A 36-year-old woman is brought to the emergency department 20 minutes after being involved in a high-speed motor vehicle collision. On arrival, she is unconscious. Her pulse is 140/min, respirations are 12/min and shallow, and blood pressure is 76/55 mm Hg. 0.9% saline infusion is begun. A focused assessment with sonography shows blood in the left upper quadrant of the abdomen. Her hemoglobin concentration is 7.6 g/dL and hematocrit is 22%. The surgeon decided to move the patient to the operating room for an emergent explorative laparotomy. Packed red blood cell transfusion is ordered prior to surgery. However, a friend of the patient asks for the transfusion to be held as the patient is a Jehovah's Witness. The patient has no advance directive and there is no documentation showing her refusal of blood transfusions. The patient's husband and children cannot be contacted. Which of the following is the most appropriate next best step in management?

Transfusion of packed red blood cells

Consult hospital ethics committee

Administer high-dose iron dextran

A 41-year-old man is admitted to the emergency room after being struck in the abdomen by a large cement plate while transporting it. On initial assessment by paramedics at the scene, his blood pressure was 110/80 mm Hg, heart rate 85/min, with no signs of respiratory distress. On admission, the patient is alert but in distress. He complains of severe, diffuse, abdominal pain and severe weakness. Vital signs are now: blood pressure 90/50 mm Hg, heart rate 96/min, respiratory rate 19/min, temperature 37.4℃ (99.3℉), and oxygen saturation of 95% on room air. His lungs are clear on auscultation. The cardiac exam is significant for a narrow pulse pressure. Abdominal examination reveals a large bruise over the epigastric and periumbilical regions. The abdomen is distended and there is diffuse tenderness to palpation with rebound and guarding, worst in the epigastric region. There is hyperresonance to percussion in the epigastric region and absence of hepatic dullness in the right upper quadrant. Aspiration of the nasogastric tube reveals bloody contents. Focused assessment with sonography for trauma (FAST) shows free fluid in the pelvic region. Evaluation of the perisplenic and perihepatic regions is impossible due to the presence of free air. Aggressive intravenous fluid resuscitation is administered but fails to improve upon the patient’s hemodynamics. Which of the following is the next best step in management?

Diagnostic peritoneal lavage (DPL)

A 30-year-old man is brought to the emergency room by ambulance after being found unconscious in his car parked in his garage with the engine running. His wife arrives and reveals that his past medical history is significant for severe depression treated with fluoxetine. He is now disoriented to person, place, and time. His temperature is 37.8 deg C (100.0 deg F), blood pressure is 100/50 mmHg, heart rate is 100/min, respiratory rate is 10/min, and SaO2 is 100%. On physical exam, there is no evidence of burn wounds. He has moist mucous membranes and no abnormalities on cardiac and pulmonary auscultation. His respirations are slow but spontaneous. His capillary refill time is 4 seconds. He is started on 100% supplemental oxygen by non-rebreather mask. His preliminary laboratory results are as follows: Arterial blood pH 7.20, PaO2 102 mm Hg, PaCO2 23 mm Hg, HCO3 10 mm Hg, WBC count 9.2/µL, Hb 14 mg/dL, platelets 200,000/µL, sodium 137 mEq/L, potassium 5.0 mEq/L, chloride 96 mEq/L, BUN 28 mg/dL, creatinine 1.0 mg/dL, and glucose 120 mg/dL. Which of the following is the cause of this patient's acid-base abnormality?

Decreased oxygen delivery to tissues

Decreased ability for the tissues to use oxygen

Increased anions from toxic ingestion

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 32-year-old woman comes to the physician because of a 2-week history of involuntary loss of urine. She loses small amounts of urine in the absence of an urge to urinate and for no apparent reason. She also reports that she has an intermittent urinary stream. Two years ago, she was diagnosed with multiple sclerosis. Current medications include glatiramer acetate and a multivitamin. She works as a librarian. She has 2 children who attend middle school. Vital signs are within normal limits. The abdomen is soft and nontender. Pelvic examination shows no abnormalities. Neurologic examination shows a slight hypesthesia in the lower left arm and absent abdominal reflex, but otherwise no abnormalities. Her post-void residual urine volume is 131 mL. Bladder size is normal. Which of the following is the most likely cause of the patient's urinary incontinence?

Impaired detrusor contractility

Damage control surgery for USMLE Step 1: High-Yield Surgery Lessons

Damage Control Surgery - The Lifeline

Core Principle: Prioritize patient physiology over complex anatomical repairs in exsanguinating trauma.
Goal: Avert the 'lethal triad' of trauma: Acidosis (pH < 7.2), Hypothermia (Temp < 35°C), and Coagulopathy.

Damage Control Surgery Phases

⭐ In DCS, the abdomen is often temporarily closed using a vacuum-assisted device (e.g., "vac-pack") to prevent abdominal compartment syndrome.

Indications - When to Bail

Decision to abort the primary operation and initiate damage control is triggered by the lethal triad of acidosis, hypothermia, and coagulopathy, or by clinical indicators of overwhelming physiological insult.

⭐ The most critical factor prompting a switch to damage control surgery is the development of profound metabolic acidosis (pH < 7.2), as it signals cellular collapse and is a strong predictor of mortality.

The Three Phases - Stop, Rewind, Repair

Damage control surgery is a staged approach for critically injured patients unable to withstand a definitive procedure, focusing on correcting physiology over immediate anatomical repair.

Key Phase I Techniques:
- Hemorrhage: Perihepatic packing, vessel shunting.
- Contamination: Bowel stapling (no anastomosis).
- Closure: Temporary Abdominal Closure (TAC).

Temporary Abdominal Closure with Vacuum-Assisted Dressing

⭐ The primary goal of the initial laparotomy is restoring physiologic stability by halting the lethal triad, not performing a definitive anatomical repair.

Complications - The Aftermath

Key challenges arising after initial damage control surgery:

Abdominal Compartment Syndrome (ACS):
- Sustained intra-abdominal pressure (IAP) > 20 mmHg plus new organ dysfunction.
- Monitored via bladder pressure, a critical bedside tool.
Sepsis / Intra-abdominal Abscess: High risk due to contamination and exposed viscera.
Enteroatmospheric Fistula (EAF): Spillage of bowel contents directly into the open abdominal wound; devastating complication.
Large Ventral Hernia: An expected consequence requiring planned, delayed reconstruction.

Organ dysfunction in abdominal compartment syndrome

⭐ ACS is a lethal condition; mortality can exceed 50% even with timely decompressive laparotomy.

High‑Yield Points - ⚡ Biggest Takeaways

Indicated for profoundly unstable trauma patients with the "triad of death": acidosis, hypothermia, and coagulopathy.

The primary goal is physiological restoration, not definitive anatomical repair, to break the lethal cycle.

Involves a three-phased approach: initial abbreviated surgery, ICU resuscitation, and planned re-exploration for definitive repair.

Key initial steps are hemorrhage control (packing) and contamination control (stapling bowel).

Temporary abdominal closure is a hallmark, used to prevent abdominal compartment syndrome.

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