Q: A 40-year-old woman is brought to the ED after a high-speed rollover collision. She is combative with GCS 13. Blood pressure is 100/65 mmHg, heart rate 110/min. She has abrasions over her abdomen. FAST examination is negative. After receiving 1 liter of crystalloid, her blood pressure improves to 115/70 mmHg and heart rate decreases to 95/min. She continues to complain of severe abdominal pain. Analyze the most appropriate next step in evaluation.

Perform CT scan of abdomen and pelvis with IV contrast. ***Perform CT scan of abdomen and pelvis with IV contrast*** - The patient is currently **hemodynamically stable** (a 'responder' to fluids), making **CT imaging** the gold standard for identifying specific intra-abdominal or retroperitoneal injuries. - A **negative FAST** does not exclude injury, especially **hollow viscus** or **solid organ** trauma that has not yet resulted in significant hemoperitoneum. *Discharge with outpatient follow-up since FAST is negative and vitals normalized* - This is dangerous as the high-speed mechanism and **persistent abdominal pain** indicate a high risk of occult internal trauma. - **FAST examination** has low sensitivity for certain injuries, and clinical observation is required even if initial tests are reassuring. *Observe for 6 hours and repeat FAST examination* - While monitoring is part of trauma care, it should not delay definitive diagnosis via **CT scan** in a stable patient with severe pain. - Delaying imaging could lead to missed **internal bleeding** or bowel perforation that may worsen during the observation period. *Proceed directly to diagnostic laparoscopy* - **Laparoscopy** or laparotomy is indicated for hemodynamically **unstable** patients with a positive FAST or signs of peritonitis. - Because this patient is currently stable, non-invasive **CT imaging** is the preferred first-line diagnostic step to guide management. *Perform diagnostic peritoneal lavage* - **Diagnostic Peritoneal Lavage (DPL)** is primarily used for **unstable** patients when ultrasound (FAST) is unavailable or inconclusive. - It is invasive and cannot provide the detailed anatomical information regarding **organ injury grading** that a CT scan provides. [Practice more Surgery questions on OnCourse]

Question 1

A mass casualty incident occurs with 25 casualties arriving simultaneously at a community hospital emergency department. The trauma team has limited resources with 2 operating rooms available and 4 surgeons present. Among the arriving patients: Patient A has traumatic amputation of forearm with tourniquet in place and stable vitals; Patient B has flail chest, respiratory distress, and unstable vitals; Patient C is in cardiac arrest with penetrating chest wound; Patient D has a femur fracture with stable vitals; Patient E has GCS 4 with bilateral blown pupils. Evaluate the triage priority according to ATLS mass casualty protocols.

Accepted Answer

Priority order: B, A, D, with E and C designated expectant. ***Priority order: B, A, D, with E and C designated expectant***
- In a **mass casualty incident (MCI)** with limited resources, the goal is to provide the **greatest good for the greatest number**; Patient B has life-threatening but **salvageable** injuries (respiratory distress) making them the top priority.
- Patients C (cardiac arrest) and E (GCS 4, blown pupils) are classified as **expectant (black tag)** because their survival probability is minimal and resuscitating them would exhaust resources needed for salvageable patients.

*Priority order: C, E, B, A, D - treat most severely injured first*
- This approach is used in standard trauma situations where resources are ample, but it is incorrect in an **MCI** where resource-heavy, low-prognosis patients are de-prioritized.
- Assigning highest priority to **cardiac arrest (C)** and **severe brain injury (E)** would likely result in the deaths of more salvageable patients like Patient B.

*Priority order: A, D, B, E, C - treat all patients equally regardless of prognosis*
- Treating all patients equally ignores the **ATLS triage categories** (Immediate, Delayed, Minimal, Expectant) and fails to address life-threatening priorities first.
- While A and D have stable vitals and are **Delayed (Yellow tag)**, waiting to treat Patient B's airway/breathing emergency would lead to a preventable death.

*Priority order: B, A, E, D, C - based on severity alone*
- Severity alone does not dictate priority in an MCI; the **likelihood of survival** with the available resources must be considered.
- Patient E, despite being "severe," has a **devastating neurological prognosis** (blown pupils, GCS 4) and should not be prioritized over stable patients with better outcomes like A and D.

*Immediate evacuation of all patients to a higher level trauma center*
- Evacuation is a secondary step; the primary task according to **ATLS protocols** is to perform triage and stabilization at the current facility during the initial influx.
- Attempting to evacuate all 25 casualties simultaneously without triage would overwhelm transport systems and delay life-saving **initial stabilization** for patients like B. [Practice more Surgery questions on OnCourse]

Question 2

A 35-year-old pregnant woman at 32 weeks gestation is involved in a motor vehicle collision. She is hemodynamically stable with blood pressure 105/70 mmHg, heart rate 100/min. She has left upper quadrant tenderness and left lower rib fractures. FAST examination shows fluid in the splenorenal recess. Fetal heart tones are 150/min and reassuring. CT scan shows a Grade III splenic laceration. After 6 hours of observation with stable vital signs and hemoglobin, she suddenly develops blood pressure 85/50 mmHg and heart rate 125/min. Evaluate the management priority.

Accepted Answer

Simultaneous laparotomy with splenectomy and obstetric standby for potential cesarean. ***Simultaneous laparotomy with splenectomy and obstetric standby for potential cesarean***
- The patient has failed **non-operative management** of a splenic injury and is now **hemodynamically unstable**, necessitating immediate **laparotomy** to control hemorrhage.
- At **32 weeks gestation**, the fetus is viable; therefore, an **obstetric standby** is essential to perform a cesarean section if the mother's condition does not improve or if **fetal distress** occurs during the procedure.

*Initiate massive transfusion and reassess after maternal stabilization*
- While **massive transfusion** is part of trauma resuscitation, delaying surgery in an unstable patient with a known **Grade III splenic laceration** and hemodynamic collapse is inappropriate.
- Definitive **hemorrhage control** (surgery) is the priority once a patient becomes unstable after initial observation.

*Perform emergency cesarean section first, then address splenic injury*
- Performing a cesarean section first in an unstable trauma patient with **intra-abdominal hemorrhage** increases maternal morbidity and can worsen **hypovolemic shock**.
- Maternal stabilization and controlling the source of **bleeding** (splenectomy) is the most critical step to ensure both maternal and fetal survival.

*Proceed with splenectomy only, as maternal stabilization is the priority*
- While maternal stabilization is the priority, ignoring the viable fetus during a major surgical intervention is suboptimal care.
- Failure to involve an **obstetric team** overlooks the risk of **placental abruption** or fetal distress induced by maternal hypotension during surgery.

*Perform angioembolization of splenic artery to avoid surgery*
- **Angioembolization** is only indicated for stable patients; this patient is **hemodynamically unstable** (BP 85/50, HR 125), which is a contraindication for the interventional radiology suite.
- In the setting of active **intraperitoneal hemorrhage** and shock, an emergent **exploratory laparotomy** is the standard of care. [Practice more Surgery questions on OnCourse]

Question 3

A 50-year-old helmeted motorcyclist is brought to the trauma bay after a collision at 50 mph. He is unconscious with GCS 6. Initial vitals show blood pressure 160/95 mmHg, heart rate 58/min. Pupils are unequal with the right pupil dilated and minimally reactive. He begins to posture with extension of extremities. He is intubated with in-line stabilization. CT scan cannot be immediately obtained due to scanner malfunction. Evaluate the most appropriate immediate management strategy.

Accepted Answer

Administer mannitol, hyperventilate to pCO2 30-35 mmHg, elevate head of bed, and arrange emergent neurosurgical consultation. ***Administer mannitol, hyperventilate to pCO2 30-35 mmHg, elevate head of bed, and arrange emergent neurosurgical consultation***
- This patient exhibits **Cushing's triad** (hypertension, bradycardia) and asymmetric pupil dilation, indicating a life-threatening **transtentorial herniation** and increased **intracranial pressure (ICP)**.
- Immediate medical decompression using **osmotic therapy** (mannitol), **controlled hyperventilation** (causing cerebral vasoconstriction), and **head elevation** is critical to prevent brainstem death while awaiting neurosurgical intervention.

*Administer hypertonic saline and wait for CT scanner to be repaired*
- While **hypertonic saline** is an effective osmotic agent, waiting for a malfunctioning scanner in the setting of active **herniation** is unsafe and delays definitive care.
- Patients with clinical signs of herniation require **immediate neurosurgical consultation** and potentially a transfer if surgery cannot be performed on-site.

*Start therapeutic hypothermia protocol and await imaging*
- **Therapeutic hypothermia** is not a primary or immediate management strategy for acute **traumatic brain injury** with signs of herniation.
- Focus must remain on **ICP reduction** and surgical decompression; hypothermia does not address the acute mass effect evidenced by the blown pupil.

*Transport to another facility for immediate CT scan*
- Transporting an unstable patient with signs of **imminent herniation** without first initiating **ICP-lowering measures** is dangerous and may lead to death during transit.
- **Stabilization** including osmotic therapy and airway protection must be prioritized before considering any inter-facility transfer.

*Perform bilateral burr holes at bedside*
- **Bedside burr holes** are generally reserved for extreme circumstances where neurosurgical support is unavailable and the patient is rapidly deteriorating.
- The priority in a trauma bay setting is focused **medical management** followed by emergent definitive surgery (craniotomy) by a **neurosurgeon**. [Practice more Surgery questions on OnCourse]

Question 4

A 19-year-old man is stabbed in the left fifth intercostal space at the anterior axillary line. He arrives alert with blood pressure 95/60 mmHg and heart rate 115/min. Chest X-ray shows a small left hemothorax. A chest tube is placed, draining 600 mL of blood initially, then 150 mL/hour for the next 3 hours. His vital signs stabilize after transfusion of 2 units of packed red blood cells. Analyze the indication for thoracotomy.

Accepted Answer

Thoracotomy is indicated due to continued bleeding >200 mL/hour for 3 hours. ***Thoracotomy is indicated due to continued bleeding >200 mL/hour for 3 hours***
- **Emergent thoracotomy** is indicated if the initial chest tube output is **>1500 mL** or if there is persistent bleeding of **>200 mL/hour for 2-4 hours**.
- This patient exhibits **ongoing hemorrhage** from a penetrating injury, suggesting a vascular source like **intercostal arteries** or internal mammary arteries that requires surgical ligation.

*Immediate thoracotomy is indicated due to initial output >500 mL*
- The criteria for **immediate operative intervention** based on initial drainage is a volume exceeding **1500 mL**, not 500 mL.
- Initial drainage of 600 mL is significant but often stops with **lung re-expansion** and does not necessitate an immediate trip to the OR.

*Continue observation as hourly output is <200 mL/hour*
- While the output is exactly **150 mL/hour**, combined with the initial loss and clinical context of a **stab wound**, persistent bleeding warrants high suspicion for internal injury.
- Guidelines emphasize that **hemodynamic stability** achieved only after **blood transfusion** in the setting of persistent drainage is a relative indication for exploration.

*Perform CT angiography before deciding on thoracotomy*
- In a patient with **active bleeding** and a history of **hypotension** (95/60 mmHg), surgical exploration is preferred over imaging to avoid delays in definitive care.
- **CTA** is more appropriate for stable patients with suspected **contained vascular injuries** or blunt aortic trauma, not active ongoing hemorrhage.

*Wait for total output to exceed 1500 mL before thoracotomy*
- Waiting for a **cumulative total** of 1500 mL is not a standard protocol; the rate of **ongoing blood loss** is a more critical indicator of active vessel injury.
- Delaying surgery until a specific total is reached can lead to **decompensation** and adverse outcomes in a patient who has already required transfusion. [Practice more Surgery questions on OnCourse]

Question 5

A 40-year-old woman is brought to the ED after a high-speed rollover collision. She is combative with GCS 13. Blood pressure is 100/65 mmHg, heart rate 110/min. She has abrasions over her abdomen. FAST examination is negative. After receiving 1 liter of crystalloid, her blood pressure improves to 115/70 mmHg and heart rate decreases to 95/min. She continues to complain of severe abdominal pain. Analyze the most appropriate next step in evaluation.

Accepted Answer

Perform CT scan of abdomen and pelvis with IV contrast. ***Perform CT scan of abdomen and pelvis with IV contrast*** 
- The patient is currently **hemodynamically stable** (a 'responder' to fluids), making **CT imaging** the gold standard for identifying specific intra-abdominal or retroperitoneal injuries.
- A **negative FAST** does not exclude injury, especially **hollow viscus** or **solid organ** trauma that has not yet resulted in significant hemoperitoneum.

*Discharge with outpatient follow-up since FAST is negative and vitals normalized*
- This is dangerous as the high-speed mechanism and **persistent abdominal pain** indicate a high risk of occult internal trauma.
- **FAST examination** has low sensitivity for certain injuries, and clinical observation is required even if initial tests are reassuring.

*Observe for 6 hours and repeat FAST examination*
- While monitoring is part of trauma care, it should not delay definitive diagnosis via **CT scan** in a stable patient with severe pain.
- Delaying imaging could lead to missed **internal bleeding** or bowel perforation that may worsen during the observation period.

*Proceed directly to diagnostic laparoscopy*
- **Laparoscopy** or laparotomy is indicated for hemodynamically **unstable** patients with a positive FAST or signs of peritonitis.
- Because this patient is currently stable, non-invasive **CT imaging** is the preferred first-line diagnostic step to guide management.

*Perform diagnostic peritoneal lavage*
- **Diagnostic Peritoneal Lavage (DPL)** is primarily used for **unstable** patients when ultrasound (FAST) is unavailable or inconclusive.
- It is invasive and cannot provide the detailed anatomical information regarding **organ injury grading** that a CT scan provides. [Practice more Surgery questions on OnCourse]

Surgery Questions

Topics

ATLS protocols

Trauma/Emergencies

Pre-operative evaluation

Anesthesia and Perioperative medicine

Post-op care

Wound healing

Surgical complications

Fluid and electrolyte management

Abdominal emergencies

Gastrointestinal Surgery

Breast Surgery

Endocrine Surgery

Cardiothoracic Surgery

Vascular Surgery

Neurosurgery Basics

Orthopedic Surgery Basics

Urology Basics

Gynecologic Surgery

Pediatric Surgery

Oncologic Surgery Principles

Transplant medicine

Minimally Invasive Surgery