A 35-year-old woman with no significant past medical history is brought in by ambulance after a major motor vehicle collision. Temperature is 97.8 deg F (36.5 deg C), blood pressure is 76/40, pulse is 110/min, and respirations are 12/min. She arouses to painful stimuli and makes incomprehensible sounds, but is unable to answer questions. Her abdomen is distended and diffusely tender to palpation. Bedside ultrasound shows blood in the peritoneal cavity. Her husband rushes to the bedside and states she is a Jehovah’s Witness and will refuse blood products. No documentation of blood refusal is available for the patient. What is the most appropriate next step in management?
Q2
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?
Q3
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?
Q4
A 45-year-old male is brought to the emergency department by emergency medical services after sustaining a gunshot wound to the abdomen. He is unresponsive. His temperature is 99.0°F (37.2°C), blood pressure is 95/58 mmHg, pulse is 115/min, and respirations are 20/min. Physical examination reveals an entry wound in the left abdominal quadrant just inferior to the left lateral costal border. Abdominal CT shows the bullet trajectory through the left abdominal cavity. Which of the following structures has the bullet most likely penetrated?
Q5
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?
Q6
A trauma 'huddle' is called. Morphine is administered for pain. Low-flow oxygen is begun. A traumatic diaphragmatic rupture is suspected. Infusion of 0.9% saline is begun. Which of the following is the most appropriate next step in management?
Q7
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?
Q8
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?
Q9
A 17-year-old adolescent male is brought to the emergency department by fire and rescue after being struck by a moving vehicle. The patient reports that he was running through his neighborhood when a car struck him while turning right on a red light. He denies any loss of consciousness. His temperature is 99.0°F (37.2°C), blood pressure is 88/56 mmHg, pulse is 121/min, respirations are 12/min, and SpO2 is 95% on room air. The patient is alert and oriented to person, place and time and is complaining of pain in his abdomen. He has lacerations on his face and extremities. On cardiac exam, he is tachycardic with normal S1 and S2. His lungs are clear to auscultation bilaterally, and his abdomen is soft but diffusely tender to palpation. The patient tenses his abdomen when an abdominal exam is performed. Bowel sounds are present, and he is moving all 4 extremities spontaneously. His skin is cool with delayed capillary refill. After the primary survey, 2 large-bore IVs are placed, and the patient is given a bolus of 2 liters of normal saline.
Which of the following is the best next step in management?
Q10
A 35-year-old male is brought into the emergency department for a trauma emergency. The emergency medical services states that the patient was wounded with a knife on his upper left thigh near the inguinal ligament. Upon examination in the trauma bay, the patient is awake and alert. His physical exam and FAST exam is normal other than the knife wound. Large bore intravenous lines are inserted into the patient for access and fluids are being administered. Pressure on the knife wound is being held by one of the physicians with adequate control of the bleeding, but the physician notices the blood was previously extravasating in a pulsatile manner. His vitals are BP 100/50, HR 110, T 97.8, RR 22. What is the next best step for this patient?
Penetrating abdominal trauma US Medical PG Practice Questions and MCQs
Question 1: A 35-year-old woman with no significant past medical history is brought in by ambulance after a major motor vehicle collision. Temperature is 97.8 deg F (36.5 deg C), blood pressure is 76/40, pulse is 110/min, and respirations are 12/min. She arouses to painful stimuli and makes incomprehensible sounds, but is unable to answer questions. Her abdomen is distended and diffusely tender to palpation. Bedside ultrasound shows blood in the peritoneal cavity. Her husband rushes to the bedside and states she is a Jehovah’s Witness and will refuse blood products. No documentation of blood refusal is available for the patient. What is the most appropriate next step in management?
A. In accordance with the husband's wishes, do not transfuse any blood products
B. Observe and reassess mental status in an hour to see if patient can consent for herself
C. Attempt to contact the patient’s parents for additional collateral information
D. Consult the hospital ethics committee
E. Administer blood products (Correct Answer)
Explanation: **Administer blood products**
- In emergency situations where a patient is incapacitated and there is no **advance directive** or **legal proxy** explicitly refusing treatment, the principle of **presumed consent** applies, allowing life-saving interventions.
- The patient's husband's statement is not legally binding without a living will or medical power of attorney, especially when the patient's capacity to consent or refuse treatment is compromised due to critical injury.
*In accordance with the husband's wishes, do not transfuse any blood products*
- The husband's stated wishes are not legally sufficient to refuse life-saving treatment for an incapacitated adult unless he holds **durable power of attorney for health care** specifically outlining these wishes, which is not stated here.
- Deferring necessary treatment based solely on the husband's assertion could lead to the patient's death and potentially expose the medical team to **malpractice liability**.
*Observe and reassess mental status in an hour to see if patient can consent for herself*
- The patient presents with **severe hypovolemic shock** (BP 76/40, HR 110/min) and signs of significant hemorrhage, indicating an urgent, life-threatening situation.
- Delaying emergent treatment to wait for a change in mental status would likely result in irreversible harm or death, as her condition is rapidly deteriorating.
*Attempt to contact the patient’s parents for additional collateral information*
- Contacting other family members for more information would cause a **critical delay** in a life-threatening situation.
- Even if parents confirm the patient's faith, their input is still not a legally binding refusal of treatment without proper documentation or court order.
*Consult the hospital ethics committee*
- Ethics committee consultations are appropriate for complex ethical dilemmas that are not immediately life-threatening or when there is sufficient time for deliberation.
- In this **critical emergency** with an actively hemorrhaging patient in shock, consulting the ethics committee would cause an unacceptable delay in life-saving treatment.
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
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.
Question 3: 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 4: A 45-year-old male is brought to the emergency department by emergency medical services after sustaining a gunshot wound to the abdomen. He is unresponsive. His temperature is 99.0°F (37.2°C), blood pressure is 95/58 mmHg, pulse is 115/min, and respirations are 20/min. Physical examination reveals an entry wound in the left abdominal quadrant just inferior to the left lateral costal border. Abdominal CT shows the bullet trajectory through the left abdominal cavity. Which of the following structures has the bullet most likely penetrated?
A. Transverse colon
B. Ascending colon
C. Descending colon (Correct Answer)
D. Sigmoid colon
E. Superior duodenum
Explanation: ***Descending colon***
- The **descending colon** is located in the left abdominal cavity, specifically in the left upper quadrant and extending into the left lower quadrant, making it highly susceptible to injury from a gunshot wound in the **left abdominal quadrant** just inferior to the left lateral costal border.
- Its position aligns directly with the described entry point and bullet trajectory.
*Transverse colon*
- The **transverse colon** lies more centrally in the upper abdomen, spanning from the right to the left upper quadrants.
- While possible to be hit by a left-sided entry wound, the trajectory described as "inferior to the left lateral costal border" makes the descending colon a more direct and likely target.
*Ascending colon*
- The **ascending colon** is located in the **right abdominal cavity**, specifically in the right upper and lower quadrants.
- A wound inferior to the left lateral costal border would be on the opposite side of the abdomen and thus unlikely to penetrate the ascending colon.
*Sigmoid colon*
- The **sigmoid colon** is located more inferiorly in the **left lower quadrant** and pelvis.
- While on the left side, the entry wound described as "inferior to the left lateral costal border" is generally higher than the typical location of the sigmoid colon.
*Superior duodenum*
- The **superior duodenum** is located in the **right upper quadrant** of the abdomen, anterior to the head of the pancreas.
- Its position on the right side makes it highly unlikely to be penetrated by a gunshot wound to the left abdominal quadrant.
Question 5: 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
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.
Question 6: A trauma 'huddle' is called. Morphine is administered for pain. Low-flow oxygen is begun. A traumatic diaphragmatic rupture is suspected. Infusion of 0.9% saline is begun. Which of the following is the most appropriate next step in management?
A. Chest fluoroscopy
B. Barium study
C. CT of the chest, abdomen, and pelvis (Correct Answer)
D. MRI chest and abdomen
E. ICU admission and observation
Explanation: ***CT of the chest, abdomen, and pelvis***
- A suspected **traumatic diaphragmatic rupture** requires a comprehensive imaging study to assess the diaphragm, surrounding organs, and potential associated injuries.
- **CT scan** of the chest, abdomen, and pelvis provides detailed anatomical information, can identify herniated abdominal contents, and is essential for surgical planning in trauma settings.
*Chest fluoroscopy*
- While fluoroscopy can detect diaphragmatic motion, it is **less sensitive** for identifying tears or herniated contents in the **acute trauma setting**.
- It does not provide the comprehensive view of surrounding organs and associated injuries often needed in trauma.
*Barium study*
- A barium study is primarily used to evaluate the **gastrointestinal tract**, but it is generally **not the initial imaging modality** for diaphragmatic rupture due to its limited ability to visualize the diaphragm itself or other solid organ injuries.
- It would be performed after suspicion is increased or for very specific indications, not as a primary diagnostic tool.
*MRI chest and abdomen*
- While MRI offers excellent soft tissue contrast, its use in **acute trauma** is limited by **longer acquisition times**, potential contraindications with metallic implants (though less common in acute trauma), and lower availability compared to CT.
- CT remains the **gold standard** for rapid, comprehensive imaging in unstable trauma patients.
*ICU admission and observation*
- While observation in the ICU is important for monitoring and supportive care, it is **not the next step for diagnosis** of a suspected diaphragmatic rupture.
- Definitive diagnosis through imaging (CT) is crucial before determining specific management strategies, including potential surgical intervention.
Question 7: 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. Perform an MRI scan of the abdomen and pelvis
B. CT of the abdomen and pelvis with contrast
C. Obtain a retrograde urethrogram
D. Take the patient to the OR for an exploratory laparotomy (Correct Answer)
E. Perform a diagnostic peritoneal lavage
Explanation: ***Take the patient to the OR for an exploratory laparotomy***
- The patient is **hemodynamically unstable** (BP 78/37 mm Hg, pulse 122/min) with signs of hemorrhagic shock (cold and clammy skin, drowsy, tachycardia) and **hypotension persists despite IV fluid resuscitation**.
- FAST examination shows **retroperitoneal fluid collection** (presumed blood), flank ecchymoses (Grey Turner sign), and hematocrit of 22% indicating **significant blood loss**.
- According to **ATLS (Advanced Trauma Life Support) protocols**, hemodynamically **unstable patients with positive FAST exams require immediate surgical intervention** and should not be delayed for further imaging.
- **Exploratory laparotomy** allows for immediate identification and control of bleeding sources, which is life-saving in this persistently hypotensive patient. The retroperitoneal hematoma can be explored and bleeding vessels ligated or repaired.
*CT of the abdomen and pelvis with contrast*
- CT scan is the **appropriate next step for hemodynamically STABLE trauma patients** or those who **respond to initial resuscitation** to characterize injuries and guide management.
- This patient has **persistent hypotension despite resuscitation**, making him too unstable to safely transport to the CT scanner. Delaying surgery for imaging in an unstable patient increases mortality risk.
- The principle is: **"Blood pressure is better than pictures"** - unstable patients need operative hemorrhage control, not diagnostic imaging.
*Perform an MRI scan of the abdomen and pelvis*
- **MRI has no role in acute trauma evaluation** due to long acquisition time (30-60 minutes), limited availability, and inability to adequately monitor critically ill patients in the MRI suite.
- This would be an inappropriate and potentially fatal delay in a patient with ongoing hemorrhage and hemodynamic instability.
*Perform a diagnostic peritoneal lavage*
- **Diagnostic peritoneal lavage (DPL)** has been largely replaced by FAST examination for detecting intraperitoneal hemorrhage in the modern trauma algorithm.
- While DPL can detect intra-abdominal blood, the **FAST has already identified retroperitoneal fluid**, and the patient's persistent instability mandates immediate surgical intervention rather than additional diagnostic procedures.
- DPL also does not evaluate the retroperitoneum well and would not change management in this unstable patient.
*Obtain a retrograde urethrogram*
- **Retrograde urethrogram (RUG)** is indicated when urethral injury is suspected (blood at meatus, high-riding prostate, perineal hematoma, inability to void).
- This patient has **normal external genitalia** and only microscopic hematuria (6 RBC/HPF), which is nonspecific in blunt trauma.
- The immediate life-threatening issue is **hemorrhagic shock from retroperitoneal bleeding**, not potential urethral injury. RUG would be an inappropriate delay in management and can be performed later if clinically indicated.
Question 8: 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 9: A 17-year-old adolescent male is brought to the emergency department by fire and rescue after being struck by a moving vehicle. The patient reports that he was running through his neighborhood when a car struck him while turning right on a red light. He denies any loss of consciousness. His temperature is 99.0°F (37.2°C), blood pressure is 88/56 mmHg, pulse is 121/min, respirations are 12/min, and SpO2 is 95% on room air. The patient is alert and oriented to person, place and time and is complaining of pain in his abdomen. He has lacerations on his face and extremities. On cardiac exam, he is tachycardic with normal S1 and S2. His lungs are clear to auscultation bilaterally, and his abdomen is soft but diffusely tender to palpation. The patient tenses his abdomen when an abdominal exam is performed. Bowel sounds are present, and he is moving all 4 extremities spontaneously. His skin is cool with delayed capillary refill. After the primary survey, 2 large-bore IVs are placed, and the patient is given a bolus of 2 liters of normal saline.
Which of the following is the best next step in management?
A. Abdominal CT
B. Diagnostic laparoscopy
C. Diagnostic peritoneal lavage
D. Focused Abdominal Sonography for Trauma (FAST) exam (Correct Answer)
E. Emergency laparotomy
Explanation: ***Focused Abdominal Sonography for Trauma (FAST) exam***
- A **FAST exam** is the most appropriate next step in a hemodynamically unstable blunt trauma patient with suspected intra-abdominal injury after initial fluid resuscitation.
- It is a rapid, non-invasive, and repeatable bedside assessment that can quickly identify the presence of free fluid (blood) in the peritoneal, pericardial, or pleural spaces.
- **ATLS protocol:** In an unstable patient, a positive FAST exam confirms the need for immediate laparotomy without further imaging.
*Abdominal CT*
- An **abdominal CT** scan is generally the imaging modality of choice for hemodynamically stable blunt trauma patients to identify specific organ injuries.
- However, performing a CT on an **unstable patient** like this one would delay critical interventions and further destabilize them due to the need to transport them to the scanner.
*Diagnostic laparoscopy*
- **Diagnostic laparoscopy** is a surgical procedure that is more invasive and time-consuming than a FAST exam.
- While it can identify injuries, it is typically reserved for hemodynamically stable patients when other non-invasive diagnostic tests are inconclusive or specific injuries are strongly suspected.
*Diagnostic peritoneal lavage*
- **Diagnostic peritoneal lavage (DPL)** is an invasive procedure with a high false-positive rate and has largely been replaced by the FAST exam and CT scans in blunt abdominal trauma.
- It involves inserting a catheter into the peritoneum to aspirate fluid, which is then analyzed for blood or other contents, but it is less specific for organ injury.
*Emergency laparotomy*
- An **emergency laparotomy** is the definitive surgical intervention for life-threatening intra-abdominal hemorrhage or organ injury.
- In this unstable patient, laparotomy would be performed immediately **after** a positive FAST exam confirms hemoperitoneum, or in cases of obvious peritonitis or hemodynamic collapse where the patient cannot wait even for FAST.
- Proceeding directly to laparotomy without FAST would bypass a rapid 2-3 minute diagnostic test that confirms the indication and location of bleeding.
Question 10: A 35-year-old male is brought into the emergency department for a trauma emergency. The emergency medical services states that the patient was wounded with a knife on his upper left thigh near the inguinal ligament. Upon examination in the trauma bay, the patient is awake and alert. His physical exam and FAST exam is normal other than the knife wound. Large bore intravenous lines are inserted into the patient for access and fluids are being administered. Pressure on the knife wound is being held by one of the physicians with adequate control of the bleeding, but the physician notices the blood was previously extravasating in a pulsatile manner. His vitals are BP 100/50, HR 110, T 97.8, RR 22. What is the next best step for this patient?
A. CT lower extremities
B. Radiograph lower extremities
C. Coagulation studies and blood typing/crossmatch
D. Tourniquet of proximal lower extremity
E. Emergent surgery (Correct Answer)
Explanation: ***Emergent surgery***
- The pulsatile bleeding from a thigh wound near the inguinal ligament is highly suggestive of a major arterial injury, such as to the **femoral artery**.
- Given the potential for rapid blood loss and hemodynamic instability, **emergent surgical exploration and repair** are necessary to control the bleeding and prevent further compromise.
*CT lower extremities*
- While CT angiography could further delineate vascular injury, the presence of **active pulsatile bleeding** necessitates immediate surgical intervention rather than delaying for imaging.
- Delaying surgery for imaging risks **exsanguination** and worsening patient outcomes, especially with a blood pressure of **100/50 mmHg** and a heart rate of **110 bpm**, indicating early shock.
*Radiograph lower extremities*
- A radiograph would primarily visualize bone structures and foreign bodies but would not provide adequate information regarding the **vascular injury** and active bleeding.
- It would not change the urgent need for **surgical exploration** to address the pulsatile hemorrhage.
*Coagulation studies and blood typing/crossmatch*
- These are important preparatory steps for major surgery involving significant blood loss, but they should be carried out **concurrently with preparations for emergent surgery**, not instead of it.
- Delaying surgery to await these results would be inappropriate when facing **active arterial bleeding**.
*Tourniquet of proximal lower extremity*
- While a tourniquet can be used for temporary hemorrhage control, especially in an uncontrolled external hemorrhage, the current bleeding is being controlled by **direct pressure**.
- Applying a tourniquet could cause **ischemic damage** to the extremity if applied for too long, and for a deep stab wound, direct compression is often effective until surgical control can be achieved.
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