ATLS - Advanced Trauma Life Support Abdominal and Pelvic Trauma Questions and Answers 1 — Questions and Answers
Question 1: A 34-year-old male involved in a high-speed motor vehicle collision is brought to the trauma bay. He is hemodynamically unstable with a blood pressure of 88/50 mmHg and a heart rate of 125 bpm. A FAST exam is performed and is positive for free fluid in the hepatorenal space (Morison's pouch). According to ATLS principles, what is the most appropriate next step in management?
- Administer a second 1L bolus of crystalloid and repeat the FAST exam.
- Obtain an urgent CT scan of the abdomen and pelvis with intravenous contrast.
- Perform an immediate exploratory laparotomy. (Correct answer)
- Perform a diagnostic peritoneal lavage (DPL) to confirm hemoperitoneum.
Correct answer: Perform an immediate exploratory laparotomy.
In a hemodynamically unstable patient with blunt abdominal trauma, a positive FAST exam is a strong indicator of intra-abdominal hemorrhage and is an indication for immediate surgical intervention. Delaying for further imaging like a CT scan or repeating the FAST exam is inappropriate as it wastes critical time. DPL is largely historic and would be redundant after a positive FAST.
Question 2: Which of the following is an absolute indication for an immediate exploratory laparotomy in a patient with a penetrating abdominal wound?
- A gunshot wound to the right upper quadrant in a stable patient.
- Evisceration of omentum. (Correct answer)
- A stab wound to the anterior abdomen without peritoneal signs.
- Hematuria following a stab wound to the flank.
Correct answer: Evisceration of omentum.
Evisceration of any intra-abdominal content (such as omentum or bowel) through a penetrating wound is a definitive sign of peritoneal violation and mandates immediate exploratory laparotomy. The other options are relative indications that may be managed with further evaluation (e.g., CT scan) or observation in a hemodynamically stable patient.
Question 3: A 22-year-old male presents after being crushed between two vehicles. He has an unstable pelvic fracture and, on physical examination, blood is noted at the urethral meatus. What is the most appropriate initial diagnostic step to evaluate the urinary tract?
- Perform a retrograde urethrogram (RUG). (Correct answer)
- Immediately attempt to place a Foley catheter.
- Obtain an urgent urology consultation for suprapubic catheter placement.
- Perform a CT cystogram.
Correct answer: Perform a retrograde urethrogram (RUG).
The presence of blood at the urethral meatus, especially in the context of a significant pelvic fracture, is highly suspicious for a urethral injury. Attempting to blindly pass a Foley catheter is contraindicated as it can convert a partial urethral tear into a complete transection. The correct first step is to perform a retrograde urethrogram (RUG) to assess the integrity of the urethra before any catheterization is attempted.
Question 4: A 45-year-old restrained driver involved in a frontal collision has a normal FAST exam. A chest x-ray is obtained, and the nasogastric tube is visualized coiled in the left hemithorax. What is the most likely diagnosis?
- Esophageal perforation.
- Tension pneumothorax.
- Tracheobronchial injury.
- Traumatic diaphragmatic rupture. (Correct answer)
Correct answer: Traumatic diaphragmatic rupture.
The visualization of an abdominal organ, such as the stomach (indicated by the coiled nasogastric tube), within the thoracic cavity on a chest x-ray is a pathognomonic sign of a traumatic diaphragmatic rupture. This occurs when a tear in the diaphragm allows abdominal contents to herniate into the chest.
Question 5: A 30-year-old female presents 36 hours after being kicked in the abdomen during an altercation. She initially declined medical care but now has a fever, tachycardia, and diffuse abdominal tenderness with rigidity. Which of the following injuries is most likely responsible for her delayed presentation and current signs of peritonitis?
- Splenic laceration with a subcapsular hematoma.
- Hepatic contusion.
- Small bowel perforation. (Correct answer)
- Renal artery thrombosis.
Correct answer: Small bowel perforation.
Injuries to hollow viscera, such as a small bowel perforation, often have a delayed presentation. The initial injury may be small, but the subsequent leakage of enteric contents leads to chemical and then bacterial peritonitis over hours to days, causing fever, tachycardia, and a rigid abdomen. Solid organ injuries (spleen, liver, kidney) typically present more acutely with signs of hemorrhage.
Question 6: The presence of ecchymosis across the lower abdomen in the distribution of a lap belt (a "seat belt sign") following a motor vehicle collision should raise the highest suspicion for which combination of injuries?
- Diaphragmatic rupture and splenic laceration.
- Aortic dissection and renal contusion.
- Hollow viscus injury and lumbar spine fracture. (Correct answer)
- Hepatic laceration and rib fractures.
Correct answer: Hollow viscus injury and lumbar spine fracture.
The "seat belt sign" indicates a significant transfer of energy to the abdominal wall and its underlying structures. This mechanism is strongly associated with compression injuries to the bowel (hollow viscus injury) and flexion-distraction injuries to the lumbar spine (e.g., a Chance fracture).
ATLS - Advanced Trauma Life Support Abdominal and Pelvic Trauma Questions and Answers 1
A 34-year-old male involved in a high-speed motor vehicle collision is brought to the trauma bay.
He is hemodynamically unstable with a blood pressure of 88/50 mmHg and a heart rate of 125 bpm.
A FAST exam is performed and is positive for free fluid in the hepatorenal space (Morison's pouch).
According to ATLS principles, what is the most appropriate next step in management?