival. His weight is $70 \text{ kg}$. Primary survey reveals a patent airway, but due to facial burns, he is electively intubated. Physical examination reveals deep partial-thickness and full-thickness burns involving his entire head and neck, his entire anterior trunk, and circumferential burns to both arms. There are no other burn injuries identified. Two large-bore intravenous catheters are placed. According to the traditional Parkland formula ($4 \text{ mL/kg/\% TBSA}$), what should be the initial rate of intravenous crystalloid infusion for the remainder of the first 8-hour post-burn period?

Paramedics bring a 34-year-old woman to the emergency department after she struck a tree at high speed while downhill mountain biking. She was found unresponsive at the scene and underwent field endotracheal intubation. Upon arrival, she is receiving mechanical ventilation. Breath sounds are present and equal bilaterally. Blood pressure is 70/40 mm Hg and heart rate is 135/min. Neurologic examination reveals a right pupil that is 8 mm and nonreactive to light, and a left pupil that is 3 mm and briskly reactive. She does not move her extremities to deep painful stimuli. An extended focused assessment with sonography for trauma (eFAST) reveals a large volume of anechoic fluid in the hepatorenal and splenorenal recesses. There is no evidence of pneumothorax. Pelvic radiography reveals no fractures. Which of the following is the most appropriate next step in the management of this patient?

Match each clinical presentation or intraoperative finding to the most appropriate eponymous hernia diagnosis.

A 26-year-old male is brought to the emergency department after being struck by a motor vehicle while riding an electric scooter. On arrival, his airway is patent and he is breathing spontaneously. Vital signs are temperature 36.5°C (97.7°F), blood pressure 80/50 mm Hg, pulse 130/min, and respirations 20/min. Physical examination reveals a pale, diaphoretic man who is drowsy but arousable. Breath sounds are clear and equal bilaterally. His abdomen is soft and non-distended, without guarding or rebound tenderness. Gentle anteroposterior compression of the iliac crests reveals abnormal mobility and elicits a groan of pain from the patient. There is a hematoma over the perineum, and blood is visible at the urethral meatus. A focused assessment with sonography for trauma (FAST) examination shows no fluid in the hepatorenal, splenorenal, or rectovesical spaces, and no pericardial effusion. Two large-bore intravenous lines are placed, and fluid resuscitation is initiated. Which of the following is the most appropriate next step in management?

A surgical consultation is requested for an 82-year-old female patient admitted earlier today with intractable vomiting and severe abdominal distension. The patient resides in an assisted living facility and has a past medical history significant for atrial fibrillation, type 2 diabetes mellitus, and symptomatic cholelithiasis for which she previously declined operative intervention. Over the past two hours, her abdominal pain has become sharp and constant. Vital signs show a temperature of 38.3°C (100.9°F), pulse of 118/min, and blood pressure of 96/60 mm Hg. Physical examination reveals a markedly distended, tympanic abdomen with focal tenderness and involuntary guarding in the right lower quadrant. Laboratory testing demonstrates a leukocyte count of 15,200/mm³ and a mild non-anion gap metabolic acidosis. A non-contrast computed tomography scan of the abdomen shows branching radiolucencies in the liver, prominent dilation of the jejunum and proximal ileum, and a 3.5-cm radiopaque structure impacted just proximal to the ileocecal valve. Which of the following is the most appropriate next step in the management of this patient?

Following a high-velocity motor vehicle collision, a 28-year-old male is admitted to the trauma resuscitation unit. He was extricated from the driver's seat after a prolonged entrapment. The patient is intubated and mechanically ventilated upon arrival. Initial vital signs demonstrate a blood pressure of 72/38 mm Hg and a heart rate of 144/min. Physical examination of the head reveals a right-sided pupil that measures 8 mm and does not react to light, whereas the left pupil is 3 mm and briskly reactive. The thorax exhibits equal breath sounds bilaterally. The abdomen is markedly distended and firm. Bedside ultrasonography reveals large anechoic spaces in the hepatorenal recess and the splenorenal recess. Which of the following is the most appropriate next step in management?

An obese 13-year-old adolescent is brought to the clinic by his parents due to a four-week history of a right-sided limp and intermittent right knee pain. The pain is exacerbated by physical activity and relieved by rest. There is no history of trauma, fever, or weight loss. His body mass index is $33 \text{ kg/m}^2$. Vital signs are within normal limits. On physical examination, there is no swelling, erythema, or localized tenderness over the right knee. Ligamentous testing of the knee is normal. However, when the patient's right hip is passively flexed, the thigh obligately deviates into external rotation. Internal rotation of the right hip is significantly limited compared to the left. Which of the following is the most appropriate next step in management?

A 62-year-old man is evaluated in the intensive care unit due to fever and lethargy. He underwent a coronary artery bypass grafting procedure 5 days ago. Yesterday, he developed a fever, and blood cultures were drawn which are currently growing methicillin-susceptible Staphylococcus aureus (MSSA). Today, his temperature is 39.2°C (102.6°F), blood pressure is 85/50 mm Hg, and heart rate is 128/min. Physical examination reveals a sternal wound with copious purulent discharge and palpable clicking of the sternal halves during respiration. Lung auscultation reveals clear breath sounds bilaterally. Electrocardiogram shows sinus tachycardia. Which of the following is the most appropriate next step in management?

A 42-year-old male is brought to the trauma bay after a high-speed motor vehicle collision. On arrival, he is unresponsive. He has audible gurgling respirations with pooling of blood in his oropharynx. His blood pressure is 75/40 mmHg, heart rate is 142/min, and respiratory rate is 32/min. Physical examination reveals tracheal deviation to the left and absent breath sounds over the right hemithorax. His pelvis is mechanically unstable on anterior-posterior compression. Arrange the following management steps in the correct chronological order according to standard trauma resuscitation protocols.

A 64-year-old male is recovering in the surgical ward after undergoing an emergency partial small bowel resection for mesenteric ischemia six days ago. He has a history of severe chronic obstructive pulmonary disease and type 2 diabetes. During a severe coughing fit, he feels a sudden 'giving way' sensation in his lower abdomen. Examination of the surgical site reveals complete separation of the surgical incision with a loop of viable-appearing small intestine protruding onto the skin surface. He is alert, with a heart rate of 98/min and blood pressure of 130/80 mmHg. Arrange the following management steps in the most appropriate chronological sequence for this complication.