A 45-year-old male was involved in a motor vehicle collision. He was a restrained passenger in a high speed, head-on collision with a death at the scene. He is brought to the ED unresponsive with a pulse of 140, a BP of 70/30, and a SpO2 of 80%. He has multiple facial lacerations, a dilated right pupil, a contusion on his chest, and a distended abdomen. The medic team has placed two large-bore IVs and given him 2 L of lactated Ringer's solution.The initial step in the care of this patient is:
Answer(s): C
The first step in any trauma assessment is the primary survey. This consists of:A--airway maintenanceB--breathing and ventilationC--circulationD--disability/neurologic statusE--exposure/environmentThe first priority in any trauma patient is to establish an airway. In an unconscious patient with decreased saturations, endotracheal intubation is indicated. While facial lacerations may indicate fractures, these patients can often be successfully orally intubated. This should be attempted first, but if this technique is unsuccessful, a cricothyroidotomy should be performed to secure the airway. Once an airway has been established, you can address breathing/ ventilation by auscultating breath sounds and evaluating for end- tidal CO2 using a capnometer. It is at this point where a life-threatening tension pneumothorax can be identified and treated. The next step is to evaluate the circulation. This includes getting adequate intravenous access. The patient described has two large-bore IVs, which should be sufficient for the initial resuscitation. Central venous access is indicated only if adequate access cannot be established peripherally. It is here that evaluation for intra-abdominal hemorrhage can be conducted using ultrasound or diagnostic peritoneal lavage.
A 45-year-old male receives a cadaveric liver transplant for alcoholic cirrhosis. Postoperatively, the patient is taken to the surgical intensive care unit (SICU). There is concern for primary nonfunction of the allograft.Which of the following is a sign of this?
Answer(s): A
Early clinical decline in a transplant patient is concerning for primary organ failure. This can be related to donor issues, technical issues, or donor organ ischemia. Signs of liver dysfunction include hypoglycemia (as the liver is unable to perform gluconeogenesis), coagulopathy with elevated prothrombin times, elevated ammonia levels, acid-base changes (unable to clear lactate via the Cori cycle), hyperkalemia, and oliguria. All liver transplant patients have an initial rise in transaminases which should decrease over the first 48 hours.
A50-year-old man undergoes a sigmoid colectomy and colostomy for perforated diverticulitis of the midsigmoid colon. The surgeon reports a difficult dissection in the pelvis secondary to adhesions of the sigmoid colon to the abdominal wall. On postoperative day 1, the patient reports appropriate abdominal pain. His pulse is 100 and BP 120/60. He has made 400 mL of urine over the past 8 hours. The urine in the Foley bag is blood-tinged.He reports no problems with his urination preoperatively. What is the appropriate management?
Answer(s): D
Ureteral injuries are a well-known complication of pelvic surgery. The risk is greatly increased in the setting of inflammation, which can make the ureters difficult to identify. Intravenous pyelogram is a sensitive test for injury. CT scan and retrograde pyelogram are also diagnostic options. Injuries identified early are usually amenable to primary surgical repair, making early diagnosis essential. Delayed recognition usually results in a staged repair requiring urinary diversion with percutaneous nephrostomy tubes.
A 75-year-old man undergoes a right colectomy for stage 3 colon cancer. He has a history of emphysema requiring chronic steroid use. He also has diabetes and coronary heart disease. On postoperative day 2, the surgeon is called because the patient acutely began to have a large amount of pinkish, serous drainage from the wound.There is no evidence of infection. Which of the following factors probably contributed to this complication?
Answer(s): E
Dehiscence refers to a separation of the fascial layer. Evisceration is when peritoneal contents extrude through the fascial separation. Malnutrition, obesity, diabetes, uremia, malignancy, immunologic abnormalities, steroid use, infection, and coughing which increases intraabdominal pressures are all factors that increase the risk of wound dehiscence. Technical factors are also very important in preventing the dehiscence, but there is no proof that interrupted sutures are better than a running stitch for fascial closure
A 22-year-old male presents complaining of a 1-month history of progressive dysphagia. He reports occasional regurgitation of undigested food at night. His past medical history is noncontributory. The condition has worsened to the point that he is on a liquid diet. A contrast swallow study is shown in Figure.What is the best treatment for this patient?
This patient has achalasia. This disorder is defined by a nonrelaxing lower esophageal sphincter (LES) and decreased peristalsis of the esophageal body. The "bird's beak" deformity is a classic sign with a dilated esophagus which tapers to a small area at the LES. Esophagomyotomy is the treatment of choice for long- standing disease. Serial botox injections and dilations can be used early in the disease process, however their long-term results are inferior to myotomy. Proton pump inhibitors can be used for gastroesophageal reflux disease (GERD). A Nissen fundoplication is also a treatment for GERD. Calcium channel blockers are sometimes used to treat other esophageal motility disorders.
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