Surgery

Front 1

Case #1:
A 19-year-old male is brought to the ER by ambulance after being shot in the abdomen 20 minutes earlier in a bar. On arrival, he is diaphoretic, pale, cold, shivering, anxious; he asks for a blanket and water. Initial survey confirms the presence of an entry wound in the mid-epigastrium, a blood pressure of 75/60, and a feeble pulse rate of 142.

Back 1

Diagnosis: Hemorrhagic shock
• Most common shock post trauma: hypovolemic (hemorrhagic)
• If trauma to the chest occurs: must also consider pericardial tamponade and tension pneumothorax. Look for elevated CVP and distended neck veins.

Front 2

Case #2:
A car accident victim arrives in the ER. Initial survey shows that he is fully conscious and speaking with a normal tone of voice, but he is also pale, perspiring and shivering. He is breathing well and his head and neck veins are not distended. Blood pressure is 85/62 and there is a barely perceptible pulse at a rate of 115 per min.

Back 2

Diagnosis: Hemorrhagic shock
• Unlike case 1 with penetrating injury, this patient sustained blunt trauma, perhaps to the chest. Must r/o pericardial tamponade and tension pneumothorax.
• Normal JVD and breathing r/o both. Again, hemorrhagic shock is most likely diagnosis.

Front 3

Case #3:
An ambulance arrives at the site where a car ran into a tree on a remote rural road. The lone occupant of the vehicle is cold, pale, perspiring and shivering. His blood pressure is 80/60, his pulse rate is 120, and he has no visible distended veins in his head and neck. The nearest hospital is at least an hour away.

Back 3

Diagnosis: Hemorrhagic shock
Management:
• Infuse Ringer’s lactate while in transit to the hospital

Front 4

Case #4:
An innocent bystander is shot in the chest and abdomen during a botched bank robbery. On arrival in the ER he is pale, diaphoretic, cold, shivering, anxious, and thirsty. He has bilateral breath sounds and is breathing well, but he has large distended veins in his neck and forehead. His blood pressure is 65/45, and his pulse rate is 150.

Back 4

Diagnosis: Cardiogenic shock due to pericardial tamponade
• Can r/o tension pneumothorax because he has normal breath sounds and is breathing well
• By exclusion, correct diagnosis is pericardial tamponade

Front 5

Case #5:
A 23-year-old gang member arrives at the ER with multiple gun shot wounds to the chest. Breathing is labored, nostrils flared, and he has big distended veins in his neck and forehead. He is pale, cold, sweating, shivering, and mumbles that he is going to die. Initial survey shows a blood pressure of 60/40, barely perceptible pulse at a rate of 150, and a right hemithorax that is hyperresonant to percussion and devoid of breath sounds. Palpation of the trachea shows it to be deviated toward the left.

Back 5

Diagnosis: Tension pneumothorax

Front 6

Case #6:
During a round of golf, a business executive is hit on the right side of his head with a golf ball. He loses consciousness for a few minutes, but wakes up promptly and continues to play. 1 hour later he is found unconscious in the locker room. His right pupil is fixed and dilated, and he has contralateral hemiparesis.

Back 6

Diagnosis: Epidural hematoma
• Sequence of trauma, coma, lucid period, coma again, ipsilateral fixed dilated pupil and contralateral hemiparesis suggests acute intracranial hematoma with displacement of the midline structures.