Laparoscopic instrumentation — MCQs

10 questions

A 27-year-old man is brought to the emergency department after a motor vehicle accident. He was the unrestrained driver in a head on collision. The patient is responding incoherently and is complaining of being in pain. He has several large lacerations and has been impaled with a piece of metal. IV access is unable to be obtained and a FAST exam is performed. His temperature is 98.2°F (36.8°C), blood pressure is 90/48 mmHg, pulse is 150/min, respirations are 13/min, and oxygen saturation is 98% on room air. Which of the following is the best next step in management?

A 27-year-old man presents to the emergency department after being stabbed. The patient was robbed at a local pizza parlor and was stabbed over 10 times with a large kitchen knife with an estimated 7 inch blade in the ventral abdomen. His temperature is 97.6°F (36.4°C), blood pressure is 74/54 mmHg, pulse is 180/min, respirations are 19/min, and oxygen saturation is 98% on room air. The patient is intubated and given blood products and vasopressors. Physical exam is notable for multiple stab wounds over the patient's abdomen inferior to the nipple line. Which of the following is the best next step in management?

A 34-year-old woman is recovering in the post-operative unit following a laparoscopic procedure for chronic endometriosis. She had initially presented with complaints of painful menstrual cramps that kept her bedridden most of the day. She also mentioned to her gynecologist that she had been diagnosed with endometriosis 4 years ago, and she could not find a medication or alternative therapeutic measure that helped. Her medical history was significant for surgery she had 6 years ago to remove tumors she had above her kidneys, after which she was prescribed hydrocortisone. An hour after the laparoscopic procedure, she calls the nurse because she is having difficulty breathing. The nurse records her vital signs include: blood pressure 85/55 mm Hg, respirations 20/min, and pulse 115/min. The patient suddenly loses consciousness. Intravenous fluids are started immediately. She gains consciousness, but her blood pressure is unchanged. Which of the following is the most likely cause of the hypotension?

A 45-year-old man undergoes elective vasectomy for permanent contraception. The procedure is performed under local anesthesia. There are no intra-operative complications and he is discharged home with ibuprofen for post-operative pain. This patient is at increased risk for which of the following complications?

A 32-year-old woman comes to the physician for a screening health examination that is required for scuba diving certification. The physician asks her to perform a breathing technique: following deep inspiration, she is instructed to forcefully exhale against a closed airway and contract her abdominal muscles while different cardiovascular parameters are evaluated. Which of the following effects is most likely after 10 seconds in this position?

One day after undergoing an open colectomy, a 65-year-old man with colon cancer experiences shivers. The procedure was originally scheduled to be done laparoscopically, but it was converted because of persistent bleeding. Besides the conversion, the operation was uneventful. Five years ago, he underwent renal transplantation because of cystic disease and has been taking prednisolone since then. He has a history of allergy to sulfonamides. He appears acutely ill. His temperature is 39.2°C (102.5°F), pulse is 120/min, respirations are 23/min, and blood pressure is 90/62 mm Hg. Abdominal examination shows a midline incision extending from the xiphisternum to the pubic symphysis. There is a 5-cm (2-in) area of purplish discoloration near the margin of the incision in the lower abdomen. Palpation of the abdomen produces severe pain and crackling sounds are heard. Laboratory studies show: Hemoglobin 12.5 g/dL Leukocyte count 18,600/mm3 Platelet count 228,000/mm3 Erythrocyte sedimentation rate 120 mm/h Serum Na+ 134 mEq/L K+ 3.5 mEq/L Cl- 98 mEq/L HCO3- 22 mEq/L Glucose 200 mg/dL Urea nitrogen 60 mg/dL Creatinine 3.2 mg/dL Creatine kinase 750 U/L Which of the following is the most appropriate next step in management?

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?

Thirty minutes after normal vaginal delivery of twins, a 35-year-old woman, gravida 5, para 4, has heavy vaginal bleeding with clots. Physical examination shows a soft, enlarged, and boggy uterus. Despite bimanual uterine massage, administration of uterotonic drugs, and placement of an intrauterine balloon for tamponade, the bleeding continues. A hysterectomy is performed. Vessels running through which of the following structures must be ligated during the surgery to achieve hemostasis?

A 56-year-old man is brought to the emergency department 25 minutes after he was involved in a high-speed motor vehicle collision where he was the unrestrained passenger. He has severe lower abdominal and pelvic pain. On arrival, he is alert and oriented. His pulse is 95/min, respirations are 22/min, and blood pressure is 106/62 mm Hg. Examination shows severe tenderness to palpation over the lower abdomen and over the left anterior superior iliac spine. There is no limb length discrepancy. Application of downward pressure over the pelvis shows no springy resistance or instability. Rectal examination is unremarkable. A focused assessment with sonography shows no free fluid in the abdomen. There is no blood at the urethral meatus. Placement of a Foley catheter shows gross hematuria. An x-ray of the pelvis shows a fracture of the left pelvic edge. Which of the following is the most appropriate next step in management?

Q10

A 28-year-old woman is brought to the emergency department 30 minutes after being involved in a high-speed motor vehicle collision in which she was the unrestrained driver. On arrival, she is semiconscious and incoherent. She has shortness of breath and is cyanotic. Her pulse is 112/min, respirations are 59/min, and blood pressure is 128/89 mm Hg. Examination shows a 3-cm (1.2-in) laceration on the forehead and multiple abrasions over the thorax and abdomen. There is crepitation on palpation of the thorax on the right. Auscultation of the lung shows decreased breath sounds on the right side. A crunching sound synchronous with the heartbeat is heard best over the precordium. There is dullness on percussion of the right hemithorax. The lips and tongue have a bluish discoloration. There is an open femur fracture on the left. The remainder of the examination shows no abnormalities. Arterial blood gas analysis on room air shows: pH 7.31 PCO2 55 mm Hg PO2 42 mm Hg HCO3- 22 mEq/L O2 saturation 76% The patient is intubated and mechanically ventilated. Infusion of 0.9% saline is begun. Which of the following is the most likely diagnosis?

Laparoscopic instrumentation US Medical PG Practice Questions and MCQs

Question 1: A 27-year-old man is brought to the emergency department after a motor vehicle accident. He was the unrestrained driver in a head on collision. The patient is responding incoherently and is complaining of being in pain. He has several large lacerations and has been impaled with a piece of metal. IV access is unable to be obtained and a FAST exam is performed. His temperature is 98.2°F (36.8°C), blood pressure is 90/48 mmHg, pulse is 150/min, respirations are 13/min, and oxygen saturation is 98% on room air. Which of the following is the best next step in management?

A. Reattempt intravenous access
B. Obtain intraosseous access (Correct Answer)
C. Place a central line
D. Administer oral fluids
E. Exploratory laparotomy

Explanation: ***Obtain intraosseous access*** - The patient is in **hypotensive shock** (BP 90/48 mmHg, HR 150/min) after a severe trauma, and **IV access cannot be obtained**. **Intraosseous (IO) access** provides a rapid and reliable route for fluid and medication administration in emergent situations when peripheral IV access is difficult or impossible. - While central line placement is also a viable option, **IO access is generally faster and easier to establish** in an emergency setting by a wide range of providers, making it the **best initial step** when peripheral IV fails. *Reattempt intravenous access* - Although obtaining IV access is critical, the question states that it "is unable to be obtained," implying initial attempts have failed or are proving too difficult/time-consuming given the patient's critical state. - Persisting with repeated attempts risks significant delay in resuscitation, which is detrimental for a patient in shock. *Place a central line* - A central line provides reliable access for fluid and medication, but its placement is generally **more time-consuming** and technically challenging than IO access, especially in an agitated, unstable patient in a chaotic emergency setting. - The immediate priority is rapid access for fluids to address the patient's shock, for which IO is superior in terms of speed of establishment. *Administer oral fluids* - The patient is **unstable**, **incoherently responding**, and likely has significant internal injuries given the mechanism of injury (head-on collision, impalement). - Oral fluids would be **ineffective** and potentially dangerous (risk of aspiration) in this critical, hemodynamically unstable patient who requires immediate intravenous fluid resuscitation. *Exploratory laparotomy* - While the patient likely has significant internal injuries requiring surgical intervention (impalement, hypovolemic shock), an **exploratory laparotomy** is a definitive treatment step, not the *best next step in management* for immediate resuscitation. - **Hemodynamic stabilization** with fluid resuscitation must occur *before* or *simultaneously with* definitive surgical intervention to improve survival chances.

Question 2: A 27-year-old man presents to the emergency department after being stabbed. The patient was robbed at a local pizza parlor and was stabbed over 10 times with a large kitchen knife with an estimated 7 inch blade in the ventral abdomen. His temperature is 97.6°F (36.4°C), blood pressure is 74/54 mmHg, pulse is 180/min, respirations are 19/min, and oxygen saturation is 98% on room air. The patient is intubated and given blood products and vasopressors. Physical exam is notable for multiple stab wounds over the patient's abdomen inferior to the nipple line. Which of the following is the best next step in management?

A. Exploratory laparotomy (Correct Answer)
B. Diagnostic peritoneal lavage
C. CT scan of the abdomen and pelvis
D. Exploratory laparoscopy
E. FAST exam

Explanation: ***Exploratory laparotomy*** - The patient presents with **multiple stab wounds** to the abdomen and signs of **hemorrhagic shock** (BP 74/54 mmHg, HR 180/min), which are clear indications for immediate surgical intervention. - An exploratory laparotomy allows for direct visualization and repair of internal injuries, which is critical in this life-threatening situation. *Diagnostic peritoneal lavage* - While DPL can detect intra-abdominal bleeding, it is an **invasive procedure** and may delay definitive treatment in a hemodynamically unstable patient with obvious penetrating trauma. - It is **less specific** than a laparotomy for identifying the exact location and nature of injuries, and it has largely been replaced by imaging studies or direct surgical exploration in unstable patients. *CT scan of the abdomen and pelvis* - A CT scan requires a **hemodynamically stable** patient and time for scanning and interpretation, which this patient does not have. - Delaying definitive treatment for imaging in a patient with severe shock could lead to worse outcomes. *Exploratory laparoscopy* - Although less invasive, laparoscopy can be time-consuming and may not be feasible or safe in a patient with **profound hemorrhagic shock** and extensive injuries, especially if major vascular or visceral damage is suspected. - Conversion to a **laparotomy** is often necessary in cases of significant injury, making immediate open exploration more efficient. *FAST exam* - A FAST exam can rapidly detect free fluid in the abdomen, suggesting internal bleeding, but it does **not provide specific information** about the source or extent of the injuries. - While useful in the initial assessment, a positive FAST exam in a hemodynamically unstable patient with penetrating trauma directly points to the need for immediate surgical intervention, not further diagnostic delay.

Question 3: A 34-year-old woman is recovering in the post-operative unit following a laparoscopic procedure for chronic endometriosis. She had initially presented with complaints of painful menstrual cramps that kept her bedridden most of the day. She also mentioned to her gynecologist that she had been diagnosed with endometriosis 4 years ago, and she could not find a medication or alternative therapeutic measure that helped. Her medical history was significant for surgery she had 6 years ago to remove tumors she had above her kidneys, after which she was prescribed hydrocortisone. An hour after the laparoscopic procedure, she calls the nurse because she is having difficulty breathing. The nurse records her vital signs include: blood pressure 85/55 mm Hg, respirations 20/min, and pulse 115/min. The patient suddenly loses consciousness. Intravenous fluids are started immediately. She gains consciousness, but her blood pressure is unchanged. Which of the following is the most likely cause of the hypotension?

A. Bleeding profusely through the surgical site
B. Improper supplementation of steroids (Correct Answer)
C. Infection involving the suture line
D. High doses of anesthetic drugs
E. Loss of fluids during the procedure

Explanation: ***Improper supplementation of steroids*** - The patient's history of **bilateral adrenalectomy (tumors above kidneys)** for which she was prescribed **hydrocortisone** indicates **adrenal insufficiency**. Stressful events like surgery require an increased dose of steroids, and improper supplementation can lead to an **adrenal crisis**. - The symptoms of **hypotension, tachycardia, and loss of consciousness** are characteristic of an **adrenal crisis (acute adrenal insufficiency)**, which occurs when the body lacks sufficient cortisol during stress. *Bleeding profusely through the surgical site* - While **hemorrhage** can cause hypotension and tachycardia, the patient regained consciousness with IV fluids but her **blood pressure remained unchanged**, which is less typical for isolated blood loss if volume is restored without addressing the underlying cause. - There is no direct mention of visible bleeding, the prompt only states the patient lost consciousness and her blood pressure is unchanged. *Infection involving the suture line* - **Surgical site infections** typically manifest several days post-op, presenting with **fever, erythema, and purulent drainage**, not acute hypotension and loss of consciousness an hour after surgery. - The immediate post-operative timeline and systemic symptoms are not consistent with a localized wound infection as the primary cause of this acute decline. *High doses of anesthetic drugs* - Anesthetic drugs can cause **vasodilation and hypotension**. However, their effects are usually transient and would likely resolve more completely with IV fluids, especially an hour after a laparoscopic procedure. - If it was due to anesthetic drugs, the patient's blood pressure would likely normalize with fluid administration once the effects of the anesthetic began to wear off, which is not the case here. *Loss of fluids during the procedure* - **Fluid loss** during surgery can cause hypotension, but intravenous fluids were administered, and the patient regained consciousness. - If fluid loss were the sole cause, resolving consciousness and maintaining low blood pressure typically indicates the fluid loss was not completely compensated, but the primary cause for the persistent hypotension is not just volume.

Question 4: A 45-year-old man undergoes elective vasectomy for permanent contraception. The procedure is performed under local anesthesia. There are no intra-operative complications and he is discharged home with ibuprofen for post-operative pain. This patient is at increased risk for which of the following complications?

A. Prostatitis
B. Seminoma
C. Testicular torsion
D. Sperm granuloma (Correct Answer)
E. Inguinal hernia

Explanation: **Sperm granuloma** - A **sperm granuloma** can occur after vasectomy due to the extravasation of sperm from the severed vas deferens, leading to a foreign body granulomatous reaction. - This complication presents as a **palpable, tender nodule** at the vasectomy site and is a relatively common long-term issue. *Prostatitis* - **Prostatitis** is an inflammation of the prostate gland, and there is no direct mechanistic link or increased risk following a vasectomy. - It is typically caused by bacterial infection or non-infectious inflammatory processes, unrelated to the **vas deferens** ligation. *Seminoma* - **Seminoma** is a type of testicular germ cell tumor, and extensive research has shown no increased risk of developing testicular cancer after vasectomy. - The procedure does not alter the cellular processes or environment within the testicles that predispose to germ cell tumor formation. *Testicular torsion* - **Testicular torsion** is a urological emergency involving the twisting of the spermatic cord, which cuts off blood supply to the testis. - This condition is not associated with vasectomy; it typically occurs due to an anatomical abnormality (e.g., **bell-clapper deformity**) or trauma. *Inguinal hernia* - An **inguinal hernia** is a protrusion of abdominal contents through a weakness in the abdominal wall, specifically in the inguinal canal. - Vasectomy is a superficial procedure that does not involve manipulating or weakening the abdominal wall in a way that would increase the risk of an inguinal hernia.

Question 5: A 32-year-old woman comes to the physician for a screening health examination that is required for scuba diving certification. The physician asks her to perform a breathing technique: following deep inspiration, she is instructed to forcefully exhale against a closed airway and contract her abdominal muscles while different cardiovascular parameters are evaluated. Which of the following effects is most likely after 10 seconds in this position?

A. Decreased intra-abdominal pressure
B. Decreased left ventricular stroke volume (Correct Answer)
C. Decreased pulse rate
D. Decreased systemic vascular resistance
E. Increased venous return to left atrium

Explanation: ***Decreased left ventricular stroke volume*** - After 10 seconds of performing the **Valsalva maneuver**, the increased intrathoracic pressure significantly reduces **venous return** to the heart. - Reduced venous return leads to decreased **ventricular filling** (preload), which in turn diminishes **left ventricular stroke volume** and cardiac output. *Decreased intra-abdominal pressure* - The instruction to "contract her abdominal muscles" during forceful exhalation against a closed airway (Valsalva maneuver) directly leads to an **increase** in **intra-abdominal pressure**, not a decrease. - This increase in intra-abdominal pressure further impedes venous return from the lower extremities to the heart. *Decreased pulse rate* - In the initial phase of the Valsalva maneuver (first 5-10 seconds), the decrease in cardiac output triggers a **reflex tachycardia** to maintain blood pressure, leading to an **increased pulse rate**. - A decrease in pulse rate (bradycardia) is more characteristic of the release phase, not during the sustained strain. *Decreased systemic vascular resistance* - During the Valsalva maneuver, the body attempts to compensate for the drop in cardiac output and blood pressure by increasing **sympathetic tone**, which causes **vasoconstriction** and thus **increases systemic vascular resistance**. - A decrease in systemic vascular resistance would further drop blood pressure and is not the physiological response during this phase. *Increased venous return to left atrium* - The Valsalva maneuver dramatically **reduces venous return** to both the right and left atria due to the high intrathoracic pressure compressing the great veins. - This decreased venous return is the primary mechanism leading to the subsequent fall in cardiac output during the maneuver.

Question 6: One day after undergoing an open colectomy, a 65-year-old man with colon cancer experiences shivers. The procedure was originally scheduled to be done laparoscopically, but it was converted because of persistent bleeding. Besides the conversion, the operation was uneventful. Five years ago, he underwent renal transplantation because of cystic disease and has been taking prednisolone since then. He has a history of allergy to sulfonamides. He appears acutely ill. His temperature is 39.2°C (102.5°F), pulse is 120/min, respirations are 23/min, and blood pressure is 90/62 mm Hg. Abdominal examination shows a midline incision extending from the xiphisternum to the pubic symphysis. There is a 5-cm (2-in) area of purplish discoloration near the margin of the incision in the lower abdomen. Palpation of the abdomen produces severe pain and crackling sounds are heard. Laboratory studies show: Hemoglobin 12.5 g/dL Leukocyte count 18,600/mm3 Platelet count 228,000/mm3 Erythrocyte sedimentation rate 120 mm/h Serum Na+ 134 mEq/L K+ 3.5 mEq/L Cl- 98 mEq/L HCO3- 22 mEq/L Glucose 200 mg/dL Urea nitrogen 60 mg/dL Creatinine 3.2 mg/dL Creatine kinase 750 U/L Which of the following is the most appropriate next step in management?

A. Surgical debridement (Correct Answer)
B. Intravenous clindamycin therapy
C. X-ray of the abdomen and pelvis
D. Vacuum-assisted wound closure device
E. CT scan of abdomen

Explanation: ***Surgical debridement*** - The patient's presentation with **fever**, **tachycardia**, **hypotension**, **purplish discoloration**, **severe pain**, and **crepitus** (crackling sounds) near the incision after abdominal surgery is highly suggestive of **necrotizing fasciitis**. - **Surgical debridement** is the most urgent and critical step to remove necrotic tissue, control the spread of infection, and improve outcomes in necrotizing soft tissue infections. *Intravenous clindamycin therapy* - While broad-spectrum antibiotics, including clindamycin, are essential in managing necrotizing fasciitis, they are **adjunctive to surgical debridement**, not a standalone primary treatment. - Delaying surgery for antibiotic therapy alone would worsen the patient's prognosis and could lead to rapid progression of the infection. *X-ray of the abdomen and pelvis* - An X-ray might show subcutaneous **gas (crepitus)**, which is consistent with necrotizing fasciitis due to gas-producing bacteria. - However, the clinical presentation is already highly indicative of the diagnosis, and waiting for imaging would **delay critical surgical intervention**. *Vacuum-assisted wound closure device* - **VAC therapy** is used for wound management to promote healing after debridement, by creating negative pressure. - It is **not a primary treatment** for an active, spreading necrotizing infection and should only be considered after adequate surgical debridement has been performed. *CT scan of abdomen* - A CT scan can confirm the presence of **gas in the soft tissues** and assess the extent of the infection, providing valuable information. - However, like X-rays, obtaining a CT scan would **delay immediate surgical intervention**, which is paramount given the rapid progression of necrotizing fasciitis.

Question 7: 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

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.

Question 8: Thirty minutes after normal vaginal delivery of twins, a 35-year-old woman, gravida 5, para 4, has heavy vaginal bleeding with clots. Physical examination shows a soft, enlarged, and boggy uterus. Despite bimanual uterine massage, administration of uterotonic drugs, and placement of an intrauterine balloon for tamponade, the bleeding continues. A hysterectomy is performed. Vessels running through which of the following structures must be ligated during the surgery to achieve hemostasis?

A. Suspensory ligament
B. Round ligament
C. Ovarian ligament
D. Uterosacral ligament
E. Cardinal ligament (Correct Answer)

Explanation: ***Cardinal ligament*** - The **uterine artery** and **uterine vein**, which supply the uterus, run through the **cardinal ligament** (also known as the transverse cervical ligament). - Ligation of these vessels is crucial during a hysterectomy to control bleeding from the uterus. *Suspensory ligament* - The **suspensory ligament of the ovary** contains the **ovarian artery** and vein, which primarily supply the ovaries and fallopian tubes. - While these may be ligated during a hysterectomy if the ovaries are removed, they are not the primary vessels causing uterine bleeding in postpartum hemorrhage. *Round ligament* - The **round ligament of the uterus** extends from the uterus to the labia majora and contains relatively small vessels, primarily contributing to uterine support. - Ligation of this ligament alone would not effectively control heavy uterine bleeding. *Ovarian ligament* - The **ovarian ligament** connects the ovary to the uterus and contains small vessels that mainly supply the ovary. - It does not house the major blood supply to the uterus itself. *Uterosacral ligament* - The **uterosacral ligaments** primarily provide support to the uterus by connecting it to the sacrum and contain small nerves and vessels. - Ligation of these ligaments would not control the main arterial supply to the uterus.

Question 9: A 56-year-old man is brought to the emergency department 25 minutes after he was involved in a high-speed motor vehicle collision where he was the unrestrained passenger. He has severe lower abdominal and pelvic pain. On arrival, he is alert and oriented. His pulse is 95/min, respirations are 22/min, and blood pressure is 106/62 mm Hg. Examination shows severe tenderness to palpation over the lower abdomen and over the left anterior superior iliac spine. There is no limb length discrepancy. Application of downward pressure over the pelvis shows no springy resistance or instability. Rectal examination is unremarkable. A focused assessment with sonography shows no free fluid in the abdomen. There is no blood at the urethral meatus. Placement of a Foley catheter shows gross hematuria. An x-ray of the pelvis shows a fracture of the left pelvic edge. Which of the following is the most appropriate next step in management?

A. Intravenous pyelography
B. External fixation of the pelvis
C. Cystoscopy
D. Retrograde urethrography
E. Retrograde cystography (Correct Answer)

Explanation: ***Retrograde cystography*** - The presence of **gross hematuria** in a patient with a **pelvic fracture** necessitates ruling out **bladder injury**. A retrograde cystography directly visualizes the bladder and can detect extravasation of contrast if a bladder rupture is present. - This imaging study specifically investigates the bladder using retrograde contrast filling, which is crucial for diagnosing **intraperitoneal** or **extraperitoneal bladder rupture**. *Intravenous pyelography* - This study evaluates the **kidneys** and **ureters** for injury, but the primary concern with gross hematuria and pelvic fracture is the bladder. - An IV pyelogram provides less detailed imaging of the bladder compared to a retrograde cystogram and is less effective for detecting bladder rupture. *External fixation of the pelvis* - While the patient has a pelvic fracture, the immediate priority in a hemodynamically stable patient with gross hematuria is to identify and manage potential **life-threatening urologic injuries** before definitive orthopedic repair. - **Pelvic external fixation** is primarily indicated for **unstable pelvic fractures** or those causing significant hemorrhage, neither of which is explicitly described as an immediate concern requiring intervention before urologic evaluation. *Cystoscopy* - **Cystoscopy** is an endoscopic procedure that allows direct visualization of the bladder's interior. While it can identify bladder injuries, it is generally considered after imaging studies like **retrograde cystography** to confirm findings or address specific issues like clot evacuation or stent placement. - The initial diagnostic step should focus on assessing for rupture via contrast study, which is often less invasive than a direct endoscopic procedure in the acute trauma setting. *Retrograde urethrography* - **Retrograde urethrography (RUG)** is used to evaluate for **urethral injury**, especially when there is blood at the urethral meatus, a high-riding prostate, or an inability to pass a Foley catheter. - The patient's Foley catheter was successfully placed, and there was **no blood at the urethral meatus**, making urethral injury less likely and thus RUG a lower priority as the initial step compared to assessing for bladder injury.

Question 10: A 28-year-old woman is brought to the emergency department 30 minutes after being involved in a high-speed motor vehicle collision in which she was the unrestrained driver. On arrival, she is semiconscious and incoherent. She has shortness of breath and is cyanotic. Her pulse is 112/min, respirations are 59/min, and blood pressure is 128/89 mm Hg. Examination shows a 3-cm (1.2-in) laceration on the forehead and multiple abrasions over the thorax and abdomen. There is crepitation on palpation of the thorax on the right. Auscultation of the lung shows decreased breath sounds on the right side. A crunching sound synchronous with the heartbeat is heard best over the precordium. There is dullness on percussion of the right hemithorax. The lips and tongue have a bluish discoloration. There is an open femur fracture on the left. The remainder of the examination shows no abnormalities. Arterial blood gas analysis on room air shows: pH 7.31 PCO2 55 mm Hg PO2 42 mm Hg HCO3- 22 mEq/L O2 saturation 76% The patient is intubated and mechanically ventilated. Infusion of 0.9% saline is begun. Which of the following is the most likely diagnosis?

A. Pulmonary embolism
B. Flail chest
C. Tension pneumothorax
D. Bronchial rupture (Correct Answer)
E. Hemopneumothorax

Explanation: ***Bronchial rupture*** - The presence of a **mediastinal crunching sound (Hamman's sign)** synchronous with the heartbeat, along with **subcutaneous emphysema (crepitation)** and a significant mechanism of injury (high-speed MVA), points strongly towards a bronchial injury. - **Decreased breath sounds** and **dullness to percussion** on the right side, combined with severe hypoxemia and hypercapnia, suggest a major airway disruption leading to air trapping and potential collapse of the lung. *Pulmonary embolism* - While pulmonary embolism can cause **dyspnea** and **hypoxemia**, it typically presents with clear lung auscultation and does not cause **crepitation** or a **mediastinal crunching sound**. - The mechanism of injury and immediate onset of symptoms are more consistent with a traumatic injury rather than an embolic event. *Flail chest* - **Flail chest** involves paradoxical movement of a segment of the chest wall due to multiple rib fractures, which would lead to respiratory distress and crepitation. - However, flail chest does not typically cause a **mediastinal crunching sound** or the severe degree of hypoxemia and hypercapnia seen with a major airway injury without other concomitant severe lung injury. *Tension pneumothorax* - A **tension pneumothorax** would cause severe respiratory distress, diminished breath sounds, and tracheal deviation (which is not described). - While it can cause crepitation (subcutaneous emphysema) and hypoxemia, it usually presents with **hyperresonance** to percussion, not dullness, and does not produce a **mediastinal crunching sound** as prominently. *Hemopneumothorax* - A **hemopneumothorax** would explain **decreased breath sounds** and **dullness to percussion** due to the presence of blood and air in the pleural space. - However, it would not typically cause a **mediastinal crunching sound** (Hamman's sign), which is highly specific for pneumomediastinum, often secondary to tracheobronchial injury.

Want unlimited practice?

Get full access to all questions, explanations, and performance tracking.

Start For Free