Damage control surgery US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for Damage control surgery. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Damage control surgery US Medical PG Question 1: 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?
- A. Administer hydroxyethyl starch
- B. Transfusion of packed red blood cells (Correct Answer)
- C. Consult hospital ethics committee
- D. Administer high-dose iron dextran
Damage control surgery Explanation: ***Transfusion of packed red blood cells***
- This patient is in **hemorrhagic shock** (tachycardia, hypotension, low hemoglobin, and hematocrit with evidence of active bleeding), requiring emergent blood transfusion to prevent irreversible organ damage and death.
- In an **emergency setting** with an **unconscious patient** and **no documented refusal** of blood products, the principle of **presumed consent** for life-saving treatment takes precedence, especially when next of kin cannot be reached.
*Administer hydroxyethyl starch*
- **Colloids** like hydroxyethyl starch can temporarily increase intravascular volume but do not provide oxygen-carrying capacity, which is critically needed for a patient with severe anemia and hemorrhagic shock.
- While useful for volume expansion, it is **not a substitute for blood products** in severe bleeding and can have adverse effects such as kidney injury.
*Consult hospital ethics committee*
- Consulting an ethics committee is appropriate for **complex ethical dilemmas** when there is time for deliberation and the patient's life is not in immediate danger.
- In this acute, life-threatening emergency, **delaying treatment** to consult an ethics committee would jeopardize the patient's life and is not appropriate.
*Administer high-dose iron dextran*
- **Iron dextran** is used to treat iron-deficiency anemia and works by supporting red blood cell production over several days to weeks.
- It is **ineffective in acute hemorrhagic shock** where immediate restoration of oxygen-carrying capacity is required.
Damage control surgery US Medical PG Question 2: 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?
- A. Emergency laparoscopy
- B. Abdominal ultrasound
- C. Diagnostic peritoneal lavage (DPL)
- D. Emergency laparotomy (Correct Answer)
- E. CT scan
Damage control surgery Explanation: ***Emergency laparotomy***
- The patient presents with **hemodynamic instability** unresponsive to fluid resuscitation, coupled with clear signs of **perforation** (hyperresonance, absent hepatic dullness, free air on FAST limited view). This clinical picture is a direct indication for immediate surgical intervention.
- The presence of bloody nasogastric tube contents, diffuse tenderness with rebound and guarding, and a history of significant blunt trauma further support the need for urgent exploratory **laparotomy** to identify and repair the source of injury.
*Emergency laparoscopy*
- While laparoscopy can be used for abdominal exploration, it is **contraindicated in hemodynamically unstable patients** due to the need for pneumoperitoneum, which can further compromise cardiovascular stability.
- In cases of suspected visceral perforation with extensive free air and massive bleeding, **laparoscopy may be technically challenging** and less efficient than open laparotomy for rapid control of hemorrhage and contamination.
*Abdominal ultrasound*
- An abdominal ultrasound (**FAST exam**) has already been partially performed, revealing free fluid and raising suspicion of free air, making further ultrasound redundant.
- While useful for initial trauma assessment, an ultrasound **cannot definitively rule out all abdominal injuries**, especially hollow viscus perforations or retroperitoneal hematomas, and is insufficient for unstable patients with clear signs of peritonitis.
*Diagnostic peritoneal lavage (DPL)*
- **DPL is largely replaced by FAST and CT scans** in most trauma centers, especially given the availability of imaging.
- Although it can detect intraperitoneal bleeding or perforation, it is an **invasive procedure** with potential complications and would only confirm what is already strongly suspected clinically; it does not address the need for immediate therapeutic intervention in an unstable patient.
*CT scan*
- A CT scan would be the imaging modality of choice for a **hemodynamically stable** patient with blunt abdominal trauma.
- However, performing a CT scan on an **unstable patient** would unnecessarily delay definitive surgical management, which is critical given the signs of ongoing internal bleeding and likely perforation.
Damage control surgery US Medical PG Question 3: 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?
- A. Decreased oxygen delivery to tissues (Correct Answer)
- B. Decreased ability for the tissues to use oxygen
- C. Increased anions from toxic ingestion
- D. Increased metabolic rate
- E. Decreased minute ventilation
Damage control surgery Explanation: ***Decreased oxygen delivery to tissues***
- The patient's presentation in a running car in a garage suggests **carbon monoxide (CO) poisoning**. CO binds to hemoglobin with higher affinity than oxygen, forming **carboxyhemoglobin (COHb)**, which impairs oxygen delivery to tissues despite normal PaO2.
- The **metabolic acidosis (pH 7.20, HCO3 10)** with an elevated anion gap (Na - (Cl + HCO3) = 137 - (96 + 10) = 31) and altered mental status are consistent with widespread tissue hypoxia due to decreased oxygen delivery, leading to **lactic acid accumulation**.
*Decreased ability for the tissues to use oxygen*
- This scenario typically occurs in conditions like **cyanide poisoning**, where cellular metabolism is inhibited, preventing oxygen utilization despite adequate delivery.
- Cyanide poisoning often presents with a narrower or normal anion gap metabolic acidosis and a **"cherry red" skin color**, which are not specifically noted here.
*Increased anions from toxic ingestion*
- While there is an **elevated anion gap metabolic acidosis**, merely stating "increased anions from toxic ingestion" is less precise than identifying the underlying mechanism of oxygen deprivation.
- Many toxins can cause an elevated anion gap, but the specific context of **CO poisoning** points to tissue hypoxia as the primary driver of acidosis, not just the presence of other toxic anions.
*Increased metabolic rate*
- An increased metabolic rate, as seen in conditions like **sepsis** or hyperthyroidism, can lead to increased acid production and metabolic acidosis.
- However, in this case, the **depressed respiratory rate** and context of CO exposure point away from a primary state of hypermetabolism.
*Decreased minute ventilation*
- **Decreased minute ventilation** would primarily lead to **respiratory acidosis** (elevated PaCO2) due to CO2 retention.
- The patient's lab results show a **low PaCO2 (23 mmHg)**, indicating respiratory compensation for a metabolic acidosis, not a primary respiratory problem.
Damage control surgery US Medical PG Question 4: A 24-year-old woman is brought to the emergency department after being assaulted. The paramedics report that the patient was found conscious and reported being kicked many times in the torso. She is alert and able to respond to questions. She denies any head trauma. She has a past medical history of endometriosis and a tubo-ovarian abscess that was removed surgically two years ago. Her only home medication is oral contraceptive pills. Her temperature is 98.5°F (36.9°C), blood pressure is 82/51 mmHg, pulse is 136/min, respirations are 24/min, and SpO2 is 94%. She has superficial lacerations to the face and severe bruising over her chest and abdomen. Her lungs are clear to auscultation bilaterally and her abdomen is soft, distended, and diffusely tender to palpation. Her skin is cool and clammy. Her FAST exam reveals fluid in the perisplenic space.
Which of the following is the next best step in management?
- A. Emergency laparotomy (Correct Answer)
- B. Abdominal radiograph
- C. Abdominal CT
- D. Fluid resuscitation
- E. Diagnostic peritoneal lavage
Damage control surgery Explanation: ***Emergency laparotomy***
- The patient presents with **hemodynamic instability** (BP 82/51 mmHg, HR 136/min) and a **positive FAST exam** showing fluid in the perisplenic space, indicating intra-abdominal hemorrhage.
- According to **ATLS guidelines**, a hemodynamically unstable patient with a positive FAST exam requires **immediate operative intervention** to control bleeding. This is the definitive management for ongoing hemorrhage.
- While fluid resuscitation is initiated simultaneously (en route to OR), **surgical control of the bleeding source** is the priority and should not be delayed.
*Fluid resuscitation*
- Fluid resuscitation with IV crystalloids is essential and should be started immediately in this patient with hypovolemic shock.
- However, in a patient with **uncontrolled intra-abdominal hemorrhage** (positive FAST, hemodynamic instability), fluids alone will not stop the bleeding. Continued fluid resuscitation without surgical intervention can lead to dilutional coagulopathy and worsening outcomes.
- Fluid resuscitation occurs **concurrently with preparation for surgery**, not as a separate step that delays definitive management.
*Diagnostic peritoneal lavage*
- DPL is an invasive diagnostic procedure that has largely been replaced by FAST exam in modern trauma care.
- Given that the **FAST is already positive**, DPL would provide no additional useful information and would only **delay definitive surgical management**.
- In hemodynamically unstable patients with positive FAST, proceeding directly to laparotomy is indicated.
*Abdominal radiograph*
- Plain radiographs have **limited sensitivity** for detecting intra-abdominal bleeding or solid organ injury.
- They may show free air (indicating hollow viscus perforation) but cannot assess for fluid or characterize solid organ injuries.
- This would **delay necessary operative intervention** without providing actionable information.
*Abdominal CT*
- CT abdomen is the imaging modality of choice for **hemodynamically stable** trauma patients to characterize injuries and guide management.
- For **unstable patients**, CT is **contraindicated** as it delays definitive treatment and removes the patient from a resuscitation environment where deterioration can be immediately addressed.
Damage control surgery US Medical PG Question 5: 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?
- A. Diagnostic peritoneal lavage
- B. Emergency laparotomy (Correct Answer)
- C. Upper gastrointestinal endoscopy
- D. Close observation
- E. Diagnostic laparoscopy
Damage control surgery Explanation: ***Emergency laparotomy***
- The patient remains **hemodynamically unstable** (BP 97/62 mmHg, HR 115/min after 2L IV fluids) with evidence of **intra-abdominal fluid on FAST exam** (fluid in Morison's pouch).
- This clinical picture indicates active intra-abdominal hemorrhage requiring **immediate surgical intervention** to identify and control the source of bleeding.
*Diagnostic peritoneal lavage*
- **Diagnostic peritoneal lavage (DPL)** has largely been replaced by the focused abdominal sonography for trauma (FAST) exam and CT scans.
- While it can detect intra-abdominal bleeding, it is **invasive** and would delay definitive treatment in a hemodynamically unstable patient with positive FAST.
*Upper gastrointestinal endoscopy*
- This procedure is primarily for diagnosing and treating **upper gastrointestinal bleeding** or mucosal abnormalities.
- It is **not indicated** for evaluating traumatic intra-abdominal hemorrhage or hemodynamic instability following blunt abdominal trauma.
*Close observation*
- Close observation is appropriate for **hemodynamically stable patients** with blunt abdominal trauma and minor injuries or equivocal findings.
- This patient's persistent hypotension, tachycardia, and positive FAST findings rule out observation as a safe or appropriate next step.
*Diagnostic laparoscopy*
- **Diagnostic laparoscopy** is a minimally invasive surgical procedure used to evaluate the abdominal cavity.
- While it can be diagnostic, it is generally **contraindicated in hemodynamically unstable patients** as it can prolong the time to definitive hemorrhage control if a major injury is found.
Damage control surgery US Medical PG Question 6: A 27-year-old-man is brought to the emergency department 30 minutes after being involved in a motorcycle accident. He lost control at high speed and was thrown forward onto the handlebars. On arrival, he is alert and responsive. He has abdominal pain and superficial lacerations on his left arm. Vital signs are within normal limits. Examination shows a tender, erythematous area over his epigastrium. The abdomen is soft and non-distended. A CT scan of the abdomen shows no abnormalities. Treatment with analgesics is begun, the lacerations are cleaned and dressed, and the patient is discharged home after 2 hours of observation. Four days later, the patient returns to the emergency department with gradually worsening upper abdominal pain, fever, poor appetite, and vomiting. His pulse is 91/min and blood pressure is 135/82 mm Hg. Which of the following is the most likely diagnosis?
- A. Abdominal compartment syndrome
- B. Aortic dissection
- C. Splenic rupture
- D. Pancreatic ductal injury (Correct Answer)
- E. Diaphragmatic rupture
Damage control surgery Explanation: ***Pancreatic ductal injury***
- A forceful impact to the **epigastrium** (e.g., falling onto handlebars) can cause **pancreatic injury**, particularly a **ductal transection**, due to the pancreas being compressed against the vertebral column.
- Initial CT scans can be normal because the injury to the **ductal system** takes time to manifest, leading to delayed symptoms like **worsening abdominal pain, fever, vomiting**, and **poor appetite** several days later due to **pancreatitis** or a **pseudocyst** formation.
*Abdominal compartment syndrome*
- This typically presents with **acute abdominal distension**, increased intra-abdominal pressure, and organ dysfunction (e.g., oliguria, respiratory compromise), which are not described here.
- It's an immediate complication of severe trauma or fluid resuscitation, not a delayed presentation like described.
*Aortic dissection*
- Characterized by **sudden-onset, severe, tearing chest or back pain** and often involves hypertension or Marfan syndrome.
- It would manifest immediately with hemodynamic instability and distinct pain, not a delayed presentation of progressive abdominal symptoms.
*Splenic rupture*
- Often causes **left upper quadrant pain**, **Kehr's sign** (referred shoulder pain), and **hemodynamic instability** due to significant blood loss.
- While possible in trauma, a normal initial CT scan makes this less likely, and its symptoms usually appear earlier or are more severe.
*Diaphragmatic rupture*
- Can present with **dyspnea, shoulder pain**, or signs of **herniated abdominal organs** into the chest.
- It causes more immediate respiratory distress or gastrointestinal obstruction symptoms, and the abdominal symptoms described are not typical for this injury.
Damage control surgery US Medical PG Question 7: A 79-year-old man presents to the emergency department with abdominal pain. The patient describes the pain as severe, tearing, and radiating to the back. His history is significant for hypertension, hyperlipidemia, intermittent claudication, and a 60 pack-year history of smoking. He also has a previously diagnosed stable abdominal aortic aneurysm followed by ultrasound screening. On exam, the patient's temperature is 98°F (36.7°C), pulse is 113/min, blood pressure is 84/46 mmHg, respirations are 24/min, and oxygen saturation is 99% on room air. The patient is pale and diaphoretic, and becomes confused as you examine him. Which of the following is most appropriate in the evaluation and treatment of this patient?
- A. Abdominal ultrasound
- B. Abdominal CT with contrast
- C. Surgery (Correct Answer)
- D. Abdominal MRI
- E. Abdominal CT without contrast
Damage control surgery Explanation: ***Surgery***
- The patient presents with classic signs of a **ruptured abdominal aortic aneurysm (AAA)**, including sudden, severe, tearing abdominal pain radiating to the back, and signs of **hypovolemic shock** (hypotension, tachycardia, pallor, diaphoresis, confusion). Immediate surgical intervention is life-saving.
- Given the patient's **hemodynamic instability** and strong clinical suspicion for AAA rupture, delaying treatment for imaging studies is inappropriate and would significantly worsen the prognosis.
*Abdominal ultrasound*
- While ultrasound can detect an AAA, it is **less effective in identifying rupture**, especially retroperitoneal hemorrhage, and in hemodynamically unstable patients, the time spent on imaging is time lost for definitive treatment.
- The patient's critical condition warrants immediate intervention, and ultrasound would not provide enough detail or be fast enough to guide surgical planning in an emergency.
*Abdominal CT with contrast*
- CT angiography is the **gold standard for diagnosing AAA rupture** in stable patients, as it can visualize the aneurysm, rupture site, and extent of hemorrhage.
- However, for a **hemodynamically unstable patient** with a high clinical suspicion of rupture, taking the patient to CT risks further deterioration and delays life-saving surgery.
*Abdominal MRI*
- MRI is **contraindicated in unstable patients** due to the time required for imaging and the logistical challenges of monitoring critically ill patients in the MRI suite.
- It also provides no additional benefit over CT in an acute rupture setting and is generally not used for emergency AAA rupture diagnosis.
*Abdominal CT without contrast*
- A non-contrast CT might show the aneurysm and some signs of hemorrhage, but it would provide **less diagnostic information** regarding the rupture site and relationship to surrounding structures compared to a contrast-enhanced study.
- Like other imaging modalities, it still represents a **critical delay** for a patient in hypovolemic shock from a ruptured AAA, for whom immediate surgical intervention is paramount.
Damage control surgery US Medical PG Question 8: A 72-year-old woman comes to the emergency department 1 hour after the sudden onset of a diffuse, dull, throbbing headache. She also reports blurred vision, nausea, and one episode of vomiting. She has a history of poorly controlled hypertension. A photograph of her fundoscopic examination is shown. Which of the following is the most likely underlying cause of this patient's symptoms?
- A. Hemorrhagic lacunar stroke
- B. Transient ischemic attack
- C. Giant cell arteritis
- D. Hypertensive emergency (Correct Answer)
- E. Epidural hematoma
Damage control surgery Explanation: ***Hypertensive emergency***
- The patient's presentation of a **sudden headache**, along with **blurred vision** and nausea, suggests increased intracranial pressure due to severely elevated blood pressure.
- Poorly controlled hypertension is a significant risk factor, leading to possible **end-organ damage** such as hypertensive retinopathy with papilledema or hypertensive encephalopathy.
- Fundoscopic examination showing **papilledema** confirms elevated intracranial pressure, consistent with malignant hypertension.
*Hemorrhagic lacunar stroke*
- Lacunar strokes are **small subcortical infarcts** caused by occlusion of penetrating arteries and are typically **ischemic, not hemorrhagic**.
- They present with focal neurological deficits (pure motor stroke, pure sensory stroke, ataxic hemiparesis) rather than the **diffuse symptoms** and papilledema seen here.
- While hypertension is a risk factor, lacunar infarcts do not cause increased intracranial pressure or papilledema.
*Transient ischemic attack*
- Characterized by temporary neurological deficits that resolve within 24 hours, typically without severe headaches or sustained symptoms.
- Patients may experience **focal weakness or sensory changes** but would not have papilledema or signs of increased intracranial pressure.
- The persistent nature of this patient's symptoms makes TIA unlikely.
*Giant cell arteritis*
- This condition usually presents with **temporal headaches**, jaw claudication, and potential vision loss from arteritic anterior ischemic optic neuropathy.
- Vision loss in GCA is due to ischemic optic nerve damage, not papilledema from increased intracranial pressure.
- More common in older adults but is associated with systemic symptoms like fever, malaise, and elevated ESR/CRP.
*Epidural hematoma*
- Typically follows head trauma and presents with a **lucid interval**, followed by rapid deterioration from expanding hematoma.
- Usually caused by middle meningeal artery injury with classic lens-shaped hematoma on CT.
- The lack of trauma history and the chronic hypertension make this diagnosis unlikely.
Damage control surgery US Medical PG Question 9: 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?
- A. Cognitive impairment
- B. Vesicovaginal fistula
- C. Bladder outlet obstruction
- D. Detrusor sphincter dyssynergia (Correct Answer)
- E. Impaired detrusor contractility
Damage control surgery Explanation: ***Detrusor sphincter dyssynergia***
- This condition is characterized by **involuntary contraction of the external urethral sphincter** during bladder contraction, leading to an **intermittent urinary stream** and incomplete bladder emptying, often seen in neurological conditions like **multiple sclerosis**.
- The **post-void residual urine volume of 131 mL** confirms incomplete bladder emptying, and the loss of small amounts of urine without urge suggests **overflow incontinence** due to chronic retention.
*Cognitive impairment*
- While cognitive impairment can cause urinary incontinence, typically it leads to **functional incontinence** where the patient is unable to recognize the need to urinate or is unable to reach the toilet in time.
- The patient's presentation of an **intermittent urinary stream** and high post-void residual is not characteristic of incontinence solely due to cognitive issues.
*Vesicovaginal fistula*
- A vesicovaginal fistula involves an **abnormal connection between the bladder and vagina**, causing **continuous leakage of urine** from the vagina, often following childbirth or surgery.
- The patient's symptoms of an **intermittent urinary stream** and neurological history are inconsistent with a fistula, and the pelvic exam was normal.
*Bladder outlet obstruction*
- Common causes include **benign prostatic hyperplasia** in men or **pelvic organ prolapse** in women, leading to difficulty emptying the bladder and symptoms like dribbling and straining.
- While it can cause incomplete emptying and overflow, without any evidence of prolapse on pelvic exam or other obstructive factors, and given her **multiple sclerosis**, a neurological cause like DSD is more likely.
*Impaired detrusor contractility*
- This condition results in the bladder being **unable to effectively contract** to empty urine, leading to incomplete emptying and overflow incontinence.
- While the patient has a high post-void residual volume, the presence of an **intermittent urinary stream** suggests that the detrusor *is* contracting, but facing resistance from a dyssynergic sphincter, rather than having impaired contractility itself.
Damage control surgery US Medical PG Question 10: A 24-year-old woman comes to the emergency department because of abdominal pain, fever, nausea, and vomiting for 12 hours. Her abdominal pain was initially dull and diffuse but has progressed to a sharp pain on the lower right side. Two years ago she had to undergo right salpingo-oophorectomy after an ectopic pregnancy. Her temperature is 38.7°C (101.7°F). Physical examination shows severe right lower quadrant tenderness with rebound tenderness; bowel sounds are decreased. Laboratory studies show leukocytosis with left shift. An abdominal CT scan shows a distended, edematous appendix. The patient is taken to the operating room for an appendectomy. During the surgery, the adhesions from the patient's previous surgery make it difficult for the resident physician to identify the appendix. Her attending mentions that she should use a certain structure for guidance to locate the appendix. The attending is most likely referring to which of the following structures?
- A. Epiploic appendages
- B. Right ureter
- C. Deep inguinal ring
- D. Ileocolic artery
- E. Teniae coli (Correct Answer)
Damage control surgery Explanation: ***Teniae coli***
- The **teniae coli** are three distinct longitudinal bands of smooth muscle that run along the length of the cecum and colon, converging at the base of the **appendix**.
- Following these bands inferiorly from the ascending colon or cecum during surgery is a reliable method to locate the **vermiform appendix**, especially in the presence of adhesions.
*Epiploic appendages*
- These are small, fat-filled sacs that protrude from the surface of the **large intestine** but are not directly used as a reliable landmark for locating the appendix.
- While present in the vicinity, they do not consistently lead to the base of the appendix like the teniae coli.
*Right ureter*
- The **right ureter** is located retroperitoneally, deep to the cecum and appendix, and is not a direct anatomical landmark used for identifying the appendix during an appendectomy.
- Identifying the ureter is important to avoid injury, but not for localizing the appendix.
*Deep inguinal ring*
- The **deep inguinal ring** is an opening in the transversalis fascia, involved in the formation of the inguinal canal, and is located far anterior and inferior to the region of the appendix.
- It has no anatomical relationship that would guide a surgeon to locate the appendix.
*Ileocolic artery*
- The **ileocolic artery** branches from the superior mesenteric artery and supplies the terminal ileum, cecum, and appendix. While it provides blood supply to the appendix, it is not a direct or consistent surface landmark for locating the appendix itself, especially in complex cases with adhesions.
- Locating the artery would be more complex and less reliable for initial identification compared to the teniae coli.
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