Surgery

A 68-year-old man is evaluated on postoperative day 5 following an elective right hemicolectomy for colon adenocarcinoma. Over the past 12 hours, he has developed a new-onset fever, generalized malaise, and worsening abdominal pain. His medical history is significant for heart failure with preserved ejection fraction and diet-controlled type 2 diabetes mellitus. His temperature is 39.1°C (102.4°F), blood pressure is 128/76 mmHg, pulse is 114/min, and respiratory rate is 22/min. Oxygen saturation is 95% on room air. Physical examination reveals a mildly distended abdomen with focal tenderness in the right lower quadrant, but no involuntary guarding or rebound. The surgical incision is clean, dry, and intact. Auscultation of the lungs reveals fine crackles at the bases bilaterally, which are unchanged from his preoperative assessment. Blood cultures that were drawn 24 hours ago during a transient low-grade temperature elevation are now returning positive for *Escherichia coli* that is susceptible to ceftriaxone. Which of the following are the most appropriate next steps in management? (Select 2)

During her sixth day of recovery following an open abdominal hysterectomy for symptomatic uterine fibroids, a 45-year-old woman develops a fever. The surgical procedure was uncomplicated, and her postoperative course has been otherwise unremarkable. She is currently ambulating in the ward and tolerating a solid diet. Her temperature is 38.8°C (101.8°F), blood pressure is 120/78 mmHg, and pulse is 96/min. The patient reports localized throbbing pain at her abdominal incision but denies dysuria, cough, or shortness of breath. Physical examination demonstrates a 12-cm lower midline incision. The inferior 4 centimeters of the wound are notably erythematous, indurated, and exquisitely tender. Gentle pressure applied adjacent to this area produces a small amount of thick, purulent discharge emerging from between the surgical staples. Auscultation of the lungs reveals clear breath sounds bilaterally. Which of the following is the most appropriate next step in the management of this patient's current condition?

Match each clinical presentation of acute thoracic trauma with the most appropriate immediate diagnostic or therapeutic next step.

A 28-year-old man is brought to the emergency department via ambulance after being struck by a sport utility vehicle while crossing the street. He complains of severe lower abdominal and groin pain. His airway is patent, and breath sounds are equal bilaterally. Temperature is 36.5°C (97.7°F), heart rate is 135/min, blood pressure is 78/40 mm Hg, and respiratory rate is 24/min. Physical examination reveals a soft, non-distended abdomen with no rebound tenderness or guarding. There is prominent ecchymosis over the suprapubic and scrotal regions, and a small amount of blood is present at the urethral meatus. Gentle anteroposterior compression of the iliac crests reveals mechanical instability. A focused assessment with sonography for trauma (FAST) examination shows no free fluid in the pericardial, right upper quadrant, left upper quadrant, or suprapubic spaces. A pelvic binder is immediately applied, and the patient receives 2 units of uncrossmatched packed red blood cells. Fifteen minutes later, his heart rate is 128/min and blood pressure is 82/45 mm Hg. Which of the following is the most appropriate next step in management?

On the sixth day following an open sigmoid colectomy for complicated diverticulitis, a 64-year-old male patient is assessed for sudden clinical deterioration. The nursing staff reports that over the previous 24 hours, the patient developed progressive abdominal distension alongside multiple episodes of bilious emesis. He has had no return of bowel function since the operation. Initially, he described the abdominal pain as crampy and intermittent, but over the last 4 hours, the pain has transitioned into a severe, unremitting, and continuous ache.

Current vital signs are:
* Temperature: $38.7^\circ\text{C}$ ($101.7^\circ\text{F}$)
* Pulse: $122/\text{min}$
* Blood pressure: $98/60\text{ mm Hg}$
* Respirations: $24/\text{min}$

Physical examination reveals a markedly distended, tympanic abdomen. Deep palpation elicits diffuse tenderness, though distinct rebound tenderness and involuntary guarding are absent. Bowel sounds are undetectable. The midline abdominal incision appears well-approximated with no exudate or surrounding erythema.

Pertinent laboratory results are as follows:

An urgent abdominal plain film exhibits several distended loops of small bowel with prominent air-fluid levels, without visible colonic gas or free intraperitoneal air.

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

Emergency medical services arrive at the trauma center with a 32-year-old male victim of a high-speed motorcycle crash. He was found unresponsive at the scene after a prolonged extrication time. Upon presentation, the patient exhibits loud, gurgling respirations and central cyanosis. Hemodynamic monitoring reveals a blood pressure of 65/40 mmHg and a heart rate of 145/min. The physical examination is notable for active, pulsatile arterial bleeding from a severely mangled left lower extremity. Arrange the following acute management steps in the correct chronological sequence according to the Advanced Trauma Life Support (ATLS) protocol.

During an amateur equestrian event, a 35-year-old woman was thrown from her horse and subsequently kicked in the left flank. She arrives at the emergency department immobilized on a backboard. She is alert but restless and complains of severe abdominal pain. Her temperature is $36.6^\circ\text{C}$ ($97.9^\circ\text{F}$), blood pressure is $82/54\text{ mmHg}$, pulse is $128/\text{min}$, and respirations are $22/\text{min}$. Oxygen saturation is $97\%$ on room air. The airway is patent, and breath sounds are vesicular and symmetric bilaterally. The pelvis is mechanically stable to anteroposterior and lateral compression. The abdomen is distended, with significant ecchymosis over the left flank, and diffuse tenderness with guarding is noted. A focused assessment with sonography for trauma (FAST) demonstrates a substantial anechoic fluid collection in the hepatorenal recess (Morison's pouch) and the splenorenal recess. Intravenous access is established, and rapid infusion of 1 L of warmed crystalloid is initiated. Which of the following is the most appropriate next step in management?

Emergency medical services bring a 32-year-old man to the trauma bay 30 minutes after he sustained a gunshot wound to the left gluteal region during an altercation. On arrival, he appears pale, diaphoretic, and confused. Blood pressure is 74/40 mm Hg, heart rate is 135/min, and respiratory rate is 24/min. Oxygen saturation is 96% on room air. The primary survey reveals a patent airway and equal breath sounds bilaterally. Physical examination shows a single entry wound in the left upper outer quadrant of the buttock with no visible exit wound. The abdomen is tense, distended, and diffusely tender with involuntary guarding. A focused assessment with sonography for trauma (FAST) is technically limited due to overlying bowel gas. Bilateral large-bore intravenous lines are established, and he receives a rapid infusion of 1 L of warmed crystalloid and 1 unit of uncrossmatched group O blood. Five minutes later, his blood pressure is 78/42 mm Hg and heart rate is 130/min. Which of the following is the most appropriate next step in management?

A 30-year-old male electrician is brought to the emergency department after sustaining a high-voltage electrical injury at a construction site. The accident occurred exactly 2 hours prior to his arrival. On physical examination, the patient is awake and alert. Vital signs show a heart rate of 115/min and blood pressure of 105/65 mm Hg. He has deep partial-thickness and full-thickness burns involving his entire right arm and his entire anterior trunk (chest and abdomen). No other areas of the body are burned. His body weight is 75 kg. Two large-bore peripheral intravenous lines are established, and a Foley catheter is placed.

Based on current Advanced Trauma Life Support (ATLS) guidelines for high-voltage electrical burns, what should be the continuous intravenous fluid infusion rate (in mL/hr) of lactated Ringer solution for this patient over the next 6 hours?

A 62-year-old woman is evaluated on postoperative day 5 following a partial gastrectomy with Billroth II reconstruction for a refractory bleeding peptic ulcer. The nursing staff alerts the physician because the patient has become increasingly confused and lethargic over the past 4 hours. Her temperature is 39.2°C (102.6°F), blood pressure is 78/45 mmHg, heart rate is 132/min, and respiratory rate is 24/min. Oxygen saturation is 94% on room air. On physical examination, her abdomen is markedly distended and rigid, with diffuse rebound tenderness and involuntary guarding. Bowel sounds are absent. Urine output has been 10 mL over the past 2 hours. Which of the following are the most appropriate next steps in management? (Select exactly 2 options)

A 19-year-old female collegiate rugby player arrives at the trauma center via ambulance shortly after sustaining an injury during a match. Witnesses report she was forcefully tackled and struck in the left abdomen by an opponent's knee. Upon arrival, her temperature is $36.2^\circ\text{C}$ ($97.2^\circ\text{F}$), heart rate is $138/\text{min}$, blood pressure is $76/42\text{ mmHg}$, and respiratory rate is $26/\text{min}$. Oxygen saturation is $95\%$ on room air. The patient is lethargic but localizes to painful stimuli. The airway is patent, and breath sounds are vesicular and equal bilaterally. The abdomen is grossly distended with severe diffuse tenderness to palpation, guarding, and rebound tenderness. A large ecchymosis is present over the left upper quadrant. The pelvis is stable to anterior-posterior and lateral compression. Bedside ultrasound of the abdomen demonstrates a significant anechoic collection in the splenorenal recess and the rectouterine pouch. Which of the following is the most appropriate next step in the management of this patient?

A 26-year-old man is evaluated in the emergency department after a mountain biking accident. He lost control on a steep downhill trail and was thrown over the handlebars, striking his left flank against a large tree stump. He complains of severe left-sided abdominal pain that radiates to his left shoulder.

His temperature is 37.1°C (98.8°F), blood pressure is 132/84 mmHg, heart rate is 86/min, and respiratory rate is 16/min. On physical examination, the patient is alert and oriented. There is an abrasion and extensive ecchymosis over the left lower rib cage. Abdominal examination reveals tenderness to palpation in the left upper quadrant, but no guarding, rigidity, or rebound tenderness is present. The pelvis is stable to anteroposterior and lateral compression.

A bedside focused assessment with sonography for trauma (FAST) demonstrates a small accumulation of anechoic fluid in the splenorenal recess.

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

A surgical team is called to assess a 68-year-old male inpatient 48 hours following an open repair of a large ventral hernia. The patient is reporting new-onset shortness of breath that began earlier in the shift. His medical history is significant for chronic obstructive pulmonary disease and heart failure with preserved ejection fraction. When asked to take a deep breath, he stops abruptly and states that the maneuver causes sharp pain localized specifically around his abdominal incision. His temperature is 37.9°C (100.2°F), pulse is 108/min, respirations are 24/min, and blood pressure is 138/86 mm Hg. Pulse oximetry shows an oxygen saturation of 91% on room air. Physical examination reveals a well-approximated surgical site that is tender to palpation, with no surrounding erythema or purulent drainage. Jugular venous pulsation is visible 2 cm above the sternal angle. Auscultation of the chest reveals decreased breath sounds at both lung bases. No wheezes, crackles, or cardiac murmurs are appreciated. The patient's calves are soft, non-tender, and without edema. Which of the following is the most appropriate initial step in the management of this patient?

Correlate each of the following thoracic trauma patient scenarios with its corresponding definitive next step in management or acute diagnostic evaluation.

A 52-year-old woman is evaluated in the surgical intensive care unit 6 hours following a complex open hepatic resection for a large hepatocellular carcinoma. The nursing staff requested an urgent evaluation due to a sudden change in her clinical status over the past 30 minutes. She has become increasingly confused and restless. Her temperature is 37.7°C (99.9°F), heart rate is 138/min, blood pressure is 76/42 mm Hg, and respiratory rate is 26/min. Oxygen saturation is 95% on room air. Physical examination reveals weak peripheral pulses and cold, clammy extremities. Her indwelling urinary catheter has drained only 5 mL of urine in the past hour. Examination of the surgical site reveals that two closed-suction drains have rapidly accumulated 600 mL of bright red blood within the last 45 minutes. Which of the following are the most appropriate immediate steps in the management of this patient? (Select exactly two)

A 31-year-old woman, gravida 2, para 1, at 34 weeks gestation is brought to the emergency department via ambulance after being involved in a high-speed motor vehicle collision. She was the restrained driver of a vehicle that struck a concrete barrier. On arrival, the patient is lethargic and complains of severe, diffuse abdominal pain.

Vital signs are:
Temperature: 36.5°C (97.7°F)
Heart rate: 138/min
Blood pressure: 78/42 mmHg
Respiratory rate: 26/min
Oxygen saturation: 96% on face mask

Physical examination reveals bruising across the lower abdomen in a seatbelt distribution. The abdomen is diffusely tender with guarding. A focused assessment with sonography for trauma (FAST) demonstrates a large amount of anechoic free fluid in the hepatorenal and splenorenal recesses.

Continuous fetal heart rate monitoring reveals a baseline of 165/min with minimal variability and recurrent late decelerations.

Intravenous access is established, and the patient receives 2 L of warmed lactated Ringer solution and 2 units of uncrossmatched type O-negative blood. Repeat vital signs show a heart rate of 132/min and a blood pressure of 80/45 mmHg.

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

A 71-year-old woman is assessed by the on-call physician in the surgical ward on postoperative day 6 following a subtotal colectomy with end ileostomy for severe ischemic colitis. Her medical history is notable for severe chronic obstructive pulmonary disease and poorly controlled type 2 diabetes mellitus. While attempting to transition from her bed to a chair, she experiences a forceful, prolonged coughing spasm. She immediately reports a sudden "tearing" sensation in her lower abdomen. Shortly thereafter, the primary nurse observes a copious amount of salmon-colored fluid soaking the patient's abdominal binder. Removal of the binder and superficial dressings reveals viable, intact loops of small intestine protruding through a complete dehiscence of the midline fascial closure. Arrange the following management steps in the most appropriate chronological order for this patient.

A 25-year-old man is brought to the trauma bay via ambulance after being ejected from a vehicle during a high-speed collision. On arrival, he is comatose with gurgling respirations. Vital signs are temperature 36.1°C (97.0°F), blood pressure 65/35 mm Hg, pulse 145/min, and respirations 8/min. Physical examination reveals a trachea deviated to the left, absent breath sounds on the right hemithorax, and dramatically distended neck veins. Anteroposterior compression of the pelvis reveals mechanical instability. Arrange the following critical interventions in the exact sequential order they should be performed according to Advanced Trauma Life Support (ATLS) priority protocols.

A 52-year-old man is brought to the emergency department after falling 20 feet from a roof. On arrival, he is confused and diaphoretic. His blood pressure is 82/50 mmHg and his pulse is 130/min. His airway is patent, and breath sounds are clear and equal bilaterally. A rigid cervical collar is in place. Physical examination reveals significant ecchymosis and guarding over the left upper quadrant of the abdomen. The pelvis is mechanically stable to anteroposterior and lateral compression. Intravenous fluid resuscitation with warmed crystalloid is initiated. A bedside 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 61-year-old man presents to the emergency department with severe, unremitting right groin pain and nausea for the past 6 hours. He has vomited dark, foul-smelling fluid three times. He has a history of a right-sided groin bulge that he normally pushes back in, but since the pain started, he has been unable to do so. His temperature is 38.2°C (100.8°F), blood pressure is 110/70 mm Hg, heart rate is 115/min, and respiratory rate is 18/min. Physical examination reveals a distended abdomen with high-pitched bowel sounds. Examination of the right groin reveals a 5-cm, firm, exquisitely tender, and erythematous mass above the inguinal ligament. Laboratory studies show a leukocyte count of 16,500/mm³ and a serum lactate level of 3.8 mmol/L. Which of the following is the most appropriate next step in the management of this patient?