__.“ T .- I. |.-"'_ f’ -I, " _ .

_- _-i,

-"' is is I - . "i,=’i-s”fi-.*§“'? c
F‘

5.}? 5: ‘fr ‘He-1."! f ‘A-

'._d.;' . __..

Trauma

CLINICAL QUESTIONS

What are the ABCs of the primary survey? Answer: B

Assess (stability of patient) Begin (treatment), Cervi-
cal spine (dont forget to stabilize the cervical spine)
Airway, Breathing, Circulation
Accident (history) Background (patient s past medical
history) Community (family medical history)
Assess, Begin (to treat), Complete (evaluation of all
injuries)
The first step in patient management is performing the pri-
mary survey, the goal of which is to identify and treat condi-
tions that constitute an immediate threat to life. The ATLS
course refers to the primary survey as assessment of the
‘ABCs’ (Airway with cervical spine protection, Breathing, and
Circulation). Although the concepts within the primary sur-
vey are presented in a sequential fashion, in reality they of-
ten proceed simultaneously. Life-threatening injuries must be
identified (Table ?- 1) and treated before advancing to the sec-
ondary survey. (See Schwartz 9"‘ ed., pp 136-137.)

visit?-1 _,_ _.,

'\. u.u-|
‘I-

,_:'et=.:-l_-g.'_- ;.'._-. ._,-., -is-'-.1-'5' '_-s-,%;- -tT="1-‘I-" -1. ---1.-é"'=3-0 F"...

if it 1
Airway
Airway obstruction
Airway injury
Breathing
Tension pneumothorax
Open pneumothorax
Flail chest with underlying pulmonary contusion
Circulation
Hemorrhagic shock
Ivlassive hemothorax
Massive hemoperitoneum
Mechanically unstable pelvis fracture
Extremity losses
Cardiogenic shoclr.
Cardiac ta mponade
Neurogenic shock
Cervical spine injury
Disability
lntracranial hemorrhagefmass lesion

Which of the following would mandate elective intubation Answer:A

in a patient with a normal voice, normal oxygen saturation, In general, patients who are conscious, do not show tac-
and no respiratory distress? hypnea, and have a normal voice do not require early atten-
Airway bleeding tion to the airway. Exceptions are patients with penetrating
Stab wound to the neck with mild swelling in the left injuries to the neck and an expanding hematoma; evidence
lateral neck of chemical or thermal injury to the mouth, nares, or hy-
Localized right lateral subcutaneous emphysema popharynx; extensive subcutaneous air in the neck; com-
Bilateral mandibular fracture plex maxillofacial trauma; or airway bleeding. Although
 these patients may initially have a satisfactory airway, it
may become obstructed if soft tissue swelling, hematoma
forrnation, or edema progresses. In these cases, elective in-
tubation should be performed before evidence of airway
compromise. Patients with stab wounds to the neck do not
necessarily require elective intubation, nor do patients with
localized subcutaneous emphysema. Bilateral mandibular
fracture without airway compromise does not require intu-
I‘ bation. [See Schwartz 9"‘ ed., pp 135-13?.)

'E':‘Ll. l' lI-3 3. What is the most common indication for intubation in a Ar1swer:A
trauma patient? Establishment of a definitive airway (i.e., endotracheal in-
A. Altered mental status tubation) is indicated in patients with apnea; inability to
B. Inhalation injury protect the airway due to altered mental status; impending
Facial injury airway compromise due to inhalation injury, hematoma, fa-
Di’? Cervical hematoma cial bleeding, soft tissue swelling, or aspiration; and inability
“____
to maintain oxygenation. Altered mental status is the most
common indication for intubation. Agitation or obtundation,
often attributed to intoxication or drug use, may actually be
due to hypoxia. {See Schwartz 9"‘ ed., p 13?.)

4. Which of the following trauma patients with airway Answer: D

compromise and failed endotracheal intubation should
undergo emergency tracheostomy (rather than a crico-
thyroidotorny)?
A. An 84-year-old male with blunt trauma to the neck
B. A 65-year-old female with a stab wound to the sub-
rnandibular region
C. A 16-year-old male with a gunshot wound to the neck
D. A 6-year-old female with a crush injury to the face
r-t
I
In patients under the age of 8, cricothyroidotomy is cont.rain-
dicated due to the risk ofsubglottic stenosis, and tracheostomy
should be performed.
Emergent tracheostomy is indicated in patients with lar-
yngotracheal separation or laryngeal fractures, in whom
cricothyroidotomy may cause further damage or result in
complete loss of the airway. This procedure is best per-
formed in the OR where there is optimal lighting and
availability of more equipment (e.g., sternal saw). In these
cases, often after a ‘clothesline’ injury, direct visualization
and instrumentation ofthe trachea usually is done through
the traumatic anterior neck defect or after a collar skin
incision.
Cricothyroidotomy (Fig. F’-1) is performed through a
generous vertical incision, with sharp division of the sub-
cutaneous tissues and strap muscles. Visualization may be
improved by having an assistant retract laterally on the neck
incision using army-navy retractors. The cricothyroid mem-
brane is verified by digital palpation through the space into
the airway. The airway may be stabilized before incision of
the membrane using a tracheostomy hoolt; the hook should
be placed under the thyroid cartilage to elevate the airway. A
6.0 tracheostomy tube (maximum diameter in adults) is then
advanced through the cricothyroid opening and sutured into
place. (See Schwartz 9"‘ ed., p 13?.)

FIG. 7-1. Cricothyroidotomy is recommended for emergent surgi-

A B
cal establishment ofa patent airway. A vertical skin incision avoids
injury to the anteriorjugular veins, which are located just lateral to the
midline. Hemorrhage from these vessels obscures vision and prolongs
the procedure.When a transverse incision is made in the cricothyroid
membrane, the blade of the knife should be angled inferiorly to avoid
injury to the vocal cords. A. Use ofa tracheostomy hook stabilizes the
thyroid cartilage and facilitates tube insertion. B. A as tracheostomy
tube or endotracheal tube is inserted after digital confirmation of
Elll'W5)" El'CCE'S5.

-'5 I

.‘'
 the following is the mo st appropriate initial treat-
a sucking chest wound?
dressing taped on 3 out of 4 sides
tube placed through the wound cover wound
chest tube) with occlusive dressing
tube placed in a clear area, closure ofthe ‘i.iH)l.lI1(Il
ofthe wound, intubation of the patient, sedation
7-2 A Full-thickness loss of the chest wall results in an open pneumothorax. Bfihe defect is temporarily managed with an
dressing that is ta ped on three sides which aiiows accumulated air to escape from the pleural space and thus prevents a tension
"iorax Repairo f t h ec h est wa ll defec t -:1 ndt u be thoracostom 1.i remote from the wound is definitive treatment-
A 4-year old is brought hypotensne to the ED after an
MVA Peripheral IV access is attempted but is unsuccess-
ful The next best access is
A. Cordis introducer in the internal jugular vein
B. Single lumen subclavian venous catheter
C Double lumen femoral venous catheter
D Intraosseous catheter
Answer: A
An open pneumothorax or ‘sucking chest wound’ occurs with
full-thickness loss of the chest wall, permitting free communi-
cation between the pleural space and the atmosphere (Pig. 7-2).
This compromises ventilation due to equilibration ofatmospher-
ic and pleural pressures, which prevents lung inflation and alveo-
lar ventilation, and results in hypoxia and hypercarbia. Complete
occlusion of the chest wall defect without a tube thoracostomy
I‘
may convert an open pneumothorax to a tension pneuinotho- or
C
rax. Temporary management of this injury includes covering the 3
wound with an occlusive dressing that is taped on three sides. ill
This acts as a flutter valve, permitting effective ventilation on in-
spiration while allowing accumulated air to escape from the pleu-
ral space on the untaped side, so that a tension pneumothorax is
prevented. Definitive treatment requires closure of the chest wall
defect and tube thoracostomy remote from the wound.
Placing the chest tube through the wound would increase in-
fectious complicatioiis and would result in inadequate closure and
healing of the wound. Closing the wound with a remotely placed
chest tube is the definitive treatment, which is usually done in the
operating room, rather than as initial treatment in the ED. Closing
the wound without a chest tube could result in a tension piieu-
mothorax and is contraindicated. (S ee Schwartz 9"‘ ed., p 138.)
Answer: D
In hypovolemic patients under 6 years of age, an intraosseous
needle can be placed in the proximal tibia (preferred) or distal
femur of an unfractured extremity (Fig. T’-3). Plow through the
needle should be continuous and does not require pressure. All
medications administered IV may be administered in a similar
dosage intraosseously. Although safe for emergent use, the needle
should be removed once alternative access is established to pre-
vent osteomyelitis. A Cordis introducer would be excessively
large for even central veins in a 4-year-old child. Both the single
and double lumen catheters would be less effective than the in-
terosseous for resuscitation. According to Poiseuille’s law, the
flow of liquid through a tube is proportional to the diameter and
inversely proportional to the length; theretbre, venous lines for
volume resuscitation should be short with a large diameter. (See
Schwartz 9*“ ed., p 139.]
 '§‘4_1.'.I-:;|::

J=-
eiuneij FIG. ?-3. lntraosseous infusions are indicated for children -:6 years
ofage in whom one or two attempts at l‘v’ access have failed. A.The
prozimal tibia is the preferred location. Alternatively, the distal femur
can be used ifthe tibia is fractured. B.The needle should be directed
away from the epiphyseal plate to avoid injury. The position is
satisfactory ifbone marrow can be aspirated and saline can be easily
infused without evidence ofextravasation.

lii F’. Which of the following is a life-threatening compromise Answer: D

I to circulation and must be identified during the primary During the circulation section of the prirriary survey, four life-
survey? threatening injuries that must be identified are (a) massive he-
I A. Unstable pelvic fracture motho rax, (b) cardiac tampon ade, (c) massive hemoperito neum,
!
B. Pericardial effusion and (cl) mechanically unstable pelvic fractures. A pericardial
C. 40% pneumothorax effusion (without tamponade) is not immediately life threaten-
D. Femoral artery injury ing, nor is a pneumothorax or a peripheral arterial injury. (See
Schwartz 9*‘ ed., p 140.)

l.
. Which of the following is defined as a massive hemotho-
rax?
Answer: A
A massive hemothorax is defined as 2>I50[l mL of blood or, in
-l A. 1600 ml of intrathoracic blood in a IOU-kg woman the pediatric population, one third ofthe patienfs blood volume
l - B. 900 m of intrathoracic blood in a F0-kg man in the pleural space. Blood volume can be quicldy estimated by
ii C. 800 ml of intrathoracic blood in a 50-kg woman multiplying body weight (in kg) it 7'0. So, the 20-kg child would
ll D. 200 ml ofintrathoracic blood in a 20-kg boy have a total blood volume of 1400 ml. Cine third of his blood
volume (the amount necessary to be classified as a massive he-
mothorax) would be 466 ml. (See Schwartz 9"‘ ed., p 140.)
l
"- 9. Which of the following is the best initial treatment for Answer: D
5 acute traumatic pericardial tamponade in a patient with a Early in the course of tamponade, blood pressure and cardiac
I: systolic blood pressure of 90 mmHg? output will transiently improve with fluid administration.
|' A. Immediate ER thoracotomy with pericardiotomy and In patients with any hemodynamic disturbance, a pericar-
i repair of the injury dial drain is placed using ultrasound guidance (Fig. 7-4].
j B. ER thoracoscopy for pericardial drainage Removing as little as 15 to 20 mL of blood will often tempo-
|| C. Fluid resuscitation to stabilize blood pressure during rarily stabilize the patienfs hemodynamic status, prevent sub-
i transfer to the operating room for definitive repair endocardial ischemia and associated lethal arrhythmias, and
_j D. Ultrasound guided placement of a pericardial catheter allow transport to the OR for sternotomy. Pericardiocentesis
is successful in decompressing tamponade in approximately
80% of cases; the majority of failures are due to the presence
.__:_-
of clotted blood within the pericardium. Patients with a SBP
-:.:?[l rnml-lg warrant emergency department thoracotomy
(EDT) with opening of the pericardium to address the injury.
ij Thoracoscopy is not considered a reasonable treatment for
traumatic chest wounds with hypotension. This patient does
not warrant an ER thoracotomy because the systolic B-P is
.2-J0 mml-lg. The best initial treatment is ultrasound guided
placement ofa pericardial catheter followed by transfer to the
operating room for definite treatment. (See Schwartz 9"“ ed.,
1
pp I40-141.]

i _ i . I
 53

eu.ine.ij

A
FIG. 7-4. Pericardiocentesis is indicated for patients with evidence of pericardial tamponade. A. Access to the pericardium is obtained through
a subxiphoid approach, with the needle angled 45 degrees up from the chest wall and toward the left shoulder. B. Seldinger technique is used to
place a pigtail catheter. Blood can be repeatedly aspirated with a syringe or the tuning may be attached to a gravity drain. Evacuation of unclotted
pericardial blood prevents suhendocardial ischemia and stabilizes the patient fortransport to the operating room for sternotomy.

10. Which of the following is an indication for emergency Answer: C

department thoracotomy (EDT)? The utility of EDT has been debated for many years. Current
A. Witnessed cardiac arrest after a stab wound to the indications are based on 30 years of prospective data
chest with 25 min of CPR (Table 7-2). EDT is associated with the highest survival rate
B. Witriessed cardiac arrest after blunt trauma to the after isolated cardiac injury; 35% of patients presenting in
chest with 10 min of CPR shock and 20% without vital signs (i.e., pulse or obtainable
C. Profound hypotension (systolic BP <70) following a blood pressure) are resuscitated after isolated penetrating in-
stab wound to the chest jury to the heart. For all penetrating wounds, survival rate is
D. Cardiac arrest in the ED following closed head injury 15%. Conversely, patient outcome is poor when EDT is done
for blunt trauma, with 2% survival among patients in shock
and <1 1% survival among those with no vital signs. A is incor-
rect because there was more than 15 min of CPR following
a penetrating injury. B is incorrect because there was more
than 5 min of CPR following a blunt injury. D is incorrect;
there is no indication for EDT after isolated head injury. (See
Schwartz 9*“ ed., pp 140- 142, and Pig. 3-"'-5.)

,1Ci;ir_rent_i_ndi'catiohs land icoh-tra"indicati'ons HI

ifinemergency department thoracotomy
lndi'cetrons
Salvagea ble postinjury cardiac arrest:
Patients sustaining witnessed penetrating trauma with <15 min of
prehospital CPR
Patients sustaining witnessed blunt trauma with -c5 min of
prehospital CPR
Persistent severe postinjury hypotension (SBP 560 mmHg] due to:
Cardiac tamponade
Hemorrhage—-intrathoracic, intra-abdominal, extremity, cervical
Air embolism
Controindi'cetions
Penetrating trauma: CPR >15 min and no signs of life {pupillary
response, respiratory effort, motor activity)
Blunt trauma: CPR >5 min and no signs of life or asystole
""' T" 1" '. it .. I . - -_ '
CPR = ca.'c'io_oulmo'iarj,-' res.is-citation; SE-P = systoi:c blood pressure.
 54
w N
Blunt ECG':_a_r}y---; "r O " 1'" Dead
Patient trauma _ C-PH --:5 min NU I
in extremis Yes j
No i
Undergoing
CPR
21min 1-; it-
. trauma .’GPH'1'45"min N0 "" "
Yes 1
Tl-.
cu
:
3
l EDT
'l
EU
NO

Yes j ‘real
5 ' Tamponade "Repair heart i FIG. Ir‘-5. Algorithm directing
Thoracic .. . .. .. the useo emergency
‘ 'hem0"h.aQg_' '—i- _ Control _ + SBP >7-U N0 departmentthoracotomy(EDT)
_ _ _ . —* mmHg? """"—""* in the injured patient undergoing
A" Embull '-"'l" Hllar x"¢l3mP i cardiopulmonary resuscitation
. . . _ _ _ | lCPl¥iIi.EC-1.3 = electrocardiogram;
E Kl th . ‘res UH _ _
hessfirgqfzsg '—i"- Afittlfl X'¢ifll'l'iP- _ —'"'"* - OR = operating room; SBP = systolic
blood pressure.

ll. Management of suspected blunt cardiac injury includes Answer: C

which of the following? Although as many as one third of patients sustaining sig-
A. Mandatory admission to an intensive care unit nificant blunt chest trauma experience blunt cardiac injury,
B. Cardiac catheterization few such injuries result in hemodynamic embarrassment.
C. Continuous monitoring if EKG abnormalities are Patients with electrocardiographic (ECG) abnormalities or
noted dysrhythmias require continuous ECG monitoring and anti-
D. Cardiac enzymes dysrhythmic treatment as needed. Unless myocardial infarc-
tion is suspected, there is no role for measurement of cardiac
enzyme levels—they lack specificity and do not predict sig-
nificant dysrhythmias. The patient with hemodynamic insta-
bility requires aggressive resuscitation and may benefit from
the placement of a pulmonary artery catheter to optimize
preload and guide inotropic support. Echocardiography may
be indicated to exclude pericardial t.amponade or valvular or
septal injuries. It typically demonstrates right ventricular dys-
kinesia but is less helpful in titrating treatment and monitor-
ing the response to therapy unless done repeatedly. Patients
with refractory cardiogenic shock may require placement of
an intra-aortic balloon pump to decrease myocardial work
and enhance coronary perfusion. Admission to an intensive
care unit is determined by whether or not there is need for
continuous monitoring andlor any hemodynamic instability.
It is not mandatory for all patients with blunt cardiac injury.
Cardiac catheterization is not used in the diagnosis or treat-
ment of bl.unt cardiac injury. Cardiac enzymes are not specif-
ic for blunt cardiac injury and do not help in the management
ofthese patients. (See Schwartz 9"‘ ed., p 143.)

12. A patient presents with stable vital signs and respiratory
distress after a stab wound to the chest. Chest tubes are
placed and an air leak is noted. The patient is electively
intubated. '1he patient arrests after positive pressure ven-
tilation is started. What is the most likely diagnosis?
A. Unrecognized hemorrhage in the abdomen
B. Tension pneumothorax
i C . Pericardial tamponade
D. Air embolism
Answer: C
Air embolism is a frequently overlooked or undiagnosed lethal
complication of pulmonary injury. Air emboli can occur after
blunt or penetrating trauma, when air from an injured bronchus
enters an adjacent injured pulmonary vein (bronchovenous fis-
tula) and returns air to the left heart. Air accumulation in the
left ventricle impedes diastolic filling, and during systole air is
pumped into the coronary arteries, disrupting coronary perfu-
sion. The typical case is a patient with a penetrating thoracic

l—-
 55
injury who is hemodynamically stable but experiences arrest af-
ter being intubated and placed on positive pressure ventilation.
The patient should immediately be placed in Trendelenburgs
position to trap the air in the apex ofthe left ventricle. Emergency
thoracotomy is followed by cross-clamping ofthe pulmonary hi-
lum on the side of the injury to prevent further introduction of
air (Fig. F’-6). Air is aspirated from the apex of the left ventricle
and the aortic root with an IS-gauge needle and 50-mL syringe.
Vigorous massage is used to force the air bubbles through the
coronary arteries; if this is unsuccessful, a tuberculin syringe
may be used to aspirate air bubbles from the right coronary ar- eu.ine.ij
tery. Once circulation is restored, the patient should be kept in
Trendelenburg’s position with the pulmonary hilum clamped
until the pulmonary venous injury is controlled operatiyely. (See
Schwartz 9*“ ed., p 14-4.)

FIG. 7-6. A. A Satinslty clamp is used t-o clamp the pulnionary hilum to prevent further hroncl". ove nous air embolism. B. Sequential sites of
aspiration include the left ventricle, the aortic root. and the right coronary artery.

13». Which ofthe following is the expected blood loss in a pa- Answer: C
tient with 6 rib fractures? For each rib fracture there is approximately 100 to 200 iiiL of
A. 240 ml blood loss; for tibial fractures, 300 to 500 inL; for femur frac-
B. 430 ml tures, 800 to i000 mL; and for pelvic fractures, :=-1l]l)0 inL.
C. T50 ml Although no single injury may appear to cause a patient’s he-
D. 15001111 modynamic. instability, the sum of the injuries may result in
life-threatening blood loss. (See Schwartz 9"‘ ed., p 145.)

14. A 25-year-old man presents following blunt trauma to Answer: B

the abdomen. FAST exam shows injury to the spleen. I—Iis i-le has class ll hemorrhagic shock (based on his vital signs)
HR is 110, RR is 25 and he is mildly anxious. ‘What per- with a loss of between 15% and 30% ofhis blood volume. (See
centage of his blood volume do you estimate he has lost? Schwartz 9"" ed., p 145, and Table F-3.)
A. :(l5%-
B. 15—3ll%
C. 30-40%
D. .1-40%

ICXR finding in a nthrax is
til fluffy infiltrates
liho
‘I33 lesions, rimarily in the upper lobes
Ill mediastinum and pleural effusions
47
Answer: D
lnhalational anthrax develops after a 1- to 6-day incubation
period, with nonspecific symptoms including malaise, myal-
gia, and fever. Dyer a short period of time, these symptoms
worsen, with development of respiratory distress, chest pain,
and diaphoresis. Characteristic chest roentgenographic find-
ings include a widened mediastinum and pleural effusions. A
key aspect in establishing the diagnosis is eliciting an expo-
sure history. Rapid antigen tests are currently under develop-
ment for identification of this gram-positive rod. Drugs such
as cephalosporins and trimethoprimsulfamethoxazole are not
active against this agent. Postexposure prophylaxis consists
of administration of either ciprofloxacin or doxycycline. (See
Schwartz 9"“ ed., p. 130.)
L-"Hi
C
"'1
l-.Cl
ED
i.-—i-aju
C3
:3
in
F56
| fTABLE It-3 Signs and symptoms of advancing stages of hemorrhagic shock
:4.-’-l .'.-';,.\~a.$ "
‘__a--. -|._|_ _ ‘ -

Class l Class ll Class lll Class IV

,1 ...
Blood loss {rnLj Up to rso rsti-istiti l 500-E000 :=-2000
Blood loss issavi Up to 15% is-sass 30-40% :>-40%
-- -
.
;-|.-
:-
.-i
Pulse rate <: l 00 ;-l 00 :-» l 20 I:-l -40
¢._
-__ ,. ..' .- .g_'i-,.-:
Blood pressure Normal Normal Decreased Decreased
. _ g . __.

Pulse pressure lm ml-lg) Normal or increased Decreased Decreased Decreased

Respiratory rate 14-20 20-30 30--40 ;-35
Urine output {mLr'hIi >30 20-30 5-l 5 Negligible
CNSfmental status Slightly anxious lvlildly anxious Anxious and confused Confused and letliarciic
_.-

ecuneij = l:-food volume; C..‘\l5 = -central nervous systerii.

I5. A 40-year-old man is struck in the head. A (,.'1 scan is ob Answer: C

'1 ‘I

tained, which is shown below. ‘What is the diagnosis? This is an epidural hematoma. Epidural heinatomas have a
A Subdural hematoma distinctive convex shape on computed tomographic scan,
B. Subarachnoid hemorrhage whe.reas subdiiral lieinatoiiias are concave along the surface of
lntraparenchyinal hemorrhage
-I the brain. (See Schwartz 9"‘ ed., p 148, and Fig. F-T.)
fjfi Epidural hematoma

FIG. T-"-7. f;CllCllllB| hemat-onia. A dist’r‘icl.ive -convex shape on

computed toniographic scar.

16. A 2?’-year-old man presents to the ED after receiving Answer:B

blows to the head. He opens his eyes with painful stimuli, His score is 2 (eye) + 4 (verbal) + 5 (motor): I1. (See Schwartz 9"‘
is co.nfused, and localizes to pain. ‘What is his Glasgow ed., p 145, and Table F-4.)
Coma Score?
A l3 TA Glasgow Coma Scales
B. ll Adults lnfa rits.-’Chili:lren
9 -
,__ eye Spontaneous Spontaneous
i?-‘C-‘i 1" .
opening U-E To voice To voice
To pain To pain
None None
verbal Oriented Alert. normal vocalization
Confused Cries but consolable
lJ~ -l1‘=-<.,-"1— 'l‘-_ inappropriate words Persistently irritable
E incomprehensible Restless, agitated,
words moaning
l None None
(ciiritfni.iet;l)
 '

TABLE z-4 i='lriti"i:i 'i li*§ii_i,é",ii _j-. _ -_ _

—q——_-rr—

Adults lnfantsffihildren
Motor Oi Clbeys commands Spontaneous, purposeful -
rggpgn 55 Localizes pain Localizes pain
Withdraws Withdraws
Abnormal llexion Abnormal tlexion
Abnormal extension Abnormal extension
—'-I‘ J‘-.I-J |'>-'l .-"I None None
“Score is calculated byaclding the scores of the best motor response. best verbal
response, and eye opening. S-cores range from 3 (the lowestl to l5 [normal].

euineij
A ‘F5-year-old woman presents to the ED following an Answer: C
MVA She has decreased strength and sensation in her There are several partial or incomplete spinal cord injury syn-
arms She has normal strength and sensation in her legs dromes. Central cord syndrome usually occurs in older per-
The most likely diagnosis is sons who experience hyperextension injuries. Motor function
Brown Sequard syndrome and pain and temperature sensation are preserved in the lower
Anterior cord syndrome extremities but diminished in the upper extremities. Some
Central cord syndrome functional recovery usually occurs but is often not a return to
UP) Posterior cord syndrome normal. Anterior cord syndrome is characterized by dimin-
ished motor function and pain and temperature sensation
below the level of the injury, but position sensing, vibratory
sensation, and crude touch are maintained. Prognosis for re-
covery is poor. Brown-Sequard syndrome is usually the result
of a penetrating injury in which the right or left half of the spi-
nal cord is transected. This rare lesion is characterized by the
ipsilateral loss of motor function, proprioception, and vibra-
tory sensation, whereas pain and temperature sensation are
lost on the contralateral side. Posterior cord syndrome does
not exist. (See Schwartz 9"‘ ed., p 150.) -

The appropriate treatment of an asymptomatic patient Answer: A

with a stab wound to Zone III of the neck is Zone III is the superior portion of the neck, above the angle of
Observation the mandible. Asymptomatic patients can be observed. Zone III
CT of the neck injuries that are symptomatic should be evaluated with angiog-
Angiography raphy and, if necessary, embolization of bleeding vessels. (See
Operative exploration Schwartz sit ed., pp 150-151, and Figs. z-s and z-9.)

FIG. Ti’-8. For the purpose of evaluating penetrating injuries, the

neck is divided into three zones. Zone I is up to the level of the
cricoid and is also known as the thoroci'coutlet. Zone ll is located
between the cricoid cartilage and the angle ofthe mandible.
Zone lll is above the angle of the mandible.
I 58
‘,2-
_\____._ ._ ._, .,..____.._..____.,_._ :___..._. __. .-_...----.-—---u—-------

iii" “iiiiyiissisiria I
__ _. . _:._ ._.,____._. _ _ .
-n | 2-
-u
, -_;-_ .-. -I. 1. _ -.--" ;---- 5 ._ - '-- . - - .' . . -

-- L -:.,_I J ,1! j_,_{,_\.‘I- I a;._-.;':i','.,.- ,:_-_- -.H_.' ; ' _;" -' _- '

PT ' ctr. _,
zDl"lEl 1}" eggphagram """I""

Gl'ie5t' . bronchoscopy l
Penetrating —---—-—i-—-—--tI-
fl,
DJ
. =- .-is
:-.*-" i-- -- .- "
1 -"'-4,.-. |_,_-1'--"12:-;I'?iI$l\f-flail =.--.i_,- i
--
zone H , Operative
C - - "" - - I E I t‘
Zonelll-——1> "-Anglo xporamn
3
DJ
l: j j
"IR-Ernbo .

QT -. iota +
Z009 l—l’ esophagram —3""
bronchoscopy

Zone H < Transeervical GSW

-- A ll Others —-—-in Obsewe

Zone Ill
“T symptoms = expanding hematoma
airway compromise
dysphagia
subcutaneous emphysema
hoarseness

FIG. 3*‘-9. Algorithm for the selective management of penetrating neck injuries. Cl : computed tomography:CTA : computed tomographic
angiography; GSW = gunshot wound; Ill limb-o = interveritlonal radiology enibolization.

19. Which of the following is an indication for CT of the chest Answer: C

to rule out a thoracic aortic injury? At least T% of patients with a descending torn aorta have a nor-
A. Left hemopneumothorax mal chest radiograph. Therefore, screening spiral CT scanning
B. Respiratory distress with multiple rib fractures is performed based on the mechanism of injury: high-energy
C. High speed head-on lvI‘v’C with normal chest radio- deceleration motor vehicle collision with frontal or lateral im-
graph pact, motor veliicle collision with ejection, falls of >25 ft, or
D. Left scapular pain direct impact (horse kick to chest, snowmobile or ski collision
with tree). The CXR finding of a @ apical cap is suggestive
of a thoracic aortic injury. Multiple rib fractures or scapular
pain alone are not suggestive of a thoracic aortic injury. (See
Schwartz 9*“ ed., p 151, arid Table F’-5.)

s_ on chest _radtograp"h..'sug_gesti.ve .
_ __ ending thoracic aortictear .
l.Widened mediastinum
2. Abnormal aortic contour
3..Tr-acheal shift
4. Nasogastric tube shift
_eft apical cap
_eft or right paraspinal stripe thickening
Depression of the left main bronchus
C‘-ibliteration of the aorticopulmonary window
'.~'9F‘P?‘~'F3"l-f Left pulmonary hilar hematoma
A 20-year-old young man presents with an left anterior
8"‘ intercostal space stab wound. I-Ie is in no distress and a
chest x-ray is normal. A diagnostic peritoneal lavage is
perfomed and has a RBC count of 8,000!p.l and a WBC
count of 300i'|.ll. Which of the following is the best treat-
ment for this patient?
A. Observation only
B. CT scan
Laparoscopy
l3i"i Exploratory Laparotomy
Answer: C
Clccult injury to the diaphragm must be ruled out in patients
with stab wounds to the lower chest. For patients undergo-
ing DPI. evaluation, laboratory value cutoffs are different for
those with thoracoabdominal stab wounds and for those with
standard anterior abdominal stab wounds (see Table 7-6). An
RBC count of :> I0,000l|.iL is considered a positive finding and
an indication for laparotomy; patients with a DPL RBC count
between 1000lpL and 10,000l|.iL should undergo laparoscopy
or thoracoscopy. (See Schwartz 9"‘ ed., pp 153-155.)
ei. uneij_

Anterior Abdomi- Thoracoabrlominal

nal Stab Wounds Stab Wounds
Red blood cell :-l00,000r'mL 2- I 0,000,?ml.
count
White blood cell :=~500rmL >50-Dfmt
count
Amylase level > I 9 lUr’I_ >1 9 IUIL
Alkaline phos- >2 IUXL >2 IU/L
phatase level
Bilirubin level :>0.0l mgfdt :>0.0l mgfdL

A 45-year-old, otherwise healthy woman presents after a Answer: B

moving vehicle accident. She is hemodynamically stable
and with only minimal tenderness in her right upper
quadrant. A FAST exam (focused abdominal sonograph-
ic test) is positive with fluid seen in the hepatorenal fossa
and the pelvis. Which of the following is the next best step
in her management?
A. Observation only
B. CT scan
C. Laparoscopy
D. Exploratory laparotomy
Patients with fluid on FAST examination, considered a
‘positive FAST,’ who do not have immediate indications for
laparotomy and are hemodynamically stable undergo CT
scanning to quantify their injuries. Injury grading using the
American Association for the Surgery ofTrauma grading scale
(Table T-2) is a key component of nonoperative management
of solid organ injuries. Because of the risk of a solid organ in-
jury, observation is not indication. If she has an isolated liver
or spleen injury, the correct treatment is most likely observa-
tion; therefore, both laparoscopy and laparotomy would not
be indicated. (See Schwartz 9"“ ed., pp 155- 157, and Fig. 7*‘-10.)

Suhcapsular Hernatoma Laceration

Liver Injury Grade
Grade I -cl 0% of su rface area -cl cm in depth
Grade ll I0-50% of surface area l-3 cm
Gradelll >50%ofsurl'aceareaor>l0cm >3 cm
in depth
Grade IV 25-25% of a hepatic lobe
Grade ‘I! >?5% of a hepatic lobe
Grade VI Hepatic avulsion
Spleniii: Injury Grade
Grade I -c I 0% of surface area cl cm in depth
Grade ll 10-50% of surface area I-3 cm
Grade Ill :>50%ofsurfaceareaor>i0cm >3 cm
in depth
Grade IV :>25% devascularization Hilum
Grades! Shattered spleen
Complete devascularization
60

__ _ Indications for GT:

Hemodvnamioallv ‘Yes _ __ No No -Altered mental status No Repeat FA5T
stable Pemfinma? I FAST "' I -Confounding injury in 30 minutes
" loGS -Gross hematuria
-Pelvic fracture
N0 Yes . f -Abdominal tenderness
candldate. Gr -Unexplained Hot ~:35"?t-.»
nonoperative
‘res N9 management
FAST+ -—i>~ Laparotomv 4-" or lYeS
Tl.
m patient with Y
t:
3 Equivocal + “i"h°S'5 ii Abdominal GT
or

DPA

FIG. 7-"ID. algorithm forthe initial evaluation ofa patientwith suspected blunt abdominal trauma. CT: computed tomographv:
DPA = diagnostic peritoneal aspiration; FAST = focused abdominal sonographv for trauma; l—lct = hematocrit.

22. After CT scan, she is shown to have a liver laceration as Answer, (3

5h"3'“’11 h‘31'3'“'+ The“? I5 3 4‘¢1T1 la-Ceralifin into the right Because she has alaceration >3 min depth, she has a Grade III
lobe with a ll)-cm subcapsular hematoma (see Fig. ’F- I I). 11%; inju1'}r_ (gee Schwartz grit Edd P 15',-r_)
What grade liver injury does she have?

FIG. F-‘I1.

Grade I
Grade II
Grade III
F3"?"1F'Il?" Grade I‘-I

23. A stable patient with a Grade Ill spienic laceration has the Answer: B
following laboratory results 2 hours after admission: Although current critical care guidelines indicate that I-‘RBC
I-Igfl-Ict 8.T"r‘29 Plt ?0,lfl00 INR 1.3. transfusion should occur once the patie-nt’s hemoglobin
A. No transfusions are indicated level is <1? gr’dL, in the acute phase of resuscitation the end-
B. Transfuse PRBCs only point is 10 gr'dL. Fresh-froaen plasma is transfused to keep
CI. Transfuse PRBCs and platelets the patients International Normalised Ratio (IN'R') less than
D. Transfuse PRBCs, platelets, and PFP 1.5 and partial thromboplastin time (PTT) -=1:-=15 seconds.
Primary hemostasis relies on platelet adherence and ag-
gregation to injured endothelium, and a platelet count of
5U,(lUUr'|.tL is considered adequate if platelet function is nor-
mal. With massive transfusion, however, platelet dvsfunction
is common, and therefore a target of l(ll1l,0El[lfuL is advocat-
ed. If fibrinogen levels drop below 100 mg/dL, cryoprecipi-
tate should be administered. This patient, who is in the acute
phase of resuscitation, should receive PRBCs because the Hg
is less than I0. Because platelets are I-'='5U,UUU and INR is <1.5,
transfusions of platelets andfor FFP are not indicated. (See
Schwartz 9“ ed., p I58.)

24. Which of the following is an indication for operative inter-
vention in a patient with an isolated duodenal hematoma?
A. Hematoma >3 cm in diameter
B. Total or near total occlusion of the duodenum by the
hematoma
C. Failure to resolve Ii) days after admission
D. Contained retroperitoneal leak
15. Which ofthe following is an indication for a lower leg fas-
ciotomy?
A. >35-mml-Ig difference in diastolic pressure and the
compartment pressure
B. >35-mmHg difference in mean arterial pressure and
the compartment pressure
C. 3-»25mmHg difference in systolic pressure and the
compartment pressure
D. r:-25-mmHg compartment pressure, regardless of
blood pressure
61
Answer: D
The majority ofduodenal hematomas are managed nonop-
eratively with nasogastric suction and parenteral nutrition.
Patients with suspected associated perforation, suggested
by clinical deterioration or imaging with retroperitoneal
free air or contrast extravasation, should undergo opera-
tive exploration. A marked drop in nasogastric tube out-
put heralds resolution of the hematoma, which typically
occurs within 2 weeks; repeat imaging to confirm these
clinical findings is optional. If the patient shows no clini-
cal or radiographic improvement within 3 weeks, operative E?UJFlE’J_|
evaluation is warranted. The size of the hematoma is not
a criterion for operative intervention, nor is the degree of
initial occlusion by the hematoma. Patients with persistent
duodenal occlusion after 3 weeks should undergo operative
exploration. any sign ofperforation is an indication for ex-
ploration. (See Schwartz 9*“ ed., p 179.]
Answer: A
In conscious patients with compartment syndrome, pain is
the prominent symptom, and active or passive motion of
muscles in the involved compartment increases the pain. i
I
Paresthesias may also be described. In the lower extrem-
ity, numbness between the first and second toes is the hall-
mark of early compartment syndrome in the exquisitely
sensitive anterior compartment and its enveloped deep
peroneal nerve. Progression to paralysis can occur, and loss
of pulses is a late sign. In comatose or obtunded patients,
the diagnosis is more difficult to secure. In patients with
a compatible history and a tense extremity, compartment
pressures should be measured with a handheld Stryker de-
vice. Fasciotomy is indicated in patients with a gradient of
-<35 mml-lg (gradient = diastolic pressure — compartment
pressure), ischemic periods of >6 hours, or combined ar-
terial and venous injuries. In the absence of clinical signs
such as pain and paresthesias, compartment pressures are
used to determine the need for fasciotomy. The difference
between the diastolic blood pressure and the compartment
pressure is measured. Patients with a gradient >35 mmHg
should undergo a fasciotomy. (See Schwartz 9*“ ed., p 185, and
Fig. r-12.)
62
Anterior
compartment
l.ater_al
incision Deep peroneal ne rv e Anterior tibial arteryfvein
, Compartment
Deep - - nerve
Tibial
Lateral _MEjd_l3|
partment |r|C|5|U|'|
Superficial
Greater peroneal
saphenous nerve
veininerve
I-';‘Ll. "il‘-.i'l_| F_-‘o_sterior Lateral sural
Superficial "ital K . ' cutaneous
compartment after? ‘*'e"" nerve
Peroneal _
artery and veins
--rm--_

Tlbialis posterior
Tibialis
anterior

Extensor
Soleus digitorum
longus

fg _

:-.,. _|I' _'

B
FIG. 7-12. A. The anterior and lateral compartments are approached from a lateral incision, with identification of the iascial raphe between
the two compartments. Care must be taken to avoid the superficial peroneal nerve running along the raphe. B. To decompress the deep tlexor
compartment, which contains the tibial nerve and two ofthe three arteries to the foot, the soleus muscle must be detached from the tibia.
iii

Answer: D
Which of the following bladder pressures is an absolute
Generally, no specific bladder pressure prompts therapeu-
indication for a decompressive laparotomy
>5 mmHg tic intervention, except when the pressure is >35 mmHg.
>15 mmHg Rather, emergent decompression is carried out when
">25 mmHg intra-abdominal hypertension reaches a level at which end-
>35 mmHg organ dysfunction occurs. Mortality is directly affected by
decompression, with 60% mortality in patients undergo-
ing presumptive decompression, ?'0% mortality in patients Ii‘
with a delay in decompression, and nearly uniform mor- CU
C
tality in those not undergoing decompression. Abdominal 3
‘DJ
hypertension is classified by grade, with Grade I (mild)
being >10 ntml-lg (1213 cm H10). Grade I‘v' hypertension
or 1:-35 mmHg (1248 cm H26] is an absolute indication
for decompressive laparotorny. (See Schwartz 9"‘ ed., p 188,
Table ‘F-8 and Fig. F- I3.)

TABLE T-B iabdominal compartment

.sr.rislrvme.sra.cii.na .$t‘5.1I_e."1 . .- .
Bladder Pressure

Grade mmHg cm H20

l IO-l 5 ‘I3-2G
ll I 6-25 2 l -35
ill Eb-35 36-—-ii?
IV ti-35 :=-48

l increased abdominal pressure Il-— — — — ‘L

I ICP
___-_ ____l
camprassian of |-qdrieys 1. Venous, _retu_ni T intrathoracic pressure

I Flenal blood flow l CC) Hypoxemia

l UOP ‘i ZED“ T Airway pressures
T S H l Compliance
V T PA pressures
I GVP readings

Extremity Splarichnic
ischemia ischemia

FIG 7-13 Abdominal compartment syndrome is defined by the end organ seouelae of intra-abdominal hypertension. CO = cardiac output;
CVP = central venous pressure, I CF‘ _— in tr ac ranial p ressure PA : pulmonary artery; sv : stroke volume; 5‘v'R = systemic vascular resistance;
UOP = urine output VEDV = ventricular end diastolic volume
64
Which of the following is a normal physiologic change Answer: A
during pregnancy? Pregnancy results in physiologic changes that may impact
A Relative anemia postinjury evaluation (Table 7-9). Heart rate increases by 10
Decrease in circulating blood volume to 15 beats per minute during the first trimester and remains
Respiratory acidosis elevated until delivery. Blood pressure diminishes during
ii‘) Bradycardia
I3
Pi‘ the first two trimesters due to a decrease in systemic vascu-
lar resistance and rises again slightly during the third trimes-
ter (mean values: first = 105i'o0, second = 102i’55, third =
Tit 108/6?). Intravascular volume is increased by up to 8 L, which
ELI
r: results in a relative anemia but also a relative hypervolemia.
3
or Consequently, a pregnant woman may lose 35% of her blood
volume before exhibiting signs of shock. Pregnant patients
have an increase in tidal volume and minute ventilation but a
decreased functional residual capacity; this results in a dimin-
ished PCO2 reading and respiratory alkalosis. Also, pregnant
patients may desaturate more rapidly, particularly in the su-
pine position and during intubation. Supplemental oxygen is
always warranted in the trauma patient but is particularly crit-
ical in the injured pregnant patient, because the oxygen dis-
sociation curve is shifted to the left for the fetus compared to
the mother (i.e., small changes in maternal oxygenation result
in larger changes for the fetus because the fetus is operating in
the steep portions of the dissociation curve).
As noted earlier there is a relative anemia during pregnancy,
but a hemoglobin level of --:11 g/dL is considered abnormal.
Additional hematologic changes include a moderate leukocyte-
sis (up to 20,000 mmi) and a relative hypercoagulable state due
to increased levels of factors VII, VIII, IX, X, and XII and de-
creased fibrinolytic activity. (See Schwartz 9"‘ ed., pp 190- I 9 I .11

-
Physiologic e-ffér.t_s of pregnancy '
Cardiovascular
increase in heart rate by I0-15 bpm
Decreased systemic vascular resistance resulting in:
la) increased intravascular volume
lb) Decreased blood pressure during the first two trimesters
Pulmonary
Elevated diaphragm
Increased tidal volume
Increased minute ventilation
Decreased functional residual capacity
Herrictopoieric
Relative anemia
Leul-iocytosis
l-lypercoagulability
Ia) increased levels of factors vii, vlll, Di, it, i-tll
Ib) Decreased fibrinolytic activity
Other
Decreased competency of lower esophageal sphincter
Increased enzyme levels on liver function tests
lm paired gallbladder contractions
Decreased plasma albumin level
Decreased blood urea nitrogen and creatinine levels
H Ii’drone P hrosis and h Fdroureter

L . i . _ . . i i -_ _ -I-1
 ‘LY;

THC-
..-
.\
irffis-3.-i" 9- -L.-=riI,¢l
— III
i-“J

Abdominal Wall, Omentum,

Mesentery, and Retroperitoneum

SCIENCE QUESTIONS

The inguinal ligament is the inferior-most part of which Answer:C

The irigiririol ligament is the inferior-most edge of the exter-
abdominal wall muscle?
nal oblique aponeurosis. reflected posteriorly in the area be-
A. Transversalis
tween the anterior superior iliac spine and pubic tubercle. [See
B. Internal oblique
Schwartz 9”‘ ed., p 126?.)
C. External oblique
D. Rectus abdominis
Answer: D
which nerve root(s) supplies innervations to the skin of
Innervation of the anterior abdominal wall is segmentally related
the umbilicus?
to specific spinal levels. The motor nerves to the rectus muscles,
A. C3, 4, and 5
the internal oblique muscles, and the transversus abdominis
B. Tl ‘
muscles run from the anterior rami of spinal nerves at the_T6 to
C. T4 and 5
T12 levels. The overlying skin is innervated by afferent branches
D. Tia of the Ta to L1 nerve roots, with the nerve roots ofT10 subserv-
ing sensation of the skin around the umbilicus. (See Schwartz 9"‘
ed., p 1269, and Fig. as-1.)

———T1
-cs

FIG. 35-1. IDerrna'.oma'= sensory innervation of the abdominal

wall. iFleprod-._ice-:;l with permission frorn Moore KL. Dailey AF [eds]:
Ci'.inr'colr'y -:.’l1n'ented.-Anotomyf. 4" eo. Phi.'.adelohia: l_ipoincott Williams 8:
Wilkiris, 1999. p i-BS.'1I
7
 -

374
CLINICAL QUESTIONS

Answer: E
1. Which ofthe following (see Fig. 35-2) is a Rocky-Davis
The incision labeled E is the Rocky-Davis niuscle-splitting
incision?
incision, most commonly used for open appendectomies. If
“___ exposure is not adequate, a Weir extension (dotted line) can
be performed. (See Schwartz 9*“ ed., p 12'.-AD.)

‘9l3Cl*r’
.-.—

-.
l 1
FIG. 35-2.
--q

2. The best treatment for the condition shown in Fig. 35-3 is Answer: D
A. Primary open repair This is the typical, epigastrie bulge of diastasis recti, which
B. Open repair using mesh in the vast majority of patients needs no treatment. Rectus
Q Laparoscopic repair using mesh ‘ abdominis diastasis for diastasis recti) is a clinically evident
e/yi
tSLUO
1?l.6u_u_iSEIil/\f'L,l)1L D. Observation separation of the rectus abdominis muscle pillars. This re-
sults in a characteristic bulging of the abdominal wall in the
rho
-\-

epigastrium that is sometimes mistaken for a ventral hernia

despite the fact that the midline aponeurosis is intact and no
hernia defect is present. Diastasis may be congenital, as a re-
sult of a more lateral insertion of the rectus muscles to the
ribs and costochondral junctions, but is more typically an ac-
A
quired condition, occurring with advancing age, in obesity,
or after pregnancy. In the postpartum setting, rectus diasta-
sis tends to occur in women who are of advanced maternal
age, who have a multiple or twin pregnancy, or who deliver
itaundoiauoiagpue
a high-birth-weight infant. Diastasis is usually easily identi-
fied on physical examination. Computed tomographic (CT)
scanning provides an accurate means of measuring the dis-
tance between the rectus pillars and can differentiate rectus
diastasis from a true ventral hernia ifclarification is required.
Surgical correction of rectus diastasis by plication of the
FlG. 35-3.
broad midline aponeurosis has been described for cosmetic
indications and for alleviation of impaired abdominal wall
muscular function. However, these approaches introduce the
risk of an actual ventral hernia and are of questionable value
in addressing pathology. {See Schwartz 9"‘ ed., p IET1.)
 37!
3. A 48-year-old patient presents with sudden onset of bilat- Answer: D
eral lower abdominal pain after spasmodic coughing. On This patient has a typical history for rectus hematoma and
examination, there is an 8-cm, tender mass in the mid lower a positive Fothergilfs sign fa palpable abdominal mass that
abdomen that remains unchanged with contraction of the remains unchanged with contraction ofthe rectus muscles).
rectus muscles. Which of the following is the most likely di- Although rectus sheath hematomas are usually unilateral,
agnosis? if the hematoma is below the arcuate line, it may cross the
A. Ruptured aortic aneurysm midline. CT or MRI can be used to confirm the diagnosis.
B. Ctbturator hernia A spigelian hernia is herniation through the lateral rec-
Spigelian hernia tus sheath, on the semilunar line. The oburator foramen
Fil "? Rectus sheath hematoma is in the posterior pelvis, and obturator hernias usually
nu-
present with bowel obstruction or medial thigh pain due I

to compression of the obturator nerve. A ruptured aortic

aneurysm would usually present with back pain and a less
prominent abdominal mass. (See Schwartz 9*“ ed., p l2?2.)

4. The indications for surgery in a patient with a rectus sheath Answer: B

hematoma include The primary indications for operating on a patient with a rec-
A. Persistent pain alter 24 hours tus sheath hematoma are hemodynamic instability and an ex-
13. Expanding hematoma after embolization panding hematonia despite embolization. (See Schwartz 9"‘ ed.,
Need for transfusion p IZTE, and Fig. 35-4.) ELIl
'33?‘ Need for ongoing anticoagulation
EAA
i

'1-I.

Suspected rectus
sheath hematoma

_1

Abdominal CT scan |__

A 21*.-iv-2: In } -_-_;_.:_‘-1l_i'
.l~_ . -
j_

._ -_ __ i.._ ~ -f_-
'
d I-I _
I
_
I 1Ig'- -
-“sill: .1 Z; I -
_-i -.

ui/e
A
niauaiuasin
-

35-4. r'vlana-'. ement alciorithrn -~.. '-=7%'--'-_‘=--§;- -

:-. - ., _'.
I
-.j=-*._ .-.r'-
-'
_.~r'__+'-:.
"-1 '
..;.--
'
-1 if-—1
-5'; -.-- : - _c- ‘ll’
- . . -. 4 it
1.!‘ I __ ‘_ J - _.' : . It-' I1
s sheath hesriat-on"ia_ l"v".ost . -s-., "TH , I _. - -, 1 . , .I_ . "' In. . '_ I I
__ 1,:--r
_._

'-Ill-li "r-""r"ll:l"l rj f lcdbb :_-‘ll Id

a rid are rr: no c_;ecl wit no .3-t

tion.The potential fora rare " HUM ,_,,m,,,,agu|,,]t;,;,,, Reverse antiocoagulation
hic bleeo'ir.ri event lT‘|._lSl be +f* 3"ll99El';1i-ili='lll9" ¢he¢|< (_‘;|3t'; volume resuscitation
Jj h|_:|1,|,-'~,|,r|_§1'
' V-r.E‘-|"_ E-§._p'.:]i,f;_=|i 53'-_,-'_5r_- UDSEWE ES DUlDEI.ll€l"l'l transtuse if r equired
'
CI
observe as inpatient
is reserved for those c.ircurn- -- --
in which clinical en.-"i:_ter'~.ce ct"
bleeding any otne-' ontunauo
ent option aster"-able.
complete blood count:
outed tomot_"._|ra,ohj_~_.-';
rating room.

of the following is the most important initial thera- Answer: C

for a patient with portal hypertension, ascites, and a Treatment and control of the ascites with diuretics, dietary
umbilical hernia? management, and paracentesis is the most appropriate initial
Primary repair with concurrent placement ofa perito- therapy. Patients with refractory ascites may be candidates
neal venous shunt for transjugular intrahepatic portocaval shunting or eventual
Emergency primary repair to avoid hernia rupture liver transplantation. Umbilical hernia repair should be de-
Medical therapy to control the ascites ferred until after the ascites is controlled. {See Schwartz 9"‘ ed.,
Transjugular intrahepatic portocaval shunt followed by p tars.)
iunbilical hernia repair
3 76
In a patient with a permanent ileostomy and 4-cm in- Answer:C
fraumbilical midline incisional hernia, which of the fol- Although mesh repair would not be contraindicated in this
lowing would be the most appropriate? patient, component separation has the advantage of no pros-
A. Open primary closure thetic material in a potentially contaminated wound.
13. Open mesh closure Primary repair. even of small hernias (defects -:3 cm), is as-
Component separation sociated with high reported hernia recurrence rates. In a ran-
F3?’-‘: Observation domized prospective study of open primary and open mesh
incisional hernia repairs in 200 patients, investigators from
the Netherlands found that after 3 years, recurrence rates were
43% and 24% for the two methods, respectively. Identified
risk factors for recurrence were primary suture repair, post-
operative wound iiifection, prostatism, and surgery for ab-
dominal aortic aneurysm. These investigators concluded that
mesh repair was superior to primary repair. In an effort to de-
crease the suture line tension associated with primary repair,
Ramirez first described the components separation technique.
11> Components separation entails the creation of large subcuta-
Cl“
c:-_ neous flaps lateral to the fascial defect followed by incision of
o
3_-.-
the external oblique muscles and, if necessary, incision of the
posterior rectus sheath bilaterally. These fascial releases allow
for primary apposition ofthe fascia under far less tension than
—

i
in simple primary repair. Components separation hernia re-
pair is associated with a high wound infection risk (20%) and
‘II

a recurrence rate of 18.2% at I year. Components separation is

most applicable for the repair ofincisional hernias when there
are converging needs to (a) avoid the use ofprosthetic materi-
-u. als, and (b) achieve a definitive repair. Most commonly this
occurs in the setting ofa contaminated or potentially contain-
H.

inated surgical field. (See Schwartz 9*“ ed., p 1223.)

A 22-year-old man presents with localized peritonitis of Answer: A

the right lateral abdomen. He is afebrile, is eating, and has In patients who are not toxic, supportive care will often result
a white blood cell count of 12,000. CT scan demonstrates in resolution of the symptoms. Antibiotics are not indicated
omental infarction. Which of the following is the most for this inflammatory condition. I.aparoscopy should be con-
appropriate treatment? sidered if the diagnosis is not sure, or for progressive or severe
A. A nonsteroidal anti-inflammatory agent and observation symptoms. Resection of the infracted omentum leads to rapid
euem
cpiuaen‘donag
_u.|-
i/ut aituagsayq I3. Broad spectrum antibiotics, morphine with explora- resolution of the symptoms. A total omentectomy is not indi-
tion if no improvement after 24 hours cated. (See Schwartz 9"‘ ed., p 1225.)
C. Laparoscopic exploration to confirm the diagnosis and
LUHBUO1 resect the infarcted omentum
D. Total omentectomy (open or laparoscopic)

A 55-year-old woman presents with a palpable abdominal Answer: D

mass and abdominal pain. CT scan and exploration show
scarring of the mesentery with shortening and retraction.
"Ihe base of the mesentery is fibrotic and thickened. Fol-
lowing biopsy confirmation of your clinical diagnosis,
which ofthe following is the best therapy for this patient?
A. Surgical debulking of the tumor
B. Chemotherapy
C. Chemotherapy and radiation therapy
D. Observation
This is the typical description of sclerosing mesenteritis. In
most cases of sclerosing mesenteritis the process appears to
be self-limited and may even demonstrate regression if fol-
lowed with interval imaging studies. Clinical symptoms are
very likely to improve without intervention, and therefore ag-
gressive surgical treatments are generally not indicated. (See
Schwartz 9"‘ ed., p I276.)
 377
15- Year-old S irl P resents with a mobile, S-cm mid ab Answer: A
rm mal mass that mos es freely from left to right but does Physical examination ofa patient with a mesenteric cyst may
it move '-iLl[JE't'1iI}l'l'y or inferiorly Which of the following reveal a mass lesion that is mobile only from the patienfs right
the most likely diagnosis? to left or left to right (Tillaux’s sign), in contrast to the find-
Omental cyst ings with omental cysts, which should be freely mobile in all
Mesenteric cvst directions. Although ovarian cysts are usually ballotable, they
Ovarian cv st are rarely mobile. Gastric duplications are virtually never pal-
Gastric duplication pable. (See Schwartz 9”‘ ed., p 1222.)

hi ch ofthefollovrin g dru g sis associated with retroperi- Answer: A

neal fibrosis? The strongest case for a causal relationship between medi-
Methysergide cation and retroperitoneal fibrosis is made for methyser-
Ctmeprazole gide, a semisynthetic ergot alkaloid used in the treatment
Prozac of migraine headaches. Ctther medications that have been
Dapsone linked to retroperitoneal fibrosis include beta blockers,
hydralazine, or-methyldopa, and entacapone, which in- DP
hibits catechol-U-methyltransferase and is used as an ad- cr
:1
junct with levodopa in the treatment ofParkinson’s disease. o
The retroperitoneal fibrosis regresses on discontinuation
3
3
of these medications. Omeprazole, Prozac, and Dapsone
have not been associated with retroperitoneal fibrosis. (See
Schwartz 9'“ ed., p 1280.)
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lhich of the following is the most appropriate treatment Answer:C

rretroperitoneal fibrosis Corticosteroids. with or without surgery, are the mainstay
Surgical debridement of potentially obstructing of medical therapy. Surgical treatment consists primarily of
fibrosis ureterolysis or ureteral stenting and is required in patients
Prevention of obstruction with anticoagulation (for who present with moderate or massive hydronephrosis.
IVC thrombosis) and ureteral stenting (for ureteral Laparoscopic ureterolysis has been shown to be as efficacious
obstruction) as open surgery in addressing this problem. Patients with il-
High dose corticosteroids iocaval thrombosis require anticoagulation, although the -1.

I. Observation required duration of this therapy is unclear. Prednisone is

initially administered at a relatively high dose (60 mg every
other day for 2 months) and then gradually tapered over the
next 2 months. Therapeutic efficacy is assessed on the basis of
patient symptoms and interval imaging studies. Cyclosporin,
tamoxifen, and azathioprine also have been used to treat pa-
tients who respond poorly to corticosteroids. (See Schwartz 9"‘
ed., p 1230.)
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