ABSITE - Trauma -Correct Questions &
Answers(RATED A+)
A 34-year-old female presents after a high-velocity MVC with right flank pain and
frank bright red blood in her urine. Her primary survey is intact, and vital signs are
HR 112 bpm, BP 86/59 mmHg, RR 20/min, and oxygen saturation is 98% on room
air. CT scan demonstrates a Grade IV laceration to the right kidney. The best choice
for management is:
A. Renorrhaphy
B. Packing of the renal fossa, temporary abdominal closure, and return to the ICU.
C. Total nephrectomy
D. Observation in the intensive care unit with blood transfusion as needed
E. Gelfoam angioembolization - ANSWERRenorrhaphy
Correct.
This patient is hemodynamically unstable, and therefore should be taken to the
operating room for laparotomy and renal exploration. Principles of operative repair
for a Grade IV, and for some Grade V kidney lacerations include renal preservation,
when possible—debridement of non-viable tissue, hemostasis using absorbable
sutures in a figure-of-eight fashion with care taken to preserve arterial supply to
distal segments, closure of the collecting system with absorbable suture in a running
fashion, and reapproximation of the capsule. An omental flap can be substituted for
large defects if necessary. Damage control laparotomy is not indicated in this patient
in the absence of coagulopathy, hypothermia, or acidosis.
A 19-year-old male presents to the emergency room after a motorcycle crash. Digital
rectal exam including the prostate is normal, and there is no blood at the urethral
meatus. He has a lateral compression pelvis fracture and gross hematuria. The
appropriate evaluation for this patient would include:
A. Retrograde cystogram
B. Retrograde cystogram and contrast CT scan of the abdomen and pelvis
C. Contrast CT scan of the abdomen and pelvis
D. Retrograde urethrogram - ANSWERRetrograde cystogram and contrast CT scan
of the abdomen and pelvis
Correct.
The combination of a cystogram and a contrast CT scan of the abdomen and pelvis
will diagnose potential bladder and renal injuries. No retrograde urethrogram (D) is
needed as the patient did not have a high-riding prostate on digital rectal exam and
did not have blood at the urethral meatus. A cystogram alone (A) would not evaluate
for renal injuries which are possible with the given mechanism and hematuria. A CT
scan alone (C) would not evaluate for a potential bladder injury which is possible with
the given mechanism and hematuria.
A 30-year-old man presents to the Emergency Department after being struck by a
motor vehicle; he was found pinned under the vehicle and required 30 minutes of
extrication. On arrival, his blood pressure is 76/50 mmHg, pulse 132 beats/min, and
he is slow to respond to stimuli. A massive transfusion protocol is initiated. The
FAST scan is positive. On exploration, he has a large zone I retroperitoneal
, hematoma, a large volume of free intraperitoneal blood, several small bowel
lacerations, and a grade III liver laceration. After packing the four quadrants,
exploration of the hematoma demonstrates complete transection of the vena cava
below the renal veins. The patient remains hemodynamically unstable despite
transfusion. What is your next step in management of the vena caval injury?
A. Perform a right medial visceral rotation, apply clamps proximally and distally on
the cava, and repair the injury primarily.
B. Insert a - ANSWERPerform a right medial visceral rotation and ligate the vena
cava.
Correct.
In the setting of an unstable patient with complete transection of the vena cava, the
best option is ligation. Repair of the vena cava is usually the preferred option;
however, this may not be feasible in the setting of damage control laparotomy in an
unstable patient with multiple injuries where prolonging the operative time risks
developing coagulopathy, acidosis, and hypothermia prior to control of all major
bleeding sources. A left medial visceral rotation is performed for aortic exposure from
the hiatus to the iliacs. A right medial visceral rotation is required for caval exposure.
A 55-year-old man sustains a stab wound to the left flank, and is taken to the
operating room for peritonitis. He has a laceration to the splenic flexure of the colon
which is primarily repaired. There is no retroperitoneal hematoma. The most
appropriate step to assess possible left ureteral injury is:
A. Methylene blue intravenously
B. Retrograde pyelogram
C. Manual palpation of the entire course of the ureter
D. Direct inspection of the entire course of the ureter
E. Placement of retroperitoneal drain and closure of the incision - ANSWERDirect
inspection of the entire course of the ureter
Correct.
Direct inspection of the entire course of the ureter is the most definitive method to
assess for ureteral injury. Retrograde pyelogram would be an acceptable option;
however, the patient needs to be in lithotomy position for a retrograde pyelogram.
The open abdomen is also a hindrance to this option. Manual palpation of the ureter
does not substitute for direct inspection.
A 55-year-old man presents with hemodynamic instability and severe abdominal pain
after being struck by a car. On exploratory laparotomy, he is found to have a grade 5
splenic injury and a 6-cm left-sided zone II retroperitoneal hematoma that is not
expanding. Microscopic hematuria was also detected on urinalysis. After performing
splenectomy, what is the next step in management?
A. Explore the zone II retroperitoneal hematoma.
B. Observe the zone II hematoma.
C. Perform a left nephrectomy.
D. Perform an on-table angiogram. - ANSWERObserve the zone II hematoma.
Correct.
Zone 2 hematomas caused by penetrating injuries are routinely explored if
encountered in the operating room. Whether proximal control of the renal pedicle
should be obtained before exploration of a perinephric hematoma is controversial. In
cases of severe ongoing hemorrhage, time should not be taken to obtain proximal
Answers(RATED A+)
A 34-year-old female presents after a high-velocity MVC with right flank pain and
frank bright red blood in her urine. Her primary survey is intact, and vital signs are
HR 112 bpm, BP 86/59 mmHg, RR 20/min, and oxygen saturation is 98% on room
air. CT scan demonstrates a Grade IV laceration to the right kidney. The best choice
for management is:
A. Renorrhaphy
B. Packing of the renal fossa, temporary abdominal closure, and return to the ICU.
C. Total nephrectomy
D. Observation in the intensive care unit with blood transfusion as needed
E. Gelfoam angioembolization - ANSWERRenorrhaphy
Correct.
This patient is hemodynamically unstable, and therefore should be taken to the
operating room for laparotomy and renal exploration. Principles of operative repair
for a Grade IV, and for some Grade V kidney lacerations include renal preservation,
when possible—debridement of non-viable tissue, hemostasis using absorbable
sutures in a figure-of-eight fashion with care taken to preserve arterial supply to
distal segments, closure of the collecting system with absorbable suture in a running
fashion, and reapproximation of the capsule. An omental flap can be substituted for
large defects if necessary. Damage control laparotomy is not indicated in this patient
in the absence of coagulopathy, hypothermia, or acidosis.
A 19-year-old male presents to the emergency room after a motorcycle crash. Digital
rectal exam including the prostate is normal, and there is no blood at the urethral
meatus. He has a lateral compression pelvis fracture and gross hematuria. The
appropriate evaluation for this patient would include:
A. Retrograde cystogram
B. Retrograde cystogram and contrast CT scan of the abdomen and pelvis
C. Contrast CT scan of the abdomen and pelvis
D. Retrograde urethrogram - ANSWERRetrograde cystogram and contrast CT scan
of the abdomen and pelvis
Correct.
The combination of a cystogram and a contrast CT scan of the abdomen and pelvis
will diagnose potential bladder and renal injuries. No retrograde urethrogram (D) is
needed as the patient did not have a high-riding prostate on digital rectal exam and
did not have blood at the urethral meatus. A cystogram alone (A) would not evaluate
for renal injuries which are possible with the given mechanism and hematuria. A CT
scan alone (C) would not evaluate for a potential bladder injury which is possible with
the given mechanism and hematuria.
A 30-year-old man presents to the Emergency Department after being struck by a
motor vehicle; he was found pinned under the vehicle and required 30 minutes of
extrication. On arrival, his blood pressure is 76/50 mmHg, pulse 132 beats/min, and
he is slow to respond to stimuli. A massive transfusion protocol is initiated. The
FAST scan is positive. On exploration, he has a large zone I retroperitoneal
, hematoma, a large volume of free intraperitoneal blood, several small bowel
lacerations, and a grade III liver laceration. After packing the four quadrants,
exploration of the hematoma demonstrates complete transection of the vena cava
below the renal veins. The patient remains hemodynamically unstable despite
transfusion. What is your next step in management of the vena caval injury?
A. Perform a right medial visceral rotation, apply clamps proximally and distally on
the cava, and repair the injury primarily.
B. Insert a - ANSWERPerform a right medial visceral rotation and ligate the vena
cava.
Correct.
In the setting of an unstable patient with complete transection of the vena cava, the
best option is ligation. Repair of the vena cava is usually the preferred option;
however, this may not be feasible in the setting of damage control laparotomy in an
unstable patient with multiple injuries where prolonging the operative time risks
developing coagulopathy, acidosis, and hypothermia prior to control of all major
bleeding sources. A left medial visceral rotation is performed for aortic exposure from
the hiatus to the iliacs. A right medial visceral rotation is required for caval exposure.
A 55-year-old man sustains a stab wound to the left flank, and is taken to the
operating room for peritonitis. He has a laceration to the splenic flexure of the colon
which is primarily repaired. There is no retroperitoneal hematoma. The most
appropriate step to assess possible left ureteral injury is:
A. Methylene blue intravenously
B. Retrograde pyelogram
C. Manual palpation of the entire course of the ureter
D. Direct inspection of the entire course of the ureter
E. Placement of retroperitoneal drain and closure of the incision - ANSWERDirect
inspection of the entire course of the ureter
Correct.
Direct inspection of the entire course of the ureter is the most definitive method to
assess for ureteral injury. Retrograde pyelogram would be an acceptable option;
however, the patient needs to be in lithotomy position for a retrograde pyelogram.
The open abdomen is also a hindrance to this option. Manual palpation of the ureter
does not substitute for direct inspection.
A 55-year-old man presents with hemodynamic instability and severe abdominal pain
after being struck by a car. On exploratory laparotomy, he is found to have a grade 5
splenic injury and a 6-cm left-sided zone II retroperitoneal hematoma that is not
expanding. Microscopic hematuria was also detected on urinalysis. After performing
splenectomy, what is the next step in management?
A. Explore the zone II retroperitoneal hematoma.
B. Observe the zone II hematoma.
C. Perform a left nephrectomy.
D. Perform an on-table angiogram. - ANSWERObserve the zone II hematoma.
Correct.
Zone 2 hematomas caused by penetrating injuries are routinely explored if
encountered in the operating room. Whether proximal control of the renal pedicle
should be obtained before exploration of a perinephric hematoma is controversial. In
cases of severe ongoing hemorrhage, time should not be taken to obtain proximal
