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39 Cards in this Set
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A 14-year-old boy is hit over the right side of the head with a baseball bat. He loses consciousness for a few minutes, but recovers promptly and continues to play. One hour later he is found unconscious in the locker room. His right pupil is fixed and dilated. - What is it? - How is it diagnosed? - Treatment? |
What is it? – Acute epidural hematoma (probably right side)
How is it diagnosed? – CT scan
Treatment? – Emergency surgical decompression (craniotomy). Good prognosis if treated, fatal within hours if it is not. |
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A 32-year-old male is involved in a head-on, high-speed automobile collision. He is unconscious at the site, regains consciousness briefly during the ambulance ride and arrives at the E.R. in deep coma, with a fixed, dilated right pupil. - What is it? - Diagnosed how? - Treatment? |
What is it? – Could be acute epidural hematoma, but acute subdural is better bet.
Diagnosis? – CT scan. Also need to check cervical spine!
Treatment? – Emergency craniotomy, poor prognosis because of brain injury. |
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A 77-year-old man becomes “senile” over a period of three or four weeks. He used to be active and managed all of his financial affairs. Now he stares at the wall, barely talks and sleeps most of the day. His daughter recalls that he fell from a horse about a week before the mental changes began. - What is it? - Diagnosed how? - Treatment? |
What is it? – Chronic subdural hematoma. (venous bleeding, size 7 brain in size 8 skull)
How is diagnosis made? – CT scan.
Treatment: Surgical decompression (craniotomy). Spectacular improvement expected. |
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A car hits a pedestrian. He arrives in the ER in coma. He has...(raccoon eyes... or clear fluid dripping from the nose...or clear fluid dripping from the ear...or ecchymosis behind the ear)... - What is it? - Diagnosed how? - Treatment? |
What is it- base of the skull fracture
Diagnosed- CT scan. Needs cervical spine X-rays
Tx: Needs neurosurgical consult, needs antibiotics |
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A 45-year-old man is involved in a high-speed automobile collision. He arrives at the ER in coma, with fixed dilated pupils. He has multiple other injuries (extremities, etc). His blood pressure is 70 over 50, with a feeble pulse at a rate of 130. What is the reason for the low BP and high pulse rate? |
Point of the question: It is not from neurological injury. (Not enough room in the head for enough blood loss to cause shock). Look for answer of significant blood loss to the outside (could be scalp laceration), or inside (abdomen, pelvic fractures). |
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A 22-year-old gang member arrives in the E.R. with multiple guns shot wounds to the abdomen. He is diaphoretic, pale, cold, shivering, anxious, asking for a blanket and a drink of water. His blood pressure is 60 over 40. His pulse rate is 150, barely perceptible. - What is it? - Management? |
What is it? – Hypovolemic shock
Management: Several things at one: Big bore IV lines, Foley catheter and I.V. antibiotics. Ideally exploratory lap immediately for control of bleeding, and then fluid and blood administration. If O.R. not available, fluid resuscitation while waiting for it. |
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A 22-year-old gang member arrives in the E.R. with multiple gun shot wounds to the chest and abdomen. He is diaphoretic, pale, cold, shivering, anxious, asking for a blanket and a drink of water. His blood pressure is 60 over 40. His pulse rate is 150, barely perceptible. - What is it? |
Hypovolemic shock still the best bet, but the inclusion of chest wounds raises possibility of pericardial tamponade or tension pneumothorax. As a rule if significant findings are not included in the vignette, they are not present. Thus, as given this is still a vignette of hypovolemic shock, but you may be offered in the answers the option of looking for the missing clinical signs: distended neck veins (or a high measured CVP) would be common to both tamponade and tension pneumo; and respiratory distress, tracheal deviation and absent breath sounds on a hemithorax that is resonant to percussion would specifically identify tension pneumothorax. |
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A 22-year-old gang member arrives in the E.R. with multiple guns shot wounds to the chest and abdomen. He is diaphoretic, cold, shivering, anxious, asking for a blanket and a drink of water. His blood pressure is 60 over 40. His pule rate is 150, barely perceptible. He has big distended veins in his neck and forehead. He is breathing OK, has bilateral breath sounds and no tracheal deviation. - What is it? - Management? |
What is it?- Pericardial tamponade
Management: No X-Rays needed, this is a clinical diagnosis!. Do Pericardial window. If positive, follow with thoracotomy, and then exploratory lap. |
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A 22-year-old gang member arrives in the E.R. with multiple guns shot wounds to the chest and abdomen. He is diaphoretic, cold, shivering, anxious, asking for a blanket and a drink of water. His blood pressure is 60 over 40. His pule rate is 150, barely perceptible. He has big distended veins in his neck and forehead. He is breathing OK, has bilateral breath sounds and no tracheal deviation. - Identical to this, but with only a single gunshot wound in the precordial area.... do what? |
When the location of the wound strongly suggests pericardial tamponade, emergency thoracotomy might be done right away without prior pericardial window. |
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A 22-year-old gang member arrives in the E.R. with multiple gun shot wounds to the chest and abdomen. He has labored breathing is cyanotic, diaphoretic, cold and shivering. His blood pressure is 60 over 40. His pulse rate is 150, barely perceptible. He is in respiratory distress, has big distended veins in his neck and forehead, his trachea is deviated to the left, and the right side of his chest is tympantic, with no breath sounds. - What is it? - Management? |
What is it? – Tension pneumothorax.
Management: Immediate big bore IV catheter placed into the right pleural space, followed by chest tube to the right side, right away! Watch out for trap that offers chest X-Ray as an option. This is a clinical diagnosis, and patient needs that chest tube now. He will die if sent to X-Ray. Exploratory lap will follow. |
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A 72 year old man who lives alone calls 911 saying that he has severe chest pain. He cannot give a coherent history when picked up by the EMT, and on arrival at the ER he is cold and diaphoretic and his blood pressure is 80 over 65. He has an irregular, feeble pulse at a rate of 130. His neck and forehead veins are distended and he is short of breath. - What is it? - Management? |
What is it? – Many findings similar to above cases, but no trauma, old man, chest pain: i.e.: straightforward cardiogenic shock, from massive MI
Management: verify high CVP. EKG, enzymes, coronary care unit etc. Do not drown him with enthusiastic fluid “resuscitation”, but use thrombolytic therapy if offered. |
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A 17 year old girl is stun by a swarm of bees...or a man of whatever age breaks out with hives after a penicillin infection...or a patient undergoing surgery under spinal anesthetic...eventually develop BP of 75 over 25, pulse rate of 150, but they look warm and flush rather than pale and cold. CVP is low. - What is it? - Management? |
What is it? – Vasomotor shock (massive vasodilation, loss of vascular tone)
Management: Vasoconstrictors. Volume replacement would not hurt. |
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A 25-year-old man is stabbed in the right chest. He is moderately short of breath, has stable vital signs. No breath sounds on the right. Resonant to percussion. - What is it? - Diagnosed how? - Management? |
What is it? – Plain pneumothorax.
How is diagnosis verified? There is time to get a chest X-Ray if the option if offered.
Treatment: Chest tube to underwater seal and suction. If given option for location, high in the pleural cavity. |
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A 25-year-old man is stabbed in the right chest. He is moderately short of breath, has stable vital signs. No breath sounds on at the base on the right chest, faint distant breath sounds at the apex. Dull to percussion. - What is it? - Diagnosed how? - Tx? |
What is it? – Sounds more like hemothorax.
How do we find out? - Chest X-Ray
If confirmed, treatment is chest tube on the right, at the base of the pleural cavity. |
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A 25-year-old man is stabbed in the right chest. He is moderately short of breath, has stable vital signs. No breath sounds on at the base on the right chest, faint distant breath sounds at the apex. Dull to percussion. A chest tube placed at the right pleural base recovers 120 cc of blood, drains another 20 c in the next hour. - Further Treatment? |
Further treatment: The point of this one is that most hemothoraxes do not need exploratory surgery. Bleeding is from lung parenchyma (low pressure), stops by itself. Chest tube is all that is needed. Key clue: little blood retrieved, even less afterwards. |
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A 25-year-old man is stabbed in the right chest. He is moderately short of breath, has blood pressure is 95 over 70, pulse rate of 100. No breath sounds on at the base on the right chest, faint distant breath sounds at the apex. Dull to percussion. A chest tube placed at the right pleural base recovers 1250 cc of blood...(or it could be only 450 cc at the outset, but followed by another 420 cc in the next hour and so on). - Further treatment? |
The rare exception who is bleeding from a systemic vessel (almost invariably intercostal). Will need thoracotomy to ligate the vessel. |
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A 25-year-old man is stabbed in the right chest. He is moderately short of breath, has stable vital signs. No breath sounds on the right. Resonant to percussion at the apex of the right chest, dull at the base. Chest X-Ray shows one single, large air-fluid level. - What is it? |
Hemo-pneumothorax. Chest tube, surgery only if bleeding a lot |
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A 33-year-old lady is involved in a high-speed automobile collision. She arrives at the E.R. gasping for breath, cyanotic at the lips, with flaring nostrils. There are bruises over both sides of the chest, and tenderness suggestive of multiple fractured ribs. Blood pressure is 60 over 45. Pulse rate 160, feeble. She has distended neck and forehead veins, is diaphoretic. Left hemithorax has no breath sounds, is tympanitic to percussion. - What is it? - Management? |
What is it? – A variation on an old theme: classic picture for tension pneumothorax...but Where is the penetrating trauma? : The fractured rubs can act as a penetrating weapon.
Management: chest tube to the left right away! Do not fall for the option of getting X-Rays first, but you need them later to rule out wide mediastinum (aortic rupture). |
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A 54-year-old lady crashes her car against a telephone pole at high speed. On arrival at the E.R. she is in moderate respiratory distress. She has multiple bruises over the chest, and multiple site of point tenderness over the ribs. X-Rays show multiple rib fractures on both sides. On closer observation it is noted that a segment of the chest wall on the left side caves in when she inhales, and bulges out when she exhales. - What is it? - Management? - Further management? |
What is it? – Classical physical diagnosis finding of paradoxical breathing, leading to classical diagnosis of flail chest. She is at high risk for other injuries.
Management: Rule out other injuries (aortic rupture, abdominal injuries) The real problem is flail chest is the underlying pulmonary-contusion, for which the treatment is controversial, including fluid restriction, diuretics, use of colloid rather than crystalloid fluids when needed, and respiratory support. The probable wrong alternatives will revolve around various ways of mechanically stabilizing the part of the chest wall that moves the wrong way...because that used to be what was believed in the past.
Further management: if other injuries require that she go to the OR, prophylactic bilateral chest tubes because she is at high risk to develop tension pneumothorax when under the positive pressure breathing of the anesthetic. |
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A 54-year-old lady crashes her car against a telephone pole at high speed. On arrival at the E.R. she is breathing well. She has multiple bruises over the chest and multiple sites of point tenderness over the ribs. X-Rays show multiple rib fractures on both sides, but the lung parenchyma is clear and both lungs are expanded. Two days later her lungs “white out” on X- Rays and she is in respiratory distress. - What is it? - Management? |
What is it? – Pulmonary contusion. It does not always show up right away, may become evident one or two days after the trauma.
Management: Fluid restriction (using colloid), diuretics, respiratory support. The latter is key, with intubation, mechanical ventilation and PEEP if needed. |
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A 54-year-old lady crashes her car against a telephone pole at high speed. On arrival at the E.R. she is breathing well. She has multiple bruises over the chest, and is exquisitely tender over the sternum at a point where there is a crunching feeling of crepitation elicited by palpation. - What is it? - Further tests? |
What is it? – Obviously a sternal fracture...but the point is that she is at high risk for myocardial contusion and for traumatic rupture of the aorta.
Further tests: as you would do for a MI : EKG, cardiac enzymes, but the real important ones would be CT scan, transesophageal echo or arteriogram looking for aortic rupture. |
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A 53-year-old man is involved in a high-speed automobile collision. He has moderate respiratory distress. Physical exam shows no breath sounds over the entire left chest. Percussion is unremarkable. Chest X-Ray shows air fluid levels in the left chest. - What is it? - Further test? - Management? |
What is it? – Classical for traumatic diaphragmatic rupture. It is always on the left.
Further test? Not really needed. A nasogastric tube curling up into the left chest might be an added tid bit.
Management: Surgical repair. |
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A motorcycle daredevil attempts to jump over the 12 fountains in front of Caesar’s Palace Hotel in Las Vegas. As he leaves the ramp at very high speed his motorcycle turns sideways and he hits the retaining wall at the other end, literally like a rag doll. At the Er. he is found to be remarkably stable, although he has multiple extremity fractures. A chest X-Ray shows fracture of the left first rib and widened mediastinum. - What is it? - Diagnosis? - Treatment? |
What is it? – Actually a real case. Classical for traumatic rupture of the aorta: King size trauma, fracture of a hard-to-break bone (it could first rib, scapula or sternum) and the tell-tale hint of widened mediastinum
How is the diagnosis made? – Arteriogram (aortogram).
Treatment: Emergency surgical repair. |
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A 34-year-old lady suffers severe blunt trauma in a car accident. She has multiple injuries to her extremities, has head trauma and has a pneumothorax on the left. Shortly after initial examination it is noted that she is developing progressive subcutaneous emphysema all over her upper chest and lower neck. - What is it? - Additional findings? - Management? |
What is it? – Traumatic rupture of the trachea or major bronchus.
Additional findings: Chest X-Ray would confirm the presence of air in the tissues.
Management: Fiberoptic bronchoscopy to confirm diagnosis and level of injury and to secure an airway. Surgical repair after that. |
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A 26-year-old lady has been involved in a car wreck. She has fractures in upper extremities, facial lacerations and no other obvious injuries. Chest X-Ray is normal. Shortly thereafter she develops hypotension, tachycardia and dropping hematocrit. Her CVP is low. - What is it? - How is it diagnosed? - Eventual therapy? |
What is it? – Obviously blood loss, but the question is where. The answer is easy: it has to be in the abdomen. To go into hypovolemic shock one has to lose 25 to 30% of blood volume, which in the average size adult will be nearly a liter and a half (25 to 30% of 4.5 to 5 liters). In the absence of external hemorrhage (scalp lacerations can bleed that much), the bleeding has to be internal. That much blood can not fit inside the head, and would not go un-noticed in the neck (huge hematoma) or chest (X-Rays can spot anything above 150 cc). Only massive pelvic fractures, multiple femur fractures or intra-abdominal bleeding can accommodate that much blood. The first two would be obvious in physical exam and X-Rays. The belly can be silent. Thus the belly is invariably the place to look for that hidden blood.
How is it diagnosed? - We have a choice here. The old, invasive way was the diagnostic peritoneal lavage. The newer, non-invasive ways are the CAT scan or sonogram. CT scan is best, but it can not be done in the patient who is “crashing”. (the X-Ray department is a never-never land where patients die unattended). Try to gage from the question whether the patient is stable – do CT scan, or literally dying on your hands, in which case diagnostic peritoneal lavage or sonogram is done in the E.R.
Eventual therapy: most likely finding will be ruptured spleen. If stable, observation with serial CT scans will follow. If not, exploratory laparotomy. |
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A 19 year old gang member is shot in the abdomen with a 38 caliber revolver. The entry wound is in the epigastrium, to the left of the midline. The bullet is lodged in the psoas muscle on the right. He is hemodynamically stable, the abdomen is moderately tender. - Management? |
No diagnostic tests are needed. A penetrating wound of the abdomen gets exploratory laparotomy every time. Only hidden trap you might get in the question relates to preparations prior to surgery: an indwelling bladder catheter, a big bore venous line for fluid administration and a dose of broad spectrum antibiotics. |
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A 19 year old gang member is shot once with a 38 caliber revolver. The entry wound is in the left mid-clavicular line, two inches below the nipple. The bullet is lodged in the left paraspinal muscles. He is hemodynamically stable, but he is drunk and combative and physical exam Is difficult to do. - What is it? - What does this person need? |
The point here is to remind you of the boundaries of the abdomen: although this sounds like a chest wound, it is also abdominal. The belly begins at the nipple line. The chest does not end at the nipple line, though. Belly and chest are not stacked up like pancakes: they are separated by a dome. This fellow needs all the stuff for a penetrating chest wound (chest X-Ray, chest tube if needed), plus the exploratory lap. |
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A 27 year old intoxicated man smashes his car against a tree. He is tender over the left lower chest wall. Chest X-Ray shows fractures of the 8th, 9th and 10th ribs on the left. He has a blood pressure of 85 over 68 and a pulse rate of 128. - What is it? - What should you do? |
What is it? – This one is a classic: ruptured spleen. We already went over the business of where blood can hide, the abdomen is the place, but within the belly the most fragile solid organ that gives clinically significant bleeding is the spleen. (The liver is actually more likely to be the site of bleeding when CT scans are done on patients with blunt abdominal trauma, but often the bleeding from the liver is not clinically significant). In the absence of other clues, clinically significant hidden intra-abdominal bleeding comes from a ruptured spleen. This case is actually full of other clues that point to the spleen.
First negotiate the diagnostic dilemma: if he responds promptly to fluid administration, and does not require blood, go for the CT scan. Further management in that case may well be continued observation with serial CT scans. If he is “crashing”, he will need the peritoneal lavage or sonogram followed by exploratory laparotomy. |
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A 27 year old intoxicated man smashes his car against a tree. He is tender over the left lower chest wall. Chest X-Ray shows fractures of the 8th, 9th and 10th ribs on the left. He has a blood pressure of 85 over 68 and a pulse rate of 128, which do not respond satisfactorily to fluid and blood administration. He has a positive peritoneal lavage and at exploratory laparotomy a ruptured spleen is found. - What is the issue here? |
What is the issue here? – You are unlikely to be asked technical surgical questions, but when dealing with a ruptured spleen an effort will be made to repair it rather than remove it. In children the effort will be even greater. But if the vignette says that the spleen had to come out, then further management includes administration of pneumovax and some would also immunize for hemophilus influenza B and Meningococcus. |
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A 31 year old lady smashes her car against a wall. She has multiple injuries including upper and lower extremity fractures. Her blood pressure is 75 over 55, with a pulse rate of 110. On physical exam she has a tender abdomen, with guarding and rebound on all quadrants. - What is it? - What should you do? |
What is it? – Blood in the belly is not always, “silent”. It can elicit peritoneal reaction. When it does, you put two and two together and do not need fancy diagnostic tests. Furthermore, blood is not the only thing that can be loose in the belly after trauma: intestinal contents can spill over from ruptured hollow viscus...and that calls for repair also. The question here would be what to do, and the answer would be exploratory lap. |
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A 31 year old lady smashes her car against a wall. Hollow viscera will spill their contents. Of ten they both happen, but one can exist without the other. Here there is not evidence of blood loss, but plenty of clues to suggest that “evil fluid” is loose in the belly. - What will she need? |
Exploratory lap, and repair of the injuries |
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A patient involved in a high speed automobile collision has multiple injuries, including a pelvic fracture. On physical exam there is blood in the meatus. - What is it? |
What is it? – The vignette will be longer, but the point is that pelvic fracture plus blood in the meatus means either bladder or urethral injury. Evaluation starts with a retrograde urethrogram because urethral injury would be compounded by insertion of a Foley catheter. |
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A 19 year old male is involved in a severe automobile accident. Among many other injuries he has a pelvic fracture. He has blood in the meatus, scrotal hematoma and the sensation that he wants to urinate but can not do it. Rectal exam shows a “high riding prostate”. - What is it? - How is the diagnosis made? - Management? |
What is it? - This is a more complete description of a posterior urethral injury.
How is the diagnosis made? - You already know: retrograde urethrogram
Management: They will not ask you, but these get a suprapubic catheter, and the repair is delayed 6 months. |
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A 19 year old male is involved in a motorcycle accident. Among many other injuries he has a pelvic fracture. He has blood in the meatus and scrotal hematoma. Retrograde urethrogram shows an anterior urethral injury. - What is it? - Diagnosis made how? - Management? |
What is it? - This is a more complete description of a posterior urethral injury.
How is the diagnosis made? - You already know: retrograde urethrogram
Management: They will not ask you, but these get a suprapubic catheter, and the repair is delayed 6 months. The anterior urtheral injuries should be repaired first! |
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A patient involved in a high speed automobile collision has multiple injuries, including a pelvic fracture. Insertion of a Foley catheter shows that there is gross hematuria. - What is it? - Diagnosis? |
What is it? – Presumably there was no blood in the meatus to warn against the insertion of an indwelling catheter, and since the latter was accomplished without problem, the urethra must be intact. That leaves us with bladder injury.
Assessment will require retrograde cystogram. |
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A patient involved in a high speed automobile collision has multiple injuries, including rib fractures and abdominal contusions. Insertion of a Foley catheter shows that there is gross hematuria, and retrograde cystogram is normal. - What is it? - How is diagnosis made? - Further management? |
What is it? – Lower injuries have been ruled out. The blood has to be coming from the kidneys.
How is the diagnosis made? – CT scan.
Further management: They will not ask you for fine-judgment surgical decisions, but the rule is that traumatic hematuria does not need surgery even if the kidney is smashed.
They operate only if the renal pedicle is avulsed or the patient is exsanguinating. |
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A 35 year old male is about to be discharged from the hospital where he was under observation for multiple blunt trauma sustained in a car wreck. It is then discovered that he has microscopic hematuria. - Management? |
Gross traumatic hematuria in the adult always has to be investigated. |
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A 14 year old boy slides down a banister, not realizing that there is a big knob at the end of it. He smashes the scrotum and comes in to the E.R. with a scrotal hematoma the size of a grapefruit. - What is it? - How is the diagnosis made? - Management? |
What is it? – The issue in scrotal hematomas is whether the testicle is ruptured or not.
How is the diagnosis made? – Sonogram will tell.
Management: If ruptured, surgery will be needed. If intact, only symptomatic treatment. |
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A 41 year old male presents to the E.R. reporting that he slipped in the shower and injured his penis. Exam reveals a large penile shaft hematoma with normal appearing glans. - What is ti? - Management? |
What is it? – A classical description of fracture of the tunica albuginea...including the usual cover story given by the patient. These always happen during sexual intercourse with woman on top...but patient will not say so.
Management: this is one of the few urological emergencies. Surgical repair is needed. |
