A 72-year-old man comes to the emergency department because of severe, acute, right leg pain for 2 hours. The patient's symptoms started suddenly while he was doing household chores. He has no history of leg pain at rest or with exertion. Yesterday, he returned home after a 6-hour bus ride from his grandson's home. He has hypertension treated with ramipril. He appears uncomfortable. His temperature is 37.4°C (99.3°F), pulse is 105/min and irregular, and blood pressure is 146/92 mm Hg. The right lower extremity is cool and tender to touch. A photograph of the limb is shown. Femoral pulses are palpable bilaterally; popliteal and pedal pulses are decreased on the right side. Sensation to pinprick and light touch and muscle strength are decreased in the right lower extremity. Which of the following is most likely to confirm the underlying source of this patient's condition?

Doppler ultrasonography of the legs

Digital subtraction angiography

A 32-year-old man is brought to the emergency department after a skiing accident. The patient had been skiing down the mountain when he collided with another skier who had stopped suddenly in front of him. He is alert but complaining of pain in his chest and abdomen. He has a past medical history of intravenous drug use and peptic ulcer disease. He is a current smoker. His temperature is 97.4°F (36.3°C), blood pressure is 77/53 mmHg, pulse is 127/min, and respirations are 13/min. He has a GCS of 15 and bilateral shallow breath sounds. His abdomen is soft and distended with bruising over the epigastrium. He is moving all four extremities and has scattered lacerations on his face. His skin is cool and delayed capillary refill is present. Two large-bore IVs are placed in his antecubital fossa, and he is given 2L of normal saline. His FAST exam reveals fluid in Morison's pouch. Following the 2L normal saline, his temperature is 97.5°F (36.4°C), blood pressure is 97/62 mmHg, pulse is 115/min, and respirations are 12/min. Which of the following is the best next step in management?

Upper gastrointestinal endoscopy

A trauma 'huddle' is called. Morphine is administered for pain. Low-flow oxygen is begun. A traumatic diaphragmatic rupture is suspected. Infusion of 0.9% saline is begun. Which of the following is the most appropriate next step in management?

CT of the chest, abdomen, and pelvis

A 25-year-old man is brought to the emergency department because of a 6-day history of fever and chills. During this period, he has had generalized weakness, chest pain, and night sweats. He has a bicuspid aortic valve and recurrent migraine attacks. He has smoked one pack of cigarettes daily for 5 years. He does not drink alcohol. He has experimented with intravenous drugs in the past but has not used any illicit drugs in the last two months. Current medications include propranolol and a multivitamin. He appears ill. His temperature is 39°C (102.2°F), pulse is 108/min, respirations are 14/min, and blood pressure is 150/50 mm Hg. Diffuse crackles are heard. A grade 3/6 high-pitched, early diastolic, decrescendo murmur is best heard along the left sternal border. An S3 gallop is heard. The remainder of the physical examination shows no abnormalities. Laboratory studies show: Hemoglobin 13.1 g/dL Leukocyte count 13,300/mm3 Platelet count 270,000/mm3 Serum Glucose 92 mg/dL Creatinine 0.9 mg/dL Total bilirubin 0.4 mg/dL AST 25 U/L ALT 28 U/L Three sets of blood cultures are sent to the laboratory. Transthoracic echocardiography confirms the diagnosis. In addition to antibiotic therapy, which of the following is the most appropriate next step in management?

Porcine valve replacement of the aortic valve

Transcatheter aortic valve implantation (TAVI)

Repeat echocardiography in 4 weeks

Mechanical valve replacement of the aortic valve

An 8-month-old boy is brought to the emergency department by his mother. She is concerned that her son has had intermittent periods of severe abdominal pain over the past several days that has been associated with emesis and "currant jelly" stool. Of note, the family lives in a rural part of the state, requiring a 2 hour drive to the nearest hospital. He currently appears to be in significant pain and has vomited twice in the past hour. On physical examination, a sausage-shaped mass is noted on palpation of the right upper quadrant of the abdomen. Ultrasound of the abdomen was consistent with a diagnosis of intussusception. An air-contrast barium enema was performed, which confirmed the diagnosis and also successfully reduced the intussusception. Which of the following is the next best step in the management of this patient?

Admit to hospital for 24 hour observation for complications and/or recurrence

Keep patient NPO and initiate work-up to identify lead-point

Pursue urgent surgical reduction with resection of necrotic segments of bowel

Repeat barium enema q6 hrs to monitor for recurrence

Discharge to home with follow-up in 3 weeks in an outpatient pediatric gastroenterology clinic

A 43-year-old woman comes to the physician because of a 3-month history of a painless ulcer on the sole of her right foot. There is no history of trauma. She has been dressing the ulcer once daily at home with gauze. She has a 15-year history of poorly-controlled type 1 diabetes mellitus and hypertension. Current medications include insulin and lisinopril. Vital signs are within normal limits. Examination shows a 2 x 2-cm ulcer on the plantar aspect of the base of the great toe with whitish, loose tissue on the floor of the ulcer and a calloused margin. A blunt metal probe reaches the deep plantar space. Sensation to vibration and light touch is decreased over both feet. Pedal pulses are intact. An x-ray of the right foot shows no abnormalities. Which of the following is the most appropriate initial step in management?

Sharp surgical debridement of the ulcer

Surgical revascularization of the right foot

Amputation of the right forefoot

Total contact casting of right foot

Surgical vs non-surgical management — USMLE Lesson

Decision Framework - The First Cut

Initial Triage: The first question is always stability. Is the patient hemodynamically stable or unstable?
The Surgical Trigger: The presence of generalized peritonitis, visceral perforation, or refractory shock mandates surgical intervention.

⭐ In trauma, "hard signs" of vascular injury (e.g., pulsatile bleeding, expanding hematoma, bruit/thrill) are direct triggers for surgical exploration, bypassing extensive imaging.

Algorithm for Acute Abdominal Pain Management

Trauma Triage - Red Flags & Green Lights

Initial assessment dictates the path: immediate surgery or watchful waiting. The decision hinges on hemodynamic stability and signs of peritoneal violation.

🔴 Red Flags (Surgical Emergency):
- Hemodynamic instability (SBP < 90 mmHg).
- Peritonitis, guarding, or rebound tenderness.
- Evisceration or impalement.
- Positive FAST scan in an unstable patient.
- Penetrating trauma with suspected peritoneal breach (e.g., gunshot).
🟢 Green Lights (Consider Non-Operative Management - NOM):
- Hemodynamically stable.
- No peritoneal signs.
- Isolated solid organ injury (low-grade) on CT without active bleeding.

FAST exam windows and probe placement

⭐ In profoundly unstable patients, Damage Control Surgery is key: an abbreviated laparotomy to control major hemorrhage and contamination, followed by ICU resuscitation before definitive repair.

Acute Abdomen - Gut Instincts

Deciding between surgical and non-surgical management hinges on identifying peritonitis and hemodynamic instability. Early and accurate assessment is key.

Surgical (Operative) Triggers:
- Peritonitis: Guarding, rigidity, rebound tenderness.
- Hemodynamic Instability: Persistent hypotension despite fluid resuscitation.
- Visceral Perforation: Free air under the diaphragm on imaging.
- Strangulated hernia, bowel ischemia, or complete obstruction.
Non-Surgical (Conservative) Management:
- Indicated for: Uncomplicated pancreatitis, diverticulitis, medical causes (e.g., DKA, porphyria).
- Core components: Nil per os (NPO), IV fluids, analgesia, antibiotics.
- Requires close monitoring for any deterioration.

⭐ Silent Abdomen: In elderly, diabetic, or immunosuppressed patients, classic signs of peritonitis may be absent. Maintain a high index of suspicion for perforation even without overt signs.

CT Abdomen: Free Air Indicating Visceral Perforation

Vascular Crises - Time is Tissue

Rutherford Classification of Acute Limb Ischemia

Immediate Management: IV Heparin bolus, then continuous infusion.
Diagnosis: Hand-held Doppler, confirmed with CT Angiography (CTA).
📌 6 P's of ALI: Pain, Pallor, Pulselessness, Paresthesia, Paralysis, Poikilothermia.
Critical Window: Revascularization goal is <6 hours to maximize limb salvage.

⭐ The most common site for a peripheral arterial embolus is the common femoral artery bifurcation.

High‑Yield Points - ⚡ Biggest Takeaways

Hemodynamic instability or generalized peritonitis are hard indications for immediate surgery.

Failure of non-operative management (NOM), evidenced by clinical worsening, necessitates surgical intervention.

Pneumoperitoneum on imaging is a classic sign of hollow viscus perforation requiring laparotomy.

The primary surgical goal is source control: repair, drain, or resect.

For high-risk surgical patients, prioritize less invasive options like percutaneous drainage when possible.

Always weigh the pathology against the patient's physiological reserve and comorbidities.

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