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  #1  
Old 07-17-2012
tyagee's Avatar
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Default managing unstable blunt trauma patient

PLEASE GIVE EXPLANATION FOR YOUR CHOICES...

1.
A 44-year-old obese male is brought to the ER after a motor vehicle accident. His cervical spine is
immobilized. He is alert and able to speak in complete sentences. He complains of abdominal pain. At the
scene of the accident, his blood pressure is 90/60 mm Hg and pulse is 120/min. Lungs are clearto
auscultation. Ecchymosis is present over the abdominal wall in distribution of the seat belt. Bowel sounds
are decreased. Neck veins are collapsed. After receiving one liter of intravenous fluids, his blood pressure
remains at 90/60 mmHg. A focused assessment with sonography for trauma is inconclusive due to the poor
image quality W hich of the following is the most appropriate next step in management of this patient?
A. CT scan of the abdomen
B. Plain X-ray films of the abdomen
C. Diagnostic peritoneal lavage
D. Immediate laparotomy
E. X-ray of the chest
F. Pericardiocentesis
G. Chest tube placement
------------------------------------
2.
A 36-year-old man is brought to the emergency department after being involved in a motor vehicle
collision
. He is in obvious distress. His blood pressure is 80/30 mm Hg, pulse is 140/min and respirations
are 23/min. Examination reveals collapsed neck veins. Breath sounds are present bilaterally, heart sounds
are normal and the trachea is midline. He is semiconscious and his pupils are bilaterally reactive. There is
no obvious head injury. Abdominal examination shows distention with tenderness in all four quadrants with
guarding and rigidity. After initial resuscitation including control of his airway, breathing and circulation, which
of the following is the most appropriate next step in management?
A. Diagnostic laparoscopy
B. Chest x-ray
C. CT of the abdomen
D. Exploratory laparotomy
E. Diagnostic peritoneal lavage
------------------------------------
3.
A 34-year-old unrestrained male driver is brought to the ER after a motor vehicle accident. His cervical spine
is immobilized. At the scene of the accident, his blood pressure is 80/40 mm Hg and heart rate is 130/min.
He is able to communicate and follows simple commands. Lungs are clear to auscultation. Abdominal wall
ecchymosis is present. Abdomen is mildly distended. Bowel sounds are decreased. Neck veins are
collapsed. After two liters of intravenous fluids, his blood pressure is 90/60 mmHg. W hich of the following is
the most appropriate next step in management of this patient?
A. Laparoscopy
B. Laparotomy
C. Angiogram
D. X-ray films of the abdomen and pelvis
E. CT scan of the chest
F. CT scan of the abdomen
G. Pericardiocentesis
H. Chest tube placement
I. Focused assessment with sonography
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Old 07-17-2012
Hitman's Avatar
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Qs 1 ) C ......... As pt appears to be still bleeding as BP doesnot improve , will confirm abdo bleed ... not xray as it may be blur like USG and x ray may show only perforation while pt might have a bleed from spleen . not laprotomy as pt not in acute distress , BP has not fallen so the bleeding may stop ....

Qs 2) D ....... Pt is hypotensive + abdo distension + guarding no other tests , operate instantly

Qs3) D ...... Pts BP has improved + no in acute distress +x ray will show ascites or perforation . not ct as pt still not well and difficult to do ct in such trauma cases ......
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Old 07-17-2012
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1-- C. Diagnostic peritoneal lavage

pt with trauma --- give fluids -- try to locate site of bleed by FAST
if inconclusive --- do DPL
if either one is + ---> do exploratory laparotomy.


2.. confused between these two options.
D. Exploratory laparotomy
E. Diagnostic peritoneal lavage

but i would go with D. Exploratory laparotomy
because there is enough evidence that there is bleeding into the abdomen on physical examination.
Doing a DPL.. WILL NOT CHANGE COURSE OF MANAGEMENT... and will also not provide any extra info .. except for confirm the bleed (which there is already high suspicion of of Physical exam)



3- I. Focused assessment with sonography
same explanation as 1.
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Old 07-17-2012
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my answers--
1.C
2.C
3.I
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  #5  
Old 09-20-2013
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I stumbled on to this thread.....saw the OP didnt update the qs, thought I would do it instead.

These are the Correct answers. Source uwqbank.

1. DPL
FAST is inconclusive, (and can be if the tech did a poor job or if a certain body type is difficult to image) you can do a DPL to assess the need for an exLAP in an unstable trauma pt.,
DPL is rarely done, but none the less will tell if you have a bleed in the peritoneal cavity if FAST can't tell you for some reason. Primary tool to asses need to emergent Lap is FAST in an unstable trauma patient. Doing a CT not ideal as it would take up valuable time in order to tell you the same thing.

2. Exploratory Lap
Physical exam signs point towards peritonitis which is an emergency. Operate.

3. FAST
Must do FAST first before ex LAP. If the stem said pt has postive FAST finding then we do ExLap. If FAST was unequivocal, then we would do DPL to assess whether a bleed is present in an unstable trauma pt.

Mbbs 2010 is correct.
1. C
2. D
3. I



If the patient is hemodynamically stable....then you can do a CT scan usually if the question tells you BAT+vitals stable and you suspect internal bleeding from the spleen...get a CT to determine if you need to remove or salvage the spleen for eg.


Hope this clears up any confusion.
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  #6  
Old 09-20-2013
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all 3 above are usmle world qs, the agree with above answers.

in blunt abdominal trauma , and unstable pressure you should think about bleeding source ,
fast is the initial thing to do with simultaneouse initial stabilization,

fast inclusive , patient still bledding possibly dpl

totally unstable patient and signs of peritonitis do exploratory laparotmy
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