Blunt abdominal trauma — MCQs

A 67-year-old woman has fallen from the second story level of her home while hanging laundry. She was brought to the emergency department immediately and presented with severe abdominal pain. The patient is anxious, and her hands and feet feel very cold to the touch. There is no evidence of bone fractures, superficial skin wounds, or a foreign body penetration. Her blood pressure is 102/67 mm Hg, respirations are 19/min, pulse is 87/min, and temperature is 36.7°C (98.0°F). Her abdominal exam reveals rigidity and severe tenderness. A Foley catheter and nasogastric tube are inserted. The central venous pressure (CVP) is 5 cm H2O. The medical history is significant for hypertension. Which of the following is best indicated for the evaluation of this patient?

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 34-year-old man is admitted to the emergency department after a motor vehicle accident in which he sustained blunt abdominal trauma. On admission, he is conscious, has a GCS score of 15, and has normal ventilation with no signs of airway obstruction. Vitals initially are blood pressure 95/65 mmHg, heart rate 87/min, respiratory rate 14/min, and oxygen saturation of 95% on room air. The physical exam is significant only for tenderness to palpation over the left flank. Noncontrast CT of the abdomen shows fractures of the 9th and 10th left ribs. Intravenous fluids are administered and the patient's blood pressure increases to 110/80 mm Hg. Three days later after admission, the patient suddenly complains of weakness and left upper quadrant (LUQ) pain. Vitals are blood pressure 80/50 mm Hg, heart rate 97/min, respiratory rate 18/min, temperature 36.2℃ (97.2℉) and oxygen saturation of 99% on room air. Prompt administration of 2L of IV fluids increases the blood pressure to 100/70 mm Hg. On physical exam, there is dullness to percussion and rebound tenderness with guarding in the LUQ. Bowel sounds are present. Raising the patient's left leg results in pain in his left shoulder. Stat hemoglobin level is 9.8 g/dL. Which of the following findings would be most likely seen if a CT scan were performed now?

A 24-year-old man is brought by ambulance to the emergency department after a motor vehicle accident. He was the front seat driver in a head on collision. He is currently unconscious. The patient’s past medical history is only notable for an allergy to amoxicillin as he developed a rash when it was given for a recent upper respiratory infection 1 week ago. Otherwise, he is a college student in good health. The patient is resuscitated. A FAST exam is notable for free fluid in Morrison’s pouch. An initial assessment demonstrates only minor bruises and scrapes on his body. After further resuscitation the patient becomes responsive and begins vomiting. Which of the following is the most likely diagnosis?

A previously healthy 27-year-old man is brought to the emergency department 35 minutes after being involved in a high-speed motor vehicle collision in which he was an unrestrained passenger. He was ambulatory at the accident scene, with stable vital signs and no major external injuries except abrasions to both upper extremities. On arrival, he is alert and oriented. His temperature is 37.3°C (99.1°F), pulse is 88/min, respirations are 14/min, and blood pressure is 128/74 mm Hg. Abdominal examination shows ecchymosis over the upper abdomen, with tenderness to palpation over the left upper quadrant. There is no guarding or rigidity. Rectal examination is unremarkable. A CT scan of the abdomen with intravenous contrast shows a subcapsular splenic hematoma comprising 8% of the surface area, with no contrast extravasation and minimal blood in the peritoneal cavity. Which of the following is the next best step in management?

A 43-year-old man is brought to the emergency department 30 minutes after falling from the roof of a construction site. He reports abdominal and right-sided flank pain. His temperature is 37.1°C (98.8°F), pulse is 114/min, and blood pressure is 100/68 mm Hg. Physical examination shows numerous ecchymoses over the trunk and flanks and a tender right abdomen without a palpable mass. Focused assessment with sonography for trauma (FAST) shows no intraperitoneal fluid collections. His hemoglobin concentration is 7.6 g/dL. The most likely cause of his presentation is injury to which of the following organs?

A 33-year-old man is brought to the emergency department because of trauma from a motor vehicle accident. His pulse is 122/min and rapid and thready, the blood pressure is 78/37 mm Hg, the respirations are 26/min, and the oxygen saturation is 90% on room air. On physical examination, the patient is drowsy, with cold and clammy skin. Abdominal examination shows ecchymoses in the right flank. The external genitalia are normal. No obvious external wounds are noted, and the rest of the systemic examination values are within normal limits. Blood is sent for laboratory testing and urinalysis shows 6 RBC/HPF. Hematocrit is 22% and serum creatinine is 1.1 mg/dL. Oxygen supplementation and IV fluid resuscitation are started immediately, but the hypotension persists. The focused assessment with sonography in trauma (FAST) examination shows a retroperitoneal fluid collection. What is the most appropriate next step in management?

A 37-year-old woman is brought to the emergency department 15 minutes after falling down a flight of stairs. On arrival, she has shortness of breath, right-sided chest pain, right upper quadrant abdominal pain, and right shoulder pain. She is otherwise healthy. She takes no medications. She appears pale. Her temperature is 37°C (98.6°F), pulse is 115/min, respirations are 20/min, and blood pressure is 85/45 mm Hg. Examination shows several ecchymoses over the right chest. There is tenderness to palpation over the right chest wall and right upper quadrant of the abdomen. Bowel sounds are normal. Cardiopulmonary examination shows no abnormalities. Neck veins are flat. Which of the following is the most likely diagnosis?

A 33-year-old man is brought to the emergency department 20 minutes after losing control over his bicycle and colliding with a parked car. The handlebar of the bicycle hit his lower abdomen. On arrival, he is alert and oriented. His pulse is 90/min, respirations are 17/min and blood pressure is 110/70 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 97%. The pupils are equal and reactive to light. There are multiple bruises over his chest and lower extremities. The lungs are clear to auscultation. Cardiac examination shows no abnormalities. The abdomen is soft and nontender. There is no pelvic instability. Rectal examination is unremarkable. A complete blood count, prothrombin time, and serum concentrations of glucose, creatinine, and electrolytes are within the reference range. Urine dipstick is mildly positive for blood. Microscopic examination of the urine shows 20 RBCs/hpf. Which of the following is the most appropriate next step in management?

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?