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Question 1 of 10
1. Question
An 18 year old male is brought to a level 1 trauma center by ambulance with a stab wound to the right abdomen. Past medical history noncontributory. Vital signs are: BP 100/60 HR 85 RR 16 Temp 98.6F (37C). Exam reveals a diffuse tender abdomen with mild guarding and no rebound. A small amount of mesentery is noted to be extravasating from the wound. Which of the following is the next best step in management?
Correct
The patient has a penetrating abdominal injury with evisceration of abdominal contents. Indications for the OR in penetrating abdominal injury include unstable vital signs, peritonitis w/ a +FAST examination, evisceration, and transabdominal GSW.
Incorrect
The patient has a penetrating abdominal injury with evisceration of abdominal contents. Indications for the OR in penetrating abdominal injury include unstable vital signs, peritonitis w/ a +FAST examination, evisceration, and transabdominal GSW.
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Question 2 of 10
2. Question
A 24-year-old man presents after being struck by a motor vehicle while crossing the street. His secondary survey is notable for an unstable pelvis which is stabilized with a pelvic binder. His initial and repeat FAST examinations in Tredelenberg are negative but he remains hypotensive and tachycardic. Intravenous fluids and uncrossmatched blood are administered. Which of the following is the most appropriate next step?
Correct
Patients with fractures of the bony pelvis are at high risk for hemorrhage due to the close proximity of the vascular structures to the pelvic bones. The internal iliac arteries and their subsequent branches provide most of the blood supply to the pelvic region. Most traumatic pelvic bleeding is venous, but in unstable patients an arterial source is suggested. In this patient with fractures and persistent hemodynamic instability without hemoperitoneum, the source of bleeding is likely the pelvis. After initial attempted stabilization with an external pelvic binder (either a sheet or commercial device), the patient needs angiography and embolization in interventional radiology. Angiography has very high success rates at controlling pelvic hemorrhage.
Incorrect
Patients with fractures of the bony pelvis are at high risk for hemorrhage due to the close proximity of the vascular structures to the pelvic bones. The internal iliac arteries and their subsequent branches provide most of the blood supply to the pelvic region. Most traumatic pelvic bleeding is venous, but in unstable patients an arterial source is suggested. In this patient with fractures and persistent hemodynamic instability without hemoperitoneum, the source of bleeding is likely the pelvis. After initial attempted stabilization with an external pelvic binder (either a sheet or commercial device), the patient needs angiography and embolization in interventional radiology. Angiography has very high success rates at controlling pelvic hemorrhage.
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Question 3 of 10
3. Question
A 55-year old male presents to the ER after being struck by a car traveling approximately twenty miles per hour. Blood pressure is 140/90, heart rate is 105, respiratory rate is 16, and the patient is afebrile. Physical exam is significant for severe pain with manipulation of the pelvis as well as blood at the urethral meatus. X-ray is shown below. In addition to orthopedics consult, which of the following is the most appropriate next step in management?
Correct
The correct answer is retrograde urethrogram to evaluate for urethral injury. Posterior urethral injuries can occur with pelvic fractures. A bladder fracture is also a possibility and a retrograde cystogram should be performed after the urethrogram to assess for bladder injury given the open book pelvic fracture on x-ray. A foley catheter is contraindicated until urethral injury has been excluded. IVP is rarely performed currently as CT scan can evaluate for renal injury reliably. Retrograde cystogram should be done as well but after a retrograde urethrogram. Intravenous pyelography may be done if suspect kidney injury but blood at the urethral meatus in the context of a pelvic fracture is more suggestive of a urethral or bladder injury. Placement of a foley catheter is contraindicated
Incorrect
The correct answer is retrograde urethrogram to evaluate for urethral injury. Posterior urethral injuries can occur with pelvic fractures. A bladder fracture is also a possibility and a retrograde cystogram should be performed after the urethrogram to assess for bladder injury given the open book pelvic fracture on x-ray. A foley catheter is contraindicated until urethral injury has been excluded. IVP is rarely performed currently as CT scan can evaluate for renal injury reliably. Retrograde cystogram should be done as well but after a retrograde urethrogram. Intravenous pyelography may be done if suspect kidney injury but blood at the urethral meatus in the context of a pelvic fracture is more suggestive of a urethral or bladder injury. Placement of a foley catheter is contraindicated
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Question 4 of 10
4. Question
A 42-year-old man was a restrained driver in a motor vehicle collision. He complains of left flank pain and is hemodynamically stable. Which of the following is an indication for a CT scan of the abdomen and pelvis with IV contrast?
Correct
The presence of gross hematuria in the setting of trauma signifies a urologic injury until proven otherwise. Gross hematuria suggests either a lower or upper urinary tract injury. Bladder injury (e.g. rupture) is suggested by lower abdominal pain and tenderness or a positive FAST examination on evaluation of the pelvis. Urethral injuries may present with blood at the meatus in which case a retrograde urethrogram is indicated. Blunt trauma accounts for approximately 90% of renal injuries and 1-5% of hospitalized trauma patients have a renal injury. In most cases, clinically significant renal injuries are associated with gross hematuria. Rarely, a significant injury is found with microscopic hematuria but also hemodynamic instability. Therefore, if renal injury is suspected, gross hematuria in the hemodynamically stable patient dictates further imaging evaluation.
Incorrect
The presence of gross hematuria in the setting of trauma signifies a urologic injury until proven otherwise. Gross hematuria suggests either a lower or upper urinary tract injury. Bladder injury (e.g. rupture) is suggested by lower abdominal pain and tenderness or a positive FAST examination on evaluation of the pelvis. Urethral injuries may present with blood at the meatus in which case a retrograde urethrogram is indicated. Blunt trauma accounts for approximately 90% of renal injuries and 1-5% of hospitalized trauma patients have a renal injury. In most cases, clinically significant renal injuries are associated with gross hematuria. Rarely, a significant injury is found with microscopic hematuria but also hemodynamic instability. Therefore, if renal injury is suspected, gross hematuria in the hemodynamically stable patient dictates further imaging evaluation.
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Question 5 of 10
5. Question
Which of the following organs is the most commonly injured in adult blunt abdominal trauma?
Correct
The spleen is the most common organ injured in adults in blunt abdominal trauma. Most blunt abdominal trauma results from motor vehicle collisions. Many splenic injuries, including high-grade lacerations, may be managed conservatively in the hemodynamically stable patient without other significant intraabdominal injuries.
Incorrect
The spleen is the most common organ injured in adults in blunt abdominal trauma. Most blunt abdominal trauma results from motor vehicle collisions. Many splenic injuries, including high-grade lacerations, may be managed conservatively in the hemodynamically stable patient without other significant intraabdominal injuries.
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Question 6 of 10
6. Question
When performing a FAST exam and assessing the spleno-renal (peri-splenic) window, which of the following is the most likely location for free fluid to accumulate?
Correct
The correct answer is between the spleen and the diaphragm. Fluid is rarely seen between the spleen and kidney. Most commonly it is between the spleen and diaphragm, or simply around the spleen.
Incorrect
The correct answer is between the spleen and the diaphragm. Fluid is rarely seen between the spleen and kidney. Most commonly it is between the spleen and diaphragm, or simply around the spleen.
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Question 7 of 10
7. Question
A 32-year-old woman presents after a motor vehicle crash in which she was the restrained driver. She has abdominal pain and is hemodynamically stable. Abdominal examination reveals ecchymosis horizontally across the abdomen near the umbilicus. Bedside FAST examination results are negative, and a CT scan revels no injuries. Re-examination reveals a tender abdomen. What is the most appropriate management?
Correct
When a patient presents after suffering blunt abdominal trauma and has a concerning abdominal examination but a negative workup, decisions about appropriate management can be challenging. In this particular patient, the negative CT scan and FAST results are reassuring in terms of solid organ injury, but there is potential for other serious injuries, such as hollow viscus injury or pancreatic injury. The seatbelt sign (ecchymosis on the abdomen) suggests that the patient could have these injuries, so a period of observation in the hospital is warranted. Discharging the patient without a period of observation either in the hospital or in the emergency department creates the potential for the patient to suffer significant complications from undiagnosed intraabdominal injury. Diagnostic peritoneal lavage would be helpful in this patient if grossly positive but might not otherwise definitively determine the indication for surgical management. The formal abdominal ultrasound examination done in the radiology department is no more accurate than a FAST examination done by an experienced provider for identifying hollow viscus injury or acute pancreatic injury.
Incorrect
When a patient presents after suffering blunt abdominal trauma and has a concerning abdominal examination but a negative workup, decisions about appropriate management can be challenging. In this particular patient, the negative CT scan and FAST results are reassuring in terms of solid organ injury, but there is potential for other serious injuries, such as hollow viscus injury or pancreatic injury. The seatbelt sign (ecchymosis on the abdomen) suggests that the patient could have these injuries, so a period of observation in the hospital is warranted. Discharging the patient without a period of observation either in the hospital or in the emergency department creates the potential for the patient to suffer significant complications from undiagnosed intraabdominal injury. Diagnostic peritoneal lavage would be helpful in this patient if grossly positive but might not otherwise definitively determine the indication for surgical management. The formal abdominal ultrasound examination done in the radiology department is no more accurate than a FAST examination done by an experienced provider for identifying hollow viscus injury or acute pancreatic injury.
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Question 8 of 10
8. Question
A 28-year-old woman presents after being involved in a high-speed motor vehicle collision. She is 32-weeks pregnant and was the back seat passenger wearing only a lap belt. Her blood pressure is 80/40 mm Hg, heart rate is 130 beats/minute, respiratory rate is 24 breaths/minute, temperature is 37°C, and oxygen saturation is 98% on 10 L via non-rebreather mask. Her abdomen is tender to palpation, with rebound and guarding. The fetus is felt in a transverse lie and you can easily palpate the fetal extremities. There is no fetal cardiac activity on ultrasound. What is the most likely diagnosis?
Correct
The patient is suffering from an acute traumatic uterine rupture a rare complication following blunt and penetrating abdominal trauma. The classic signs include maternal shock, abdominal pain, peritoneal signs, abnormal fetal lie, easily palpable fetal anatomy and fetal demise. The use of a lap belt alone increases the risk of developing uterine rupture and placental abruption. The patient should be aggressively resuscitated and emergent surgical and obstetric consultation is necessary for operative repair.
Incorrect
The patient is suffering from an acute traumatic uterine rupture a rare complication following blunt and penetrating abdominal trauma. The classic signs include maternal shock, abdominal pain, peritoneal signs, abnormal fetal lie, easily palpable fetal anatomy and fetal demise. The use of a lap belt alone increases the risk of developing uterine rupture and placental abruption. The patient should be aggressively resuscitated and emergent surgical and obstetric consultation is necessary for operative repair.
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Question 9 of 10
9. Question
A 19-year-old male with no past medical history, presents with abdominal pain. He was skateboarding and doing tricks off a handrail, when he slipped and landed directly onto his abdomen against the handrail. He denies loss of consciousness, but has developed progressively worsening epigastric abdominal pain with nausea and vomiting. Vital signs are BP 124 /72, HR 99, RR 24, Temp 99.2°F, and 98% on room air. CT abdomen was negative. Electrolytes are within normal limits, WBC 13.1, Hemoglobin 14.5 g/dL, AST 56 IU/L, ALT 55 IU/L, Alkaline phosphatase 60 IU/L, total bilirubin 0.9 mg/dL, lipase 66 IU/L. Given the scenario, which of the following is the best next step for this patient?
Correct
CT imaging is excellent in detecting solid organ injury (e.g. kidney, liver, spleen, pancreas) but not good at detecting mesenteric hematoma/tears or hollow viscus injury.
Incorrect
CT imaging is excellent in detecting solid organ injury (e.g. kidney, liver, spleen, pancreas) but not good at detecting mesenteric hematoma/tears or hollow viscus injury.
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Question 10 of 10
10. Question
What is the most common sign of bladder injury?
Correct
Gross hematuria is the most common sign of bladder injury and occurs in more than 95% of the cases. Bladder injury most commonly results from blunt motor vehicle trauma and 80% are associated with fracture of the bony pelvis. Bladder injuries include contusions, intraperitoneal and extraperitoneal ruptures and combination ruptures. Other signs of bladder rupture include suprapubic and lower abdominal pain, inability to urinate, pelvic fracture, and blood at the urethral meatus. Blood at the urethral meatus is a sign of underlying urethral or bladder injury, although is not the most common sign for bladder injury. A high-riding prostate is a sign of urethral injury, not bladder injury. An inability to urinate is a sign of bladder injury, however is not the most common sign.
Incorrect
Gross hematuria is the most common sign of bladder injury and occurs in more than 95% of the cases. Bladder injury most commonly results from blunt motor vehicle trauma and 80% are associated with fracture of the bony pelvis. Bladder injuries include contusions, intraperitoneal and extraperitoneal ruptures and combination ruptures. Other signs of bladder rupture include suprapubic and lower abdominal pain, inability to urinate, pelvic fracture, and blood at the urethral meatus. Blood at the urethral meatus is a sign of underlying urethral or bladder injury, although is not the most common sign for bladder injury. A high-riding prostate is a sign of urethral injury, not bladder injury. An inability to urinate is a sign of bladder injury, however is not the most common sign.
This week covers Abdominal and Pelvic Trauma. We will begin with a FUR with Dr. Moss, then move onto FLIPs with Drs. Maqbool, Inman and Praamsma. Next, a special lecture from one of our Trauma Surgeons, Dr. Isaacson. Finally, CCC of the month with Drs. Pickos and Rousseau.
TEXT
HARWOOD & NUSS
Chapter 33: Blunt Abdominal Trauma
Chapter 34: Penetrating Abdominal Trauma
Chapter 35: Genitourinary Trauma
ONLINE MATERIAL
EMRAP
— Blunt Abdominal Trauma
— Penetrating Abdominal and Chest Trauma
— Pelvic Fractures
Corependium
HippoEM
EMCrit – podcast
— Severe Pelvic Trauma
FOAMcast
— GU Trauma
ARTICLES
— EBM – Pediatric Blunt Abdominal Trauma PDF
EBM- Renal-GU Trauma PDF
ROSENS TEXT
Chapter 46. Abdominal Trauma
Chapter 47. Genitourinary System