TCRN Abdominal and Pelvic Trauma Questions and Answers — Questions and Answers
Question 1: A patient brought to the trauma center after a high-speed motor vehicle collision is hemodynamically unstable with a suspected unstable pelvic fracture. After initiating massive transfusion protocol, what is the most appropriate next step for hemorrhage control?
- Immediate transfer to the operating room for exploratory laparotomy.
- Application of a pelvic binder or sheet. (Correct answer)
- Urgent transfer to interventional radiology for angioembolization.
- Obtaining a CT scan of the abdomen and pelvis with contrast.
Correct answer: Application of a pelvic binder or sheet.
In a hemodynamically unstable patient with a suspected pelvic fracture, the immediate priority after starting resuscitation is to stabilize the pelvis mechanically. Applying a pelvic binder or sheet provides temporary stabilization, reduces the pelvic volume, and can help control venous and bony bleeding sources, which are the most common causes of hemorrhage in these injuries. While angioembolization or surgery may be necessary, mechanical stabilization is the crucial first intervention.
Question 2: A trauma nurse is assessing a restrained driver from a frontal impact collision and notes a linear ecchymosis across the lower abdomen. This finding, known as the 'seatbelt sign,' should raise the highest suspicion for which type of injury?
- Splenic laceration
- Lumbar spine fracture
- Hollow viscus injury (Correct answer)
- Diaphragmatic rupture
Correct answer: Hollow viscus injury
The 'seatbelt sign' is strongly associated with underlying intra-abdominal injuries, particularly hollow viscus injuries like bowel perforation or mesenteric lacerations. The mechanism involves the compression of the bowel between the seatbelt and the vertebral column during sudden deceleration. While solid organ and spine injuries can also occur, the highest index of suspicion should be for bowel and mesenteric trauma.
Question 3: A patient with blunt abdominal trauma is complaining of acute, sharp pain in the left shoulder. This finding, known as Kehr's sign, is most indicative of an injury to which organ?
- Liver
- Stomach
- Spleen (Correct answer)
- Left Kidney
Correct answer: Spleen
Kehr's sign is referred pain to the left shoulder caused by irritation of the diaphragm from blood in the peritoneal cavity. This sign is a classic clinical indicator of a ruptured or injured spleen, as the phrenic nerve (which innervates the diaphragm) shares the same nerve roots (C3-C5) as the supraclavicular nerves that supply the shoulder area.
Question 4: A trauma patient is undergoing a Focused Assessment with Sonography for Trauma (FAST) exam. The primary purpose of this examination in the initial assessment of a trauma patient is to detect:
- Specific solid organ injury grades.
- The presence of free fluid in the peritoneum or pericardium. (Correct answer)
- Retroperitoneal hemorrhage.
- Bowel wall thickening or perforation.
Correct answer: The presence of free fluid in the peritoneum or pericardium.
The FAST exam is a rapid, non-invasive ultrasound screening tool designed to identify the presence of free fluid (assumed to be blood in the context of trauma) in dependent areas of the peritoneal, pericardial, and pleural spaces. It is used to rapidly identify potential life-threatening hemorrhage, not to grade specific organ injuries, definitively diagnose retroperitoneal bleeding, or identify bowel injuries.
Question 5: A patient with a pelvic fracture has gross hematuria. A CT cystogram reveals extravasation of contrast into the peritoneal cavity. Which of the following is the most definitive management for this type of injury?
- Placement of a suprapubic catheter.
- Prolonged Foley catheter drainage for 10-14 days.
- Serial abdominal examinations and bed rest.
- Surgical exploration and repair. (Correct answer)
Correct answer: Surgical exploration and repair.
The finding of contrast in the peritoneal cavity on a cystogram confirms an intraperitoneal bladder rupture. This type of injury requires surgical exploration and repair to prevent complications such as urinary ascites, peritonitis, and sepsis. Conservative management with catheter drainage alone is typically reserved for uncomplicated extraperitoneal bladder ruptures.
Question 6: Which of the following interventions is the priority for a hemodynamically unstable patient with a severe pelvic fracture and a positive FAST exam?
- Application of a pelvic binder and transfer to the operating room. (Correct answer)
- CT scan to delineate the pelvic fracture pattern.
- Insertion of a suprapubic catheter for bladder decompression.
- Immediate transfer for angiographic embolization.
Correct answer: Application of a pelvic binder and transfer to the operating room.
In a patient who is hemodynamically unstable with both a pelvic fracture and evidence of intra-abdominal hemorrhage (positive FAST), the priority is controlling both sources of bleeding. A pelvic binder should be applied immediately to address the pelvic bleeding. The patient should then be taken directly to the operating room for an exploratory laparotomy to control the intra-abdominal source of hemorrhage. Delaying for a CT scan or angioembolization is inappropriate in a patient with ongoing instability and a positive FAST.
TCRN Abdominal and Pelvic Trauma Questions and Answers
A patient brought to the trauma center after a high-speed motor vehicle collision is hemodynamically unstable with a suspected unstable pelvic fracture.
After initiating massive transfusion protocol, what is the most appropriate next step for hemorrhage control?