Surgery

Emergency medical services bring a 32-year-old male warehouse worker to the trauma center 30 minutes after he was pinned between a forklift and a concrete loading dock. He is awake, diaphoretic, and complains of agonizing pain in his hips and lower back.

Vital signs on arrival are temperature 36.8°C (98.2°F), blood pressure 76/40 mmHg, heart rate 138/min, and respiratory rate 24/min. The airway is patent, and breath sounds are equal bilaterally. The trachea is midline. Two large-bore intravenous catheters are placed, and 1 L of warmed lactated Ringer solution is administered rapidly. Following fluid resuscitation, his blood pressure remains 74/42 mmHg.

Physical examination reveals a rapidly expanding scrotal hematoma and a small amount of blood at the urethral meatus. Gentle anteroposterior compression of the iliac crests demonstrates gross mechanical instability, and a pelvic binder is immediately applied.

A bedside focused assessment with sonography for trauma (FAST) demonstrates no free fluid in the pericardial, pleural, or peritoneal cavities. A portable chest radiograph is normal. A portable anteroposterior pelvic radiograph confirms a 4-cm diastasis of the pubic symphysis and disruption of the left sacroiliac joint.

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

An otherwise healthy $48$-year-old female presents to the surgical assessment unit with a $24$-hour history of intermittent, crampy abdominal pain. She reports three episodes of bilious vomiting and states she has not passed flatus or stool since the pain began. Her surgical history is significant for a total abdominal hysterectomy performed five years ago for uterine fibroids.

Vital signs include a blood pressure of $122/78$ mmHg, heart rate of $82$/min, respiratory rate of $14$/min, and temperature of $37.0^\circ$ C ($98.6^\circ$ F). Physical examination reveals a moderately distended abdomen with high-pitched, 'tinkling' bowel sounds. The abdomen is softly to moderately tender diffusely, but there is no rigidity, guarding, or rebound tenderness.

Laboratory studies show a leukocyte count of $8,200$/mm $^3$ and a serum lactate level of $1.1$ mmol/L. A computed tomography (CT) scan of the abdomen and pelvis with intravenous contrast demonstrates dilated loops of small bowel measuring up to $4.2$ cm with multiple air-fluid levels and a discrete transition point in the mid-ileum. The distal small bowel and colon are collapsed. There is no evidence of pneumatosis intestinalis, mesenteric fat stranding, or free intraperitoneal fluid.

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

A $65$-year-old man presents to the emergency department with a $2$-day history of colicky abdominal pain, intractable nausea, and failure to pass flatus or stool. He underwent an open appendectomy $20$ years ago. His temperature is $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), pulse is $105/\text{min}$, and blood pressure is $118/76\text{ mmHg}$. Abdominal examination reveals a distended and tympanitic abdomen with high-pitched bowel sounds, but no rebound tenderness or guarding. Laboratory studies show a leukocyte count of $9,500/\text{mm}^3$ and normal serum lactate levels. An abdominal computed tomography (CT) scan reveals dilated small bowel loops with a transition point in the right lower quadrant, consistent with a mechanical small bowel obstruction, and no evidence of bowel ischemia.

Arrange the following steps in the most appropriate chronological sequence for the management of this patient, assuming his condition does not resolve with nonoperative measures.

A 42-year-old woman is transported to the emergency department after a grease fire erupted at the commercial kitchen where she works. The incident occurred exactly 3 hours before her arrival at the trauma center. She weighs $80 \text{ kg}$. On primary survey, her airway is patent, breathing is spontaneous but tachypneic, and hemodynamics are stable. Physical examination reveals deep partial-thickness and full-thickness burns involving her entire anterior trunk, her entire right arm, and the anterior surface of her right lower extremity. The remainder of her skin is uninjured. Using the traditional Parkland formula ($4 \text{ mL/kg/\%TBSA}$), at what rate (in $\text{mL/hour}$) should the initial intravenous crystalloid infusion be set to deliver the appropriate fluid volume over the remainder of the first 8-hour window?

A $42$-year-old woman is evaluated in the surgical step-down unit due to an acute exacerbation of abdominal pain. She was admitted yesterday for a bowel obstruction attributed to adhesions from a previous pelvic surgery. Initial treatment consisted of intravenous hydration, fasting, and placement of a nasogastric tube. Over the past two hours, her symptoms have shifted from colicky and intermittent discomfort to severe, unyielding pain. Vital signs show a temperature of $38.6^\circ\text{C}$ ($101.5^\circ\text{F}$), blood pressure of $110/68\text{ mmHg}$, heart rate of $122/\text{min}$, and respiratory rate of $24/\text{min}$. Abdominal examination demonstrates marked rigidity, involuntary guarding, and focal rebound tenderness. Blood tests reveal a white blood cell count of $19,500/\text{mm}^3$ with $85\%$ neutrophils and a serum lactate level of $4.5\text{ mmol/L}$. Which of the following is the most appropriate next step in the management of this patient?

Paramedics bring a 28-year-old construction worker to the emergency department following a 15-foot (4.5-meter) fall from scaffolding. He is conscious but reports intense pain across his entire abdomen. Vital signs reveal a blood pressure of 82/50 mmHg, a heart rate of 128/min, and a respiratory rate of 24/min. Pulse oximetry is 96% on ambient air. Primary evaluation demonstrates an intact airway with bilateral breath sounds present and equal. No obvious sources of external blood loss are identified. Abdominal examination reveals marked distension, diffuse tenderness, and involuntary guarding. The pelvis is mechanically stable to manual compression. A bedside ultrasound examination (FAST) demonstrates a large anechoic collection in Morison's pouch. Which of the following is the most appropriate next step in management?

A $52$-year-old man is evaluated by the surgical team for an elevated temperature $28$ hours after undergoing an open partial gastrectomy for a refractory bleeding peptic ulcer. He has a history of type 2 diabetes mellitus and hypertension. His current medications include subcutaneous insulin and intravenous lactated Ringer solution. The patient reports mild, localized pain at the abdominal incision site but denies dyspnea, cough, dysuria, or calf pain. His temperature is $38.4^{\circ}\text{C}$ ($101.1^{\circ}\text{F}$), blood pressure is $135/85\text{ mmHg}$, pulse is $92/\text{min}$, and respirations are $18/\text{min}$. Pulse oximetry shows $96\%$ on room air. Physical examination reveals decreased breath sounds at the lung bases bilaterally, without crackles or wheezes. The abdominal incision is well-approximated, clean, and dry, with no surrounding erythema. His indwelling urethral catheter is draining clear yellow urine at a rate of $45\text{ mL/hour}$. Which of the following is the most appropriate next step in the management of this patient's fever?

Match each clinical presentation of an acutely injured trauma patient with the most appropriate next step in diagnostic or therapeutic management.

An unrestrained driver is ejected from his vehicle during a rollover collision and airlifted to the regional trauma center. Upon arrival, the patient is unresponsive. His airway is rapidly secured via endotracheal intubation. Initial vital signs reveal a heart rate of 138/min and a blood pressure of 72/40 mmHg. Breath sounds are clear and equal bilaterally. The abdomen is grossly distended and rigid to palpation. Anteroposterior compression of the pelvis reveals no mechanical instability. Despite the rapid infusion of 1 L of warmed crystalloid and 1 unit of uncrossmatched packed red blood cells, his blood pressure remains critically low at 76/42 mmHg. A focused assessment with sonography for trauma (FAST) examination demonstrates a significant amount of free fluid in both the splenorenal and hepatorenal spaces. Which of the following is the most appropriate next step in the management of this patient?

Following a sigmoid colectomy for recurrent diverticulitis four days ago, a 72-year-old female patient suddenly develops severe, poorly localized abdominal pain accompanied by altered mental status. Her vital signs show a temperature of 39.5°C (103.1°F), a heart rate of 128/min, a blood pressure of 78/46 mm Hg, and a respiratory rate of 26/min. Abdominal examination demonstrates diffuse board-like rigidity, involuntary guarding, and profound rebound tenderness. The patient is diagnosed with septic shock secondary to a suspected anastomotic leak. Arrange the following clinical interventions in the most appropriate chronological order of execution.

A $68$-year-old woman is evaluated on postoperative day $5$ following an open right hemicolectomy for a localized cecal adenocarcinoma. Over the last $24$ hours, she has developed crampy, intermittent abdominal pain, significant nausea, and three episodes of bilious vomiting. The patient passed flatus on postoperative day $2$ but has not passed flatus or had a bowel movement since then. Her temperature is $38.3^\circ\text{C}$ ($100.9^\circ\text{F}$), blood pressure is $118/76\text{ mm Hg}$, and pulse is $98/\text{min}$. Physical examination reveals a diffusely distended and tympanitic abdomen with mild, diffuse tenderness. There is no rebound tenderness or guarding. The surgical incision is clean, intact, and without erythema or drainage.

An abdominal computed tomography (CT) scan with oral and intravenous contrast reveals dilated loops of small bowel up to $4.5\text{ cm}$ in diameter, terminating in the right lower quadrant near the ileocolic anastomosis. The distal colon is completely decompressed. There is no evidence of bowel wall thickening, pneumatosis intestinalis, or pelvic fluid collection. Which of the following is the most appropriate next step in the management of this patient?

A 22-year-old man is brought to the emergency department after a motorcycle collision where he struck a guardrail at highway speeds. Emergency medical services report that he was found unresponsive at the scene. Upon arrival in the trauma bay, the trauma team observes bright red, pulsatile blood spurting from a deep laceration on his right mid-thigh. He is making gurgling respiratory sounds, and there is visible pooling of blood in his oropharynx. Tracheal deviation to the right is noted, and breath sounds are absent over the left hemithorax. His blood pressure is 68/40 mm Hg, and his heart rate is 145/min. Arrange the following acute management steps in the most appropriate sequential order according to the Advanced Trauma Life Support (ATLS) protocol.

A $76$-year-old man from a nursing home is brought to the emergency department due to a $3$-day history of progressive abdominal distension, colicky abdominal pain, and obstipation. His temperature is $37.4^\circ\text{C}$ ($99.3^\circ\text{F}$), blood pressure is $118/76$ mm Hg, and pulse is $92$/min. Physical examination reveals a markedly distended, tympanitic abdomen without rebound tenderness or guarding. Arrange the following management steps in the most appropriate sequential order for this patient.

An emergency response team brings a 45-year-old male industrial worker to the trauma center after a heavy steel beam collapsed, briefly pinning his lower torso against a concrete floor. On arrival, he is groggy but vigorously localizes to painful stimuli. His temperature is 36.5°C (97.7°F), blood pressure is 82/44 mmHg, heart rate is 134/min, and respiratory rate is 24/min. Pulse oximetry shows 98% on high-flow oxygen. Primary survey reveals a patent airway and bilateral breath sounds without adventitious noises. The trachea is midline, and neck veins are flat. Radial pulses are barely palpable, while femoral pulses are weak but present. A large ecchymosis is visible across the infraumbilical region, and the abdomen appears distended. Pelvic rock testing reveals no mechanical instability. Intravenous access is established with two large-bore peripheral catheters, and rapid crystalloid resuscitation is initiated. Which of the following is the most appropriate next step in the evaluation of this patient?

A previously healthy $59$-year-old male is brought to the surgical triage unit by his family after developing sudden, severe, and constant lower abdominal pain accompanied by multiple episodes of bilious emesis. The symptoms began $12$ hours prior to arrival, and he has not passed stool or flatus since the onset. He denies any prior abdominal operations. Vital signs include a temperature of $38.5^\circ\text{C}$ ($101.3^\circ\text{F}$), a blood pressure of $96/60\text{ mmHg}$, and a heart rate of $118\text{/min}$. Abdominal examination reveals significant distension, hypoactive bowel sounds, and involuntary guarding. A tense, irreducible $5\text{-cm}$ bulge is noted in the right inguinal region. The skin overlying the bulge is dusky and erythematous. Laboratory studies are significant for a leukocyte count of $18,500\text{/mm}^3$ and a serum lactate of $4.2\text{ mmol/L}$. Which of the following is the most appropriate next step in management?

Match each clinical presentation of an acute surgical abdomen with its most appropriate specific intervention or definitive surgical management.

A 72-year-old woman is evaluated on postoperative day 4 following an open reduction and internal fixation of a right femoral neck fracture. Her medical history includes chronic obstructive pulmonary disease (COPD) and heart failure with preserved ejection fraction. On postoperative day 2, she developed a fever of $38.7^\circ\text{C}$ ($101.7^\circ\text{F}$) and a productive cough. A chest radiograph demonstrated a new left lower lobe consolidation. She was empirically started on intravenous vancomycin and cefepime. Today, her fever has resolved, but she reports new-onset orthopnea and worsening shortness of breath over the last 12 hours. Her blood pressure is $135/85\text{ mmHg}$, pulse is $98/\text{min}$, and oxygen saturation is $92\%$ on room air. Physical examination reveals elevated jugular venous pressure and bilateral basilar crackles without wheezing. There is 2+ bilateral lower extremity pitting edema. Sputum cultures from two days ago have finalized, showing heavy growth of Streptococcus pneumoniae that is exquisitely sensitive to ceftriaxone. Which of the following are the most appropriate next steps in the management of this patient? (Select 2)

A 34-year-old woman arrives at the regional burn center via ambulance after being rescued from a residential house fire. She sustained deep partial-thickness and full-thickness thermal burns. Physical examination reveals that her entire right leg and her entire right arm are burned. Her uninjured skin is intact. The patient weighs $75 \text{ kg}$. The incident occurred exactly $2 \text{ hours}$ prior to her arrival at the hospital. Two large-bore intravenous lines are established.

Using the traditional Parkland formula ($4 \text{ mL/kg/}\% \text{TBSA}$), what should be the initial intravenous fluid infusion rate (in $\text{mL/hr}$) to administer the required volume over the remainder of the first 8 hours post-injury?

A 58-year-old man is evaluated on postoperative day 7 for fever and abdominal pain. He underwent an emergent exploratory laparotomy and partial ileocecal resection for a perforated appendix. His recovery was initially uncomplicated; his urinary catheter was removed on postoperative day 2, and he has been tolerating a soft diet since day 4. Today, he reports nausea, anorexia, and a persistent dull ache in his right lower abdomen. His temperature is 39.2°C (102.6°F), blood pressure is 114/76 mm Hg, pulse is 112/min, and respiratory rate is 18/min. Physical examination reveals a midline surgical incision that is clean, dry, and well-approximated with intact surgical staples. There is no surrounding erythema, induration, or discharge. His abdomen is mildly distended with localized tenderness in the right lower quadrant, but no rebound or guarding is present. Laboratory studies show a leukocyte count of $18,000/\text{mm}^3$. Which of the following is the most appropriate next step in management?

A 68-year-old woman is brought to the emergency department by her family due to severe right upper quadrant abdominal pain, worsening jaundice, and shaking chills over the past 24 hours. Her temperature is 39.5°C (103.1°F), blood pressure is 88/54 mmHg, heart rate is 122/min, and respiratory rate is 22/min. She appears lethargic and is oriented only to her name. Physical examination reveals scleral icterus and marked right upper quadrant tenderness with guarding. Laboratory tests show a leukocyte count of 18,000/mm³, total bilirubin of 5.8 mg/dL, and alkaline phosphatase of 410 U/L. Arrange the following interventions in the most appropriate sequential order for the management of this patient.