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

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

Question 1

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

Accepted Answer

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

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

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

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

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

Question 2

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

Accepted Answer

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

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

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

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

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

Question 3

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

Accepted Answer

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

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

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

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

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

Question 4

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

Accepted Answer

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

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

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

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

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

Question 5

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

Accepted Answer

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

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

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

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

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

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