The limitations of

mammography include

(A) 1015% false negative rate

(B) 10% false positive rate

(C) difficulty visualizing tumors in the tail of Spence

(D) all of the above

(E) none of the above


Explanation:
There is a 1015% false negative rate of current mammography. In women
4049 years old, nearly 25% of invasive breast cancers are not visualized.
This drops to 10% for women 5059 years old. Almost 10% of patients
who have routine screening mammography are asked to return for
additional studies. This is to better clarify the abnormality. The additional
studies may include additional mammographic views or ultrasounds, or it
may require invasive studies such as a biopsy. Mammograms in general are
less sensitive in younger women with dense breast tissue. Breast implants
may also obscure a mammographic evaluation. Routine mammography has
a difficult time visualizing lesions deep against the chest wall, lateral in the
tail of breast, or inferior in the inframammary fold.

BibliographyKopans D. Imaging analysis of breast lesions. In: Harris JR,
Lippman ME, Morrow M, et al. (eds.), Diseases of the Breast, 2nd ed.
Philadelphia, PA: Lippincott, Williams & Wilkins, 2000, 128134.

Phyllodes tumors

(A) present in postmenopausal women

(B) are often malignant

(C) require mastectomy because of their high recurrence
rate

(D) tend to recur

(E) are responsive to hormonal manipulation


Explanation
: Phyllodes tumors, also known as cystosarcoma phyllodes, are stromal tumors. They are well
circumscribed and do not have a true capsule. The cut surface of one of these tumors tends to be
mucoid. There are numerous small projections that make surgical enucleation difficult.
Phyllodes tend to occur in an older population than fibroadenomas (FAs). FAs are also stromal
tumors, and it is thought that phyllodes may arise from these benign tumors. Phyllodes tend to
occur in the fourth decade of life. Most of these tumors present as painless masses that are
round and smooth. On mammogram and ultrasound they are similar in appearance to FAs
smooth, solid, multilobulated margins. There may also be fluid within the mass on ultrasound,
suggesting phyllodes over FA.
Seventy-five percent of phyllodes tumors are benign. Similar to other stromal tumors, malignancy
is difficult to establish and is based on histologic appearance. Stromal overgrowth is now
considered the most important predictor of aggressive behavior. Other characteristics that are
considered are cellular atypia, mitotic activity, and tumor margins.
Phyllodes tend to recur regardless of benign or malignant status. The reported incidence is 20
25% of recurrence. Current recommendations for initial surgical treatment of theses tumors are
wide local excision with a 23 cm margin. This can usually be done without requiring a
mastectomy and is based on tumor to breast mass ratio. Usually if the tumor recurs, a total
mastectomy is required; however, some women may be able to tolerate a reexcision without poor
cosmesis. Less than 5% of all phyllodes tumors metastasize. Regional lymph node metastasis is
rare and an axillary dissection is not warranted. Radiation therapy is also not indicated because
this is not a multifocal disease like ductal breast cancer. The tumors are only weakly
radiosensitive; however, radiation therapy may offer some palliation for recurrent disease.
Hormonal manipulation is not beneficial for these patients. This is felt to represent the mixed
epithelial (positive receptors) and stromal (no receptors) components.

BibliographyDonegan W. Sarcomas of the breast. In: Donegan W, Sprattt J (eds.), Cancer of the
Breast, 5th ed. St. Louis, MO: W.B. Saunders, 2002, 918923.

Petrek J. Phyllodes tumor. In: Harris JR, Lippman ME, Morrow M, et al. (eds.), Diseases of the
Breast, 2nd ed. Philadelphia, PA: Lippincott, Williams & Wilkins, 2000, 669675.

Wood W. Benign breast disease. In: Cameron J (ed.), Current Surgical Therapy, 7th ed. St. Louis,
MO: Mosby, 2001, 691.


The most common etiology of
senescent gynecomastia is

(A) cirrhosis

(B) testicular tumor

(C) renal disease

(D) idiopathic causes

(E) drug induced


Explanation
: Gynecomastia is the benign proliferation of breast glandular tissue
in males. This tends to occur in infancy, at puberty, and in old age.
Gynecomastia results from an imbalance of the normal hormonal
milieu or a change in breast tissue sensitivity to estrogen. The
testes secrete 95% of the total body testosterone and only 15% of
the circulating estradiol. The vast majority of circulating estradiol is
from the peripheral conversion of testosterone and adrenal steroids
via the aromatase enzyme. Most of the hormones are bound to sex-
hormone binding globulin (SHBG), a protein formed in the liver.
SHBG has a higher affinity for androgens than estrogen. An
imbalance in any of these pathways may results in an increase of
free estrogen as compared to bound estrogen (Fig. 15-5).
Tamoxifen

(A) is an estrogen receptor (ER) agonist

(B) is an ER antagonist

(C) has been shown to decrease the incidence of
recurrent breast cancer by 47%

(D) has been shown to decrease the risk of future breast
cancer by 49% in high-risk patients

(E) all of the above

Explanation
: Tamoxifen, a selective estrogen receptor (ER) agonist antagonist, first
came into the market in the 1970s. It is a well-studied drug. The antagonist
effects of tamoxifen are related to its competitive binding of the estrogen
receptor, especially in breast tissue. This results in a reduced transcription
of estrogen related proteins and effective blockade of cell cycle in G1. This
in turn then translates to ineffective tumor growth.
Tamoxifen has apparent estrogen agonist effects on the endometrial lining,
as shown by the increase in endometrial cancer found in women being
treated with the drug. This risk is about 1%. The cancers are usually found
in stage I and are very treatable. In addition, there is an increased risk of
venous embolic phenomena that is related to the estrogen agonist effects.
Tamoxifen also increases bone density and improves lipid profilesboth
related to ER agonist activity. The major side effects that women complain
about while taking tamoxifen are hot flashes and sleep disturbances
similar to menopausal symptoms attributed to decreased estrogen.
A 34-year-old lady is referred to your office for evaluation of breast pain. She describes the pain as
burning, occasionally sharp in nature. It is mostly located in the subareolar area and seems to be fairly
well localized. When asked when the pain occurs, she states that it is always present and is very
troublesome to her. On physical examination, she has dense glandular tissue throughout both breasts,
but no discrete nodules.
Your working diagnosis at this point is noncyclical breast pain.
Your next step in management is
(A) reassurance

(B) start a diuretic

(C) refer her to a psychologist

(D) give a steroid injection

(E) perform a surgical excision of the painful
area
Explanation
: Mastalgia, or breast pain, is a common
complaint and a common reason for referral to a
breast center. Evaluation of breast pain should
include a thorough history and examination.
With a good history, you can begin to categorize
the pain. Typical types of mastalgia can be
described as cyclical pronounced, noncyclical,
trauma, musculoskeletal/chest wall, and
miscellaneous uncommon cause.
Cyclical pronounced pain is the most common. It
is related to the menstrual cycle, especially
ovulation. The average age is 34 years. Patients
complain of "heaviness" and "tenderness."
Nodularity is common, especially in the upper
outer quadrants. This also tends to fluctuate
with the menstrual cycle. The pain is often in the
upper outer quadrant, may be bilateral, and can
radiate down the arm.
Noncyclical mastalgia is not related to the
menstrual cycle. The average age of the
patient is again 34 years old. The pain is
different from cyclical pain in that is more
localized and described as a "burning" or
"pulling." Nodularity is typically less
pronounced, but it is present in greater
than 50% of the patients.
A 40-year-old woman presents with a 2 cm mass in her right breast
first detected by mammography (Fig. 15-2). Radiographic core biopsy of
the lesion is selected for diagnosis and reveals infiltrating ductal carcinoma.
She has no palpable axillary lymph nodes, core bx: invasive malignant,
SLNB:POSITIVE
AJCC) TNM staging system is

(A) I

(B) II

(C) III

(D) IV

(E) V


The AJCC TNM Clinical Staging
System is as follows
:
1. Primary tumor (T)
Tx: primary tumor cannot be assessed
T0: no primary tumor
Tis: carcinoma in situ
T1: tumor 2 cm.
T2: tumor > 2 cm. but 5 cm.
T3: tumor > 5 cm.
T4: tumor with extension to chest wall, skin edema or
ulceration or inflammatory carcinoma
Regional lymph nodes (N)

. Nx: regional lymph nodes cannot be assessed
N0: no regional lymph node metastasis
N1: metastases to mobile axillary lymph nodes
N2: metastases to fixed, matted or clinically
apparent axillary lymph nodes or internal
mammary nodes
N3: metastases to axillary and infraclavicular
lymph nodes, clinically apparent internal
mammary nodes or supraclavicular lymph nodes
Distant metastasis

Mx: distant metastasis cannot be
assessed
M0: no distant metastasis
M1: distant metastasis
Stage grouping
.
Stage 0: TisN0M0
Stage 1: T1N0M0
Stage 2A: T0N1M0, T1N1M0, T2N0M0
Stage 2B: T2N1M0, T3N0M0
Stage 3A: T0N2M0, T1N2M0, T2N2M0, T3N1M0,
T3N2M0
Stage 3B: T4N0M0, T4N1M0, T4N2M0
Stage 3C: AnyTN3M0
Stage 4: AnyT AnyN M1
Which of the following is false regarding
lobular carcinoma in situ?

(A) It is a marker for increased risk of breast cancer.

(B) Mirror image breast biopsy is indicated.

(C) Subsequent invasive cancer is more often ductal in origin.

(D) Treatment is close observation versus bilateral prophylactic
mastectomy.

(E) Prognosis is solely related to the development of subsequent
cancer.


Explanation:
The histologic picture consists of many clusters of epithelial cells forming
islands of neoplastic cells but maintaining a lobular architecture. It occurs
more often in premenopausal women and does not form a palpable mass.
It is most commonly found as an incidental finding on biopsy, as it does not
have any mammographic findings.
Lobular carcinoma in situ carries a risk of developing into an invasive ductal
carcinoma in 1035% of patients over a period of 1520 years.
Because the risk of subsequent breast cancer is almost the same for both
breasts, mirror image biopsies of the opposite breast are not indicated.
Histologic examinations are generally favorable and deaths are unusual in
women with appropriate medical care. Any treatment of in situ carcinoma is
aimed at preventing invasive disease.
Treatment options include close observation or pharmacologic prophylaxis.
A 5-year course of tamoxifen has been shown to reduce the relative risk of
invasive cancer by 56% in women with LCIS. Surgical options such as
bilateral mastectomy or breast-conserving surgery are considered only in
special circumstances in which the patient may have multiple risk factors
The effective osmotic pressure between the plasma
and interstitial fluid compartments is primarily
controlled by

(A) Bicarbonate

(B) Chloride ion

(C) Potassium ion

(D) Protein


Explanation
: The dissolved protein in plasma does not
pass through the semipermeable cell
membrane, and this fact is responsible for
the effective or colloid osmotic pressure.
(See Schwartz 7th ed.)
The simplest effective method of estimating the
degree of acidosis in a patient in shock is the
measurement of

(A) Arterial pH

(B) End tidal CO2 concentration

(C) pH of mixed venous blood

(D) Serum CO2 level
Explanation:
Only the measurement of arterial pH and
PCO2 gives an accurate picture of the
degree of acid-base imbalances. (See
Schwartz 7th ed.)
Each of the following is a symptom of a hemolytic
transfusion reaction EXCEPT

(A) Constricting chest pain

(B) Flushing of the face

(C) Lumbar pain

(D) Syncope

Explanation:
Syncope is not associated with a hemolytic
transfusion reaction, whereas the other
listed symptoms are common occurrences.
(See Schwartz 7th ed.)
After drainage of a pelvic abscess, a 45-year-old patient
receiving 70% oxygen is found to have the following arterial
blood gases: pH, 7.48; PO2, 55 mm Hg; PCO2, 30 mm Hg.
These results are most consistent with the diagnosis of

(A) Chronic obstructive pulmonary disease

(B) Postoperative pain and anxiety

(C) Adult respiratory distress syndrome

(D) Postoperative atelectasis
Explanation:
The combination of hypoxemia that is resistant to high
oxygen concentrations and hyperventilation is
characteristic of the adult respiratory distress syndrome
(ARDS). There are four general causes of hypoxemia:
hypoventilation, a low ventilation-perfusion ratio,
diffusion abnormalities, and pulmonary shunting.
Although the first three conditions improve in response
to an increased inspired oxygen concentration most of
the hypoxemia seen in ARDS is secondary to shunting
and so is not ameliorated by oxygen. The abnormalities
seen in ARDS are thought to result from injury to the
alveolar-capillary membrane that causes an increased
permeability of the membrane, which in turn leads to
interstitial pulmonary edema and decreased pulmonary
compliance. (See Schwartz 7th ed.)
All of the following result from the placement of an intraaortic
balloon pump in a patient with acute myocardial failure
EXCEPT

(A) Diastolic blood pressure elevation

(B) Increased cardiac output

(C) Increased pulmonary perfusion

(D) Increased probability of survival


The P50 value (the PO2 at which 50% of hemoglobin is saturated
with oxygen) indicates the position of the oxyhemoglobin
dissociation curve along the horizontal axis. All of the following
conditions can produce a leftward-shifted curve (decreased P50)
EXCEPT

(A) Carbon monoxide poisoning

(B) Hypothermia

(C) Acidosis

(D) 2,3-diphosphoglycerate deficiency
Explanation:
Determinations of P50 are used to monitor the affinity of oxygen for
hemoglobin, with the normal value being approximately 26 mm Hg.
A low P50, indicating an increased affinity of oxygen for hemoglobin
and a decreased release of oxygen to the tissues, causes a leftward
shift in the oxyhemoglobin dissociation curve. Low red blood cell
levels of 2,3-diphosphoglycerate (which occur when blood is stored
more than 2 weeks), carbon monoxide poisoning, and hypothermia
lower the P50. Conversely, the natural affinity of hemoglobin for
oxygen is decreased by high levels of diphosphoglycerate, by carbon
dioxide (Bohr effect), by heat, and by hydrogen ions. In acidosis,
shifting of the oxyhemoglobin dissociation curve to the right
(increased P50) reflects a protective mechanism to improve oxygen
supply to the tissues. However, in spite of elevations of the P50,
severe arterial desaturation (e.g., pulmonary shunting) may offset
any potential gains in oxygen availability. (See Schwartz 7th ed.)
The earliest manifestations of serious gram-negative infection
may consist of a triad of signs that includes

(A) Tachypnea, hypotension, and an altered
sensorium

(B) Tachypnea, hypotension, and lactic acidosis

(C) Thrombocytopenia, hypotension, and lactic
acidosis

(D) Mild hyperventilation, respiratory alkalosis,
and an altered sensorium
Explanation:
The development of mild hyperventilation, respiratory
alkalosis, and an altered sensorium may be the earliest
sign of gram-negative infection. This triad may precede
the usual signs and symptoms of sepsis by several hours
to several days. Although the exact pathophysiology of
this manifestation is unknown, the triad of signs is
thought to represent a primary response to bacteremia.
Early recognition of the findings, followed by a prompt
search for the source of infection, may allow diagnosis
and treatment prior to the onset of shock. (See Schwartz
7th ed.)
Cardiac preload is determined
by

(A) End-diastolic volume

(B) End-diastolic pressure

(C) End-systolic volume

(D) End-systolic pressure
Explanation:
Starling's law of the heart states that the force of muscle
contraction depends on the initial length of the cardiac fibers. Using
terminology that derives from early experiments using isolated
cardiac muscle preparations, preload is the stretch of ventricular
myocardial tissue just prior to the next contraction. Preload is
determined by end-diastolic volume (EDV). For the right ventricle,
central venous pressure (CVP) approximates right ventricular end-
diastolic pressure (EDP). For the left ventricle, pulmonary artery
occlusion pressure (PAOP), which is measured by transiently
inflating a balloon at the end of a pressure monitoring catheter
positioned in a small branch of the pulmonary artery, approximates
left ventricular end-diastolic pressure. The presence of
atrioventricular valvular stenosis will alter this relationship. (See
Schwartz 8th ed., Chapter 12, Cardiac Output and Related
Parameters
Positive end-expiratory pressure (PEEP) ventilation is widely
used in the treatment of acute pulmonary failure. The
beneficial effects of PEEP include all of the following EXCEPT

(A) Decreased pulmonary shunting

(B) Decreased extravascular lung water

(C) Increased resting volume of the lung

(D) Increased oxygenation


Explanation:
The mechanism of action of PEEP ventilation has not
been completely elucidated. However, the beneficial
effects of PEEP include (1) an increase in oxygenation
(PaO2); (2) an increase in resting volume (i.e.,
functional residual capacity, of the lung); (3) an increase
in pulmonary compliance; (4) an increase in the ratio of
ventilation to perfusion when the ratio is initially low;
and (5) decreased pulmonary shunting (venous
admixture). There has been no good experimental
evidence that PEEP leads to a direct decrease in lung
water. (See Schwartz 7th ed.)
All of the following findings would indicate that a patient
requires mechanical ventilatory support EXCEPT

(A) Respiratory rate greater than 30 breaths per
minute

(B) Vital capacity less than 15 mL/kg

(C) Maximal inspiratory force of 40 cm H2O

(D) Alveolar-arterial oxygen gradient greater
than 350 torr
Explanation:
The treatment of acute respiratory insufficiency is based primarily
on ventilatory support. Endotracheal intubation, preferably through
the nose, is considered the technique of choice. A maximal
inspiratory force of 40 cm H2O is not a criterion for ventilatory
support. On the other hand, a patient who has stable vital signs and
who (1) exhibits adequate oxygenation on an inspired oxygen
concentration of 0.4 or less, (2) has a resting minute ventilation less
than 10 L/min, (3) has a vital capacity greater than 15 mL/kg, and
(4) has a tidal volume greater than 5 mL/kg almost certainly will
tolerate withdrawal of ventilatory support. A maximal inspiratory
force of 30 cm H2O or less (i.e., more negative), however,
generally is necessary to maintain spontaneous ventilation.
Consideration of all of these parameters together would greatly
assist in a decision whether or not to withdraw mechanical
ventilation. (See Schwartz 7th ed.)
Which of the following statements about organelle
function is incorrect?

(A) The rough endoplasmic reticulum (rER) is the site of protein synthesis and the
cotranslational modification of proteins.

(B) The smooth endoplasmic reticulum (sER) is the site of phospholipid synthesis,
steroid hormone synthesis, drug detoxification, and calcium store release.

(C) The Golgi complex is the site of vesicular packaging of proteins, membrane
component recycling, and posttranslational modification of proteins.

(D) The mitochondrion functions in acetyl-CoA production, tricarboxylic acid (TCA)
cycle, oxidative phosphorylation, and fatty acid oxidation.

(E) The lysosome contains amino acid oxidase, urate oxidase, catalase, and other
oxidative enzymes relating to the production and degradation of hydrogen peroxide
and oxidation of fatty acids.

Explanation
: Lysosomes contain acid hydrolases or lysosomal enzymes that include proteases, nucleases,
lipases, and galactosidases that function at an acidic pH to degrade old intracellular organelles or
phagocytosed substances. Organelles have a relatively rapid rate of turnover (e.g., liver
mitochondria have a lifetime of 10 days) and are broken down in a process called autophagy. Old or
damaged organelles are enveloped by an additional membrane to create an autophagosome, which
fuses with a lysosome for degradation. For phagocytosed or endocytosed substances, these are
taken-up into early endosomes where some of the materials are recycled back to the plasma
membrane and others continue as late endosomes. Golgi hydrolase vesicles containing inactive
lysosomal enzymes fuse with late endosomes to form mature lysosomes. The late endosomes
contain proton pumps to produce a pH 5 environment to activate the lysosomal enzymes from the
Golgi hydrolase vesicles. Although most lysosomes function in intracellular digestion, a few cell
types such as neutrophils and osteoclasts are able to release lysosomal contents extracellularly for
degrading materials. There are numerous lysosomal storage diseases (e.g., Hunter's, Hurler's,
Sanfilippo A, Tay-Sachs, Gaucher's, Niemann-Pick, Pompe's, I-cell, and Krabbe's disease) each
associated with mutations of different lysosomal enzymes and abnormal accumulation of undigested
materials.
Peroxisomes are unique organelles in that they are surrounding only by a single membrane and
contain amino acid hydrolase, hydroxyacid oxidase, urate oxidase, and catalase for the production
and breakdown of hydrogen peroxide. The oxidative reactions performed by peroxisomes are
important for the breakdown of toxic substances and fatty acid molecules. Peroxisomes are also
essential for the production of certain phospholipid classes in myelin; therefore many peroxisomal
disorders result in neurologic disease. Although peroxisomes are self-replicating organelles, they do
not contain their own DNA or ribosomes and must import their proteins from the cytosol, which are
marked by a 3-amino acid signal sequence. The peroxisomal import process involves docking
proteins, peroxins, and ATP hydrolysis. Peroxisomal dysfunction is the etiology of Zellweger's
syndrome (aka cerebrohepatorenal syndrome), which is an autosomal recessive neonatal syndrome
characterized by incomplete myelinization of nervous tissue and muscular hypotonia, hepatomegaly,
and small glomerular cysts of the kidney resulting in death shortly after birth.
Adrenoleukodystrophy (ALD) is an X-linked recessive disorder involving the absence or dysfunction
of peroxisomal enzymes essential for fatty acid -oxidation. ALD results in the myelin degeneration
in the nervous system and abnormal intracellular accumulation of lipids, manifesting in progressive
dementia, spastic paralysis, and adrenal insufficiency in children (see Figs. 1-12 and 1-13).
A 41-year-old female presents to the emergency department after
sustaining a gunshot wound to the abdomen, with injuries to the liver
and large bowel. Despite successful resuscitation and operative
intervention, the patient dies 2 weeks later of multisystem organ
failure in the intensive care unit. Which organ most likely first
experienced dysfunction?

(A) liver

(B) gastrointestinal tract

(C) lung

(D) kidney

(E) heart

Explanation:
Death due to trauma with hemorrhagic shock is arranged in a trimodal distribution: immediate (at the scene),
within the first 24 hours, and 1 week or more following the injury. In the acute period after trauma, mortality is
attributable to massive hemorrhage or neurologic injury. Direct injury to an organ contributes to a primary
multiple organ dysfunction in this early period. In contrast, late deaths, occurring at least 1 week subsequent to
the trauma, generally arise from secondary multiple organ dysfunction syndrome (MODS). This condition
develops in 3060% of these trauma patients and is associated with an 80% mortality rate.
MODS is defined as the failure of multiple organs in a critically ill patient in whom the maintenance of
homeostasis requires intervention. This syndrome appears as the end point in a variety of conditions, not isolated
to trauma and hemorrhagic shock. In the case of trauma, the prevalence of MODS is ascribed to a two-hit
phenomenon, first proposed by Partrick et al. This hypothesis suggests that trauma represents an initial insult
which predisposes the immune system to react later to a lesser injury with a massive response, mediated
primarily by neutrophils, resulting in great collateral damage (Fig. 6-12). The primed neutrophils mediate further
tissue injury by means of proteolytic enzymes, reactive oxygen species, and vasoactive substances. A study from
Fan et al. (1998) demonstrated that, in a model of murine hemorrhagic shock, intratrachial administration of LPS
1 hour after successful resuscitation provoked enhanced neutrophil sequestration and edema in the lung; this
response was not generated in the absence of resuscitated hemorrhagic shock or LPS. Following traumatic
hemorrhagic shock, the patient is resuscitated into not only a local but also a systemic inflammatory response
syndrome (SIRS), with generalized inflammation generated within 1 hour of injury. Neutrophils and monocytes
are first activated, releasing inflammatory mediators. TNF- , IL-1, and IL-6 are particularly implicated in the
evolution of MODS, found in studies to induce this syndrome and to be present in elevated levels. Additionally,
the coagulation and alternative complement cascades are initiated. In the absence of further injury, SIRS is
beneficial to recovery from the trauma. The second, often trivial, insult, however, results in an enhanced immune
response from the already primed immune cells, notably neutrophils. This second hit may arise from a mild
infection, pulmonary aspiration, or blood transfusion (Table 6-2). Bacterial translocation from the ischemic
mucosa of the gastrointestinal tract is a focus of investigation as a potential source of contamination. Ultimately,
organs not involved in the original trauma experience an alteration in function. Usually, the lung is affected prior
to the kidneys, liver, and gastrointestinal tract. Offiner and Moore (2000) attribute this predilection to direct lung
injury, to the lung's filtration of toxins and cytokines as well as to its sensitivity for developing vascular
permeability
Risk Factors Associated with the Development of Multiple Organ Dysfunction
Following Trauma
1.Associated with the first insult
Severity of tissue injury
Shock-ischemia/reperfusion
Severity of the systemic inflammatory response
2.Associated with the second insult
Infection
Transfusion
Secondary operative procedures
3.Host factors
Age
Preexisting conditions
A 23-year-old male presents to the emergency department after being involved in a
motor vehicle accident. On physical examination, he opens his eyes to painful
stimulation, he occasionally mumbles incomprehensible sounds, he localizes to painful
stimulation with his right upper extremity, and he withdraws his left upper extremity to
pain. His pupils are 4 mm bilaterally and reactive. What is this patient's Glasgow Coma
Scale (GCS) score?
A) 7

(B) 9

(C) 8

(D) 10
A 42-year-old male presents to the emergency department as a level I trauma after being
involved in a motor vehicle accident. On initial examination, the patient has a GCS of 7
(localizes to pain, no eye opening, and no verbal response). The patient has multiple
injuries including a long bone fracture. The patient's vital signs are stable. You consult
orthopedic surgery, and they want to take the patient to the operating room (OR) to
repair his fracture. A CT scan of the head shows mild-to-moderate diffuse cerebral
edema. What is the most appropriate course of action to take with this patient?
A) Allow the patient to go the OR immediately for repair
of his fracture.

(B) Consult neurosurgery to evaluate for placement of
an ICP monitor prior to his going to the OR.

(C) Consult neurosurgery to evaluate for placement of
an ICP monitor after he returns from the OR.

(D) Delay surgery indefinitely until the patient's
neurologic status improves
Explanation: Although there is much debate regarding the precise indications for and benefit of ICP monitoring, several recent studies have suggested that
an aggressive stance toward monitoring head-injured patients is associated with a reduced risk of mortality. In
2000, the American Association of Neurological Surgeons Joint Section on Neurotrauma and Critical Care in
association with the Brain Trauma Foundation published guidelines relating to the indications for ICP monitoring.
In this review, it was noted that ICP monitoring helps in the early detection of intracranial mass lesions, limits the
indiscriminate use of therapies to control ICP that may be potentially harmful, helps in determining prognosis,
and may improve outcome. Therefore, the Brain Trauma Foundation guidelines state that a comatose head-
injured patient (GCS 38) with an abnormal CT scan should undergo ICP monitoring. Additionally, comatose
head-injured patients with normal CT scans should undergo ICP monitoring if they have two or more of the
following features at admission: age over 40, unilateral or bilateral motor posturing, or a SBP of less than 90
mmHg. A review of the Ontario Trauma Registry from 1989 to 1995 was completed to test the hypothesis that
insertion of ICP monitors in patients with traumatic brain injuries is not associated with a decrease in the death
rate. The conclusions were that monitor insertion rates varied widely from hospital to hospital and that, after
controlling for injury scale and injury mechanism, insertion of an ICP monitor was associated with statistically
significant decrease in the death rate among patients with severe traumatic brain injury. Finally, a retrospective
review of data for consecutive patients with severe closed head injury (GCS 8) and long bone fracture admitted
over an 8-month period in 34 academic trauma centers in the United States was completed. The purpose of this
study was to examine variations in the care of patients with severe head injury, to determine the proportion of
patients who received care according to the Brain Trauma Foundation guidelines, and to correlate the outcome
from severe traumatic brain injury with the care received. The results revealed, in addition to considerable
variation in the rates of ICP monitoring, that management at an aggressive center (defined as those placing ICP
monitors in >50% of patients meeting the Brain Trauma Foundation criteria) was associated with a significant
reduction in the risk of mortality. Another consideration regarding the patient in the above question is the
anticipated use of intravenous fluids in the operating room under the situation of general anesthesia in which the
neurologic examination is compromised. Worsening cerebral edema and secondary neurologic injury may
progress unnoticed without the ability to monitor ICP and CPP. With all of these factors in mind, the most
appropriate course of action is to consult neurosurgery to evaluate the patient for placement of an ICP monitor
prior to his going to the operating room.
Indications for operating on gunshot wounds to the spine
include all of the following except:

(A) persistent CSF leak

(B) neurologic deterioration

(C) compression of a nerve root

(D) operate on all cases


Explanation
: Most penetrating wounds of the spine in the United States of America today are caused by
gunshot wounds. These are more common in urban areas where the rates of violent crimes are
relatively high. Civilian gunshot wounds cause direct injury to the spinal cord by the bullet,
whereas high velocity military weapons tend to cause more indirect damage from cavitation and
shock waves. Although debated, surgery has been shown to have little effect on recovery for
patients with spinal cord injury secondary to gunshot wounds to the spine. For this reason, the
trend seems to be now to treat patients with gunshot wounds to the spine without surgery unless
they have a specific indication to do so. One of the historically cited reasons for operating on all
gunshot wounds to the spine was to prevent infection. This may likely remain pertinent with
military gunshot wounds since these cause massive tissue injury. With the creation of new
antibiotics, however, infections may be prevented in civilian gunshot wounds with adequate
courses of antibiotics alone.
The more commonly accepted indications for operating on gunshot wounds to the spine include
neurologic deterioration, compression of a nerve root, and persistent cerebrospinal
fluid leak or fistula. In addition, there are a few late complications which may develop that
require surgical treatment. First, an abscess could develop that requires surgical drainage,
especially if there is compression of the spinal cord. Second, a syrinx may develop and be the
cause of late neurologic deterioration. This could require a shunting procedure to alleviate the
symptoms. Third, lead intoxication may result if the bullet is lodged in a disc space or joint
capsule. The treatment for this would include removing the bullet fragment and administering a
chelating agent. Finally, spinal deafferentation following spinal cord injury may result in
intractable dysesthetic pain. Placement of a dorsal column stimulator or dorsal root entry zone
lesioning may help in these cases.
A 19-year-old army recruit presents to the emergency department with a 24-h
history of right lower quadrant pain, fever to 100.5F, anorexia, and two loose
stools. He was taken to surgery for the presumptive diagnosis of appendicitis;
however, the appendix looked completely normal while the terminal ileum
was quite inflamed. What procedure should be performed?

(A) appendectomy

(B) ileocecectomy with ileostomy

(C) full abdominal exploration to evaluate for
further obvious lesions and colonoscopy prior to
discharge

(D) None. The patient should be closed and
request immediate medical discharge from the
army as he now must battle CD

Explanation:
This patient has acute ileitis. This may or may not be related to Crohn's (and most often is not
related to CD). The correct procedure in this case is appendectomy only. Although the appendix
appears normal on direct examination, the right lower quadrant wound or the laparoscopic
wounds that the patient already has would be confusing in the future. There is no indication for
an ileocecectomy as this is an infectious process and will heal with antibiotics. If this is in fact an
initial presentation of CD, additional therapy will be required but will heal without surgery.
Acute ileitis presents with right lower quadrant pain, fever, and anorexia much the same as acute
appendicitis. It is often caused by Campylobacter or Yersinia species. These can be cultured from
the appendix and from the patient's stool. In one study of patients with signs and symptoms of
acute appendicitis, nine patients had only thickened terminal ileum on ultrasound. Five of these
proceeded to surgery in spite of these results. All nine had positive cultures of C. jejuni, and all
recovered easily with no progression to CD. There were no adverse events from the
appendectomies. Similarly, a study of 138 normal appendices excised for presumed appendicitis
yielded positive cultures for C. jejuni and Y. enterocolitoca. At the time of surgery, the appendix
appeared normal, but 62% of these culture positive patients had terminal ileitis or mesenteric
adenitis. There were no pathologic cultures of C. jejuni or Y. enterocolitoca isolated from 326
normal appendices excised during gynecologic surgeries. Although acute terminal ileitis can
present as appendicitis and appear to be early Crohn's, the majority are of infectious etiologies.

BibliographyEvers BM. Small bowel. In: Townsend CM, Beauchamp RD, Evers BM, et al. (eds.),
Sabiston Textbook of Surgery, 16th ed. Philadelphia, PA: W.B. Saunders, 2001, 893.

Intraabdominal adhesions following abdominal surgery have been associated
with all of the following except:

(A) small bowel obstruction

(B) infertility

(C) chronic pelvic pain

(D) intestinal malabsorption

(E) increased risk for enterotomy on subsequent
laparotomy
Explanation:
Following laparotomy, up to 95% of patients will develop adhesions. Although the majority of
patients will not develop any clinical consequences from adhesion formation, there are significant
morbidities associated with their development. In a retrospective study using the Scottish
National Health Service database, 5.7% of all readmissions following abdominal or pelvic surgery
over 10 years were found to be related to adhesions. Mid- and hind-gut procedures had the
highest number of adhesion-related readmissions, and most admissions occurred in the first year
after surgery.
Intraabdominal adhesions are the leading cause for small bowel obstruction in the industrialized
world. Up to 80% of admissions for small bowel obstruction are secondary to postoperative
adhesions. Types of procedures most commonly associated with adhesions-related small bowel
obstruction are gynecologic operations, appendectomy, and small bowel operations. Overall,
patients who undergo any abdominal procedure have a 5% incidence of developing adhesion-
related intestinal obstruction. Obstruction may occur at any time following laparotomy; however,
in 1729% of patients who develop postoperative obstruction, it occurs within the first month
after surgery. In terms of location, obstructions from adhesions tend to occur at the level of the
ileum, possibly because of its greater mobility within the abdomen.
Intraabdominal adhesions account for up to 20% of secondary infertility in women.
Adhesions in the pelvis can cause infertility by blocking the fallopian tubes or interfering in ovum
transfer from the ovary to the tubes. The risk of infertility is probably related to the degree of
peritoneal trauma and severity of the ensuing adhesions. In a retrospective study of women with
tubal infertility, a history of appendectomy with appendiceal rupture significantly increased the
risk of infertility while the history of simple appendectomy without rupture did not. It is also
believed that pelvic and abdominal adhesions can cause chronic pain. Theoretically, adhesions
may cause pain by putting tension on the sensitive parietal peritoneum. Histologic study has also
shown the presence of sensory nerve fibers within abdominal adhesions. Pain symptoms and
degree of adhesions do not correlate well; however, most studies in the gynecologic literature
show at least short-term improvement in pain following laparoscopic lysis of adhesions.
Patients with adhesions from previous laparotomy who undergo reoperation have an increased
rate of inadvertent enterotomy. A study of 270 of such patients showed a 19% incidence of
bowel injury. In this group, increased age and more than three prior laparotomies were
independent predictors of greater risk of enterotomy.
Intestinal malabsorption is not associated with the presence intraabdominal adhesions.

BibliographyEllis H, Moran B, Thompson J, et al. Adhesion-related hospital readmissions after
abdominal and pelvic surgery: a retrospective cohort study. Lancet 1999;353:1476
1480. [PubMed: 10232313]

Evers B, Townsend C, Thompson J. Small intestine. In: Schwartz S, Shires G, Spencer F, et al.
(eds.), Principles of Surgery, 7th ed. New York, NY: McGraw-Hill, 1999, 12171263.

Letterie G. Pelvic adhesive disease. In: Letterie G (ed.), Structural Abnormalities and
Reproductive Failure: Effective Techniques for Diagnosis and Management. Oxford: Blackwell
Science, 1998, 475501.

Monk B, Berman M, Montz F. Adhesions after extensive gynecologic surgery: clinical significance,
etiology, and prevention. Am J Obstet Gynecol 1994;170(5):13961403. [PubMed: 8178880]

Reijnen M, Bleichrodt R, van Goor H. Pathophysiology of intra-abdominal adhesion and abscess
formation, and the effect of hyaluronan. Br J Surg 2003;90:533541. [
Which of the following is not an indication for surgical
intervention in ulcerative colitis?

(A) intractable bloody diarrhea

(B) perforation

(C) toxic colitis

(D) diagnosis of ulcerative colitis for more than 5 years

(E) poorly controlled extraintestinal manifestations


Explanation:
Indications for surgical intervention in ulcerative
colitis include intractable symptoms, perforation,
toxic colitis, increasing cancer risk, hemorrhage,
fulminating disease, and poorly controlled
extraintestinal manifestations. The cancer risk
after initial diagnosis is approximately 57%
during the first 57 years, but increases to 40%
at 20 years postdiagnosis. Therefore, surgical
intervention is commonly recommended
beginning approximately 10 years after initial
diagnosis.
All of the following are associated with an increased risk of
perforation in acute colonic pseudoobstruction (Ogilvie's
syndrome) except:

(A) older age

(B) increasing cecal diameter

(C) delay in decompression

(D) diabetes mellitus

(E) chronic ischemia

Explanation:
Acute colonic pseudoobstruction is a syndrome of massive dilation
of the colon without mechanical obstruction that develops in
hospitalized patients with serious underlying medical and surgical
conditions. Increasing age, cecal diameter, delay in decompression,
and status of the bowel significantly influence mortality, which is
approximately 40% when ischemia or perforation is present.
Evaluation of the markedly distended colon in the intensive care unit
setting involves excluding mechanical obstruction and other causes
of toxic megacolon such as Clostridium difficile infection, and
assessing for signs of ischemia and perforation. The risk of colonic
perforation in acute colonic pseudoobstruction increases when cecal
diameter exceeds 12 cm and when the distention has been present
for greater than 6 days. Appropriate management includes
supportive therapy and selective use of neostigmine and
colonoscopy for decompression. Early recognition and management
are critical in minimizing complications.
Which of the statements regarding cecal volvulus is
not true?

(A) Cecal volvulus accounts for 10% of cases of colonic volvulus.

(B) Cecal vovulus is thought to have a congenital etiology related to
incomplete peritoneal fixation of the right colon.

(C) Radiographic evidence of a cecal volvulus includes a large,
dilated loop of colon with the loop of colon pointing to the left upper
quadrant of the abdomen.

(D) Definitive treatment for cecal volvulus includes a right
hemicolectomy.

(E) Reduction of the cecal volvulus with fixation of the cecum to the
abdominal wall provides a similar outcome to segmental resection.

Explanation:
While sigmoid volvulus accounts for >80% of colonic volvulus cases,
cecal volvulus is relatively rare, accounting for 10% of cases.
Sigmoid volvulus is felt to be "acquired" through accumulation of
risk factors while cecal volvulus is considered "congenital" because
of individual anatomic variation. Both sigmoid and cecal volvulus
demonstrate a large, dilated loop of colon on plain radiograph. The
loop "points" to the left upper quadrant of the abdomen with a cecal
volvulus and to the right upper quadrant with a sigmoid volvulus.
While cecopexy has been well described and does have some
success, the definitive treatment for cecal volvulus is right
hemicolectomy with primary anastomosis in the appropriate setting
with resection, ileostomy, and mucous fistula in the presence of
perforation or peritonitis
A previously healthy 22-year-old male college football player presents to your emergency
department 24 h after the homecoming football game with complaints of severe left
lower quadrant abdominal pain, fever of 102F, nausea and vomiting. Laboratory findings
include a WBC count of 16,300 with 7% bands. On physical examination his abdomen is
soft, but he has marked tenderness in the left lower quadrant.
Which of the following is the most appropriate diagnostic study in this patient?
(A) CT abdomen and pelvis

(B) barium enema

(C) abdominal ultrasound

(D) colonoscopy

(E) laparoscopy
Explanation:
This patient has acute uncomplicated diverticulitis. This disease is characterized by
localized diverticular perforation without abscess formation, free perforation, or
bleeding. The majority of patients present with left lower quadrant pain, fever, and leukocytosis,
making diverticulitis principally a clinical diagnosis. Diagnostic dilemmas do occur, however, and a
wide differential including bowel perforation or obstruction, appendicitis, inflammatory bowel
disease, and ischemic colitis must be considered. An imaging study is indicated when the clinical
picture is not clear, or to help guide future therapy.
Endoscopy is contraindicated in the setting of acute diverticulitis because the insuflation required
can disturb the tenuous seal containing the diverticular perforation and result in the conversion to
free perforation and a need for more urgent surgical intervention with substantially higher
morbidity and mortality. Endoscopy can be useful after the acute episode has resolved to
evaluate for other distal pathologic processes.
Barium enema is also contraindicated in the acute setting for reasons similar to those described
above. It is a very important part of the preparation for elective resection after recovery, as it
accurately describes the extent of involvement and severity of disease, including strictures that
may develop after acute diverticulitis.
Laparoscopy has been described as a highly sensitive diagnostic modality; however, its invasive
nature precludes its routine use for this purpose.
Both CT and ultrasound can accurately diagnose diverticulitis. CT has a sensitivity of up to 95%
and specificity of 72%. Both modalities can also identify abscesses, making it possible for patients
to have early drainage of these collections. CT is generally more available in most institutions and
is substantially less operator-dependent. CT findings such as presence of an abscess, extraluminal
contrast or air strongly suggest that conservative treatment with antibiotics will not be successful.
A 73-year-old male presents to your emergency department
complaining of a large amount of bright red blood per rectum. He is
moderately tachycardic, but otherwise is hemodynamically stable.
Which of the following statements regarding the management of this
patient is false?
A) Anoscopy followed by proctoscopy should be performed
to exclude localized anorectal disease as the cause of
hemorrhage.

(B) Before surgical intervention is considered, he must
undergo esophagogastroduodenoscopy (EGD).

(C) He should undergo colonoscopy if clinically stable.

(D) A positive tagged RBC scan should prompt segmental
surgical resection.

(E) None of the above.
Explanation:
LGIH is defined as persistent gross bleeding from the rectum, with or without
hemodynamic instability and hemorrhagic shock. This patient has early signs of
hemodynamic instability, so aggressive resuscitation must be undertaken prior to
engaging in any diagnostic studies. Anoproctosigmoidoscopy is the next step in his
evaluation and management. Occasionally, localized and treatable lesions of the anus
may be responsible for the hemorrhage. In hemodynamically stable patients, the next
step would be to pursue colonoscopy. This study can identify active bleeding or
stigmata of recent bleeding in up to 90% of patients. Endoscopic hemostasis can be
attempted, although the success rate varies with the type of lesion (angiodysplasias
have 8590% success rate).
In stable patients, EGD can be deferred until after colonoscopy, but it remains an
essential part of the evaluation, and with 515% of LGIH caused by upper GI bleed,
it must be performed before surgical intervention is considered.
Tagged RBC scan allows for identification of the source of bleeding down to 0.1
mL/min; however, localization of these findings is somewhat vague, making
segmental surgical resection based on bleeding scan alone a risky proposition.
Findings should be correlated with a mesenteric arteriogram or the endoscopist
should label the area with dye while performing the colonoscopy.
An 80-year-old female presents to the emergency room with abdominal pain. She complains that the pain seems to be
radiating to the right thigh, knee, and hip. She also has nausea and vomiting that is bilious in nature. Although this pain has
been intermittent for the past year, she believes that this episode is more severe, which prompted her to seek assistance at
the emergency room. She denies any history of prior surgery. However, she suffers from diabetes mellitus and had a
myocardial infarction in the past. On physical examination, the patient is tachycardic, normotensive, and afebrile. Abdominal
examination reveals a distended abdomen, with guarding, rebound, diffuse tenderness and high pitched bowel sounds. No
obvious umbilical, nor inguinal hernias were detected. A palpable mass was discovered high in the medial aspect of the right
thigh. What is your diagnosis
A) femoral hernia

(B) mesenteric ischemia

(C) obturator hernia

(D) ruptured appendicitis

(E) lymphoma
Explanation
: Obturator hernias accounts for less than 5% of all mechanical bowel obstructions. It
is most commonly found in females, on the right side, in the seventh and eighth
decade of life. The hernia passes through the obturator canal, bounded by the
superior pubic ramus and the obturator membrane. The obturator vessels and nerve
passes through the canal and they lie posterolateral to the hernia sac. There are four
cardinal features of this hernia, the most common being intestinal obstruction;
another is the Howship-Romberg sign (pain down the inner surface of thigh, knee
joint, and hip). This is referred pain from the cutaneous branch of the anterior
division of the obturator nerve, which is compressed by the hernia in the canal. The
next feature is a palpable mass high in the medial aspect of the thigh at the origin of
the adductor muscles. The mass is best felt with the thigh flexed, adducted, and
rotated outward. The last feature is repeated attacks of intestinal obstruction that
pass spontaneously. Treatment entails operative intervention as soon as possible,
secondary to the high rate of strangulation. The three preferred operative
approaches are a midline transperitoneal approach, midline extraperitoneal approach,
and exposure in the thigh. The former two are better since these hernias can be
bilateral and therefore one can explore the other side if needed. Figures 26-2 and 26-
3 show the classical radiologic findings of an incarcerated obturator hernia causing
small bowel obstruction.
A 65-year-old male with a history of peptic ulcer disease presents
with an acute onset of epigastric pain and hematemesis. He
reports relief with antacids and proton pump inhibitors for 1 year.
His past medical history is significant for hypertension and
coronary artery disease. On physical examination, the patient is
hypotensive, and tachycardic. His abdomen is soft and tender at
the epigastric region, but otherwise benign. Endoscopy reveals a
large amount of clot in the stomach with an active arterial bleeder
in the area of the duodenal bulb. Multiple attempts of endoscopic
therapy failed. The patient continued to require additional IV fluids
and blood products. He was taken to the operating room, where a
laparotomy was performed. A longitudinal incision along the
pylorus spanning 3 cm on each side of the great vein of Mayo was
created. Traction sutures were placed superiorly and inferiorly
prior to the enterotomy. The ulcer was readily identified at the
posterior duodenal bulb and a clot was removed. What is the next
step in the procedure?
(A) sclerotherapy

(B) perform a figure of eight stitch

(C) vasopressin infusion

(D) three suture ligation encompassing the proximal and
distal branches of the gastroduodenal arteries and a U-
type stitch to transfix the transverse branch of the
pancreatic artery.

(E) Kocherize the duodenum and perform a graham
patch
Explanation: This is an example of a bleeding duodenal ulcer in the
posterior wall. There are some studies that state that the incidence of
emergent or urgent operations for bleeding duodenal ulcers has remained
unchanged over the past years. Most patients with this disorder are
successfully treated with medical or endoscopic management. Endoscopy
remains the initial standard of care for the diagnosis and treatment of
bleeding duodenal ulcers. Surgery is indicated when there is active
hemorrhage which is refractory to endoscopic techniques. Initial
management should include replacement of blood volume by large bore IVs
as well as continuous monitoring of vital signs and urinary output.
Emergent surgery is also indicated when transfusion is in excess of 6 units
in a 24-h period. Antrectomy and vagotomy was historically considered the
gold standard for this condition secondary to low recurrence rate, but has
been replaced by the three suture technique, which has a significantly lower
morbidity and mortality in the elderly, and unstable patient. With this
technique, we add pyloroplasty and truncal vagotomy. A highly selective
vagotomy can be done for the young, hemodynamically stable patient with
minimal comorbidities
A 50-year-old male presents to the emergency room with a
history of melena, and most recently 3 episodes of
hematemesis. The patient denies attacks of reflux or history
of peptic ulcer disease. He has no other significant medical
problems. He had a right inguinal hernia repair 10 years
ago. The patient's vital signs are stable. Physical exam of
the abdomen was unremarkable. Rectal examination
reveals a positive fecal occult blood test. At this point in the
exam, the patient retches and vomits approximately 250 cc
of maroon emesis with specks of blood. Endoscopy reveals a
large submucosal vessel along the lesser curvature that is
not actively bleeding. What is the management for this
condition?
A) endoscopic cauterization

(B) vagotomy and antrectomy

(C) wedge resection of gastric wall

(D) distal gastrectomy without vagotomy


Explanation: This is an example of Dielafoy's lesion, which is a vascular
malformation and a rare cause of upper GI hemorrhage. It is also called
"caliber-persistent artery." The malformation is a large submucosal or
mucosal vessel that may bleed when there is erosion into it. It is usually
found along the lesser curvature, middle aged individuals, and no
association with any vascular, or peptic ulcer disease. The hemorrhage
produced from the lesion can be massive and can cease spontaneously at
times. It is difficult to diagnose endoscopically because there is no ulcer
surrounding the lesion. Diagnosis is best achieved by performing endoscopy
at the time of bleeding and visualizing a pinpoint mucosal defect with blood.
Once the lesion is identified, the area is marked with India ink to delineate
the area during surgical resection. Definitive management calls for wedge
resection of the gastric wall, rather than an extended blind gastric
resection. Vagotomy is not required since it is not associated with peptic
ulcer disease. Endoscopic ablation with sclerotherapy or electrocoagulation
has proved unsuccessful for this lesion. Surgery is required because of
recurrent bouts of hemorrhage. Angiography and embolectomy are now
also being used as first line therapy.
How should locked or perched facets in the cervical spine be
treated initially?

(A) open reduction and internal fixation

(B) closed reduction with cervical traction

(C) keep patient immobilized in cervical
collar

(D) no treatment is needed

Explanation:
Severe flexion injuries of the cervical spine may cause unilateral or bilateral locked
facets. Typically, unilateral locked facets result from flexion plus rotation injuries, and
bilateral locked facets result from hyperflexion injuries. Anatomically, locked facets
refer to the condition when the inferior articular facets of the upper dislocated
vertebra slide forward over the superior facets of the vertebra below (Fig. 9-16).
Bilateral locked facets are extremely unstable given the extensive amount of
ligamentous injury involved. The forces applied in this type of injury rupture the
posterior ligamentous complex, the joint capsules, the intervertebral disc, and,
usually, the posterior and anterior longitudinal ligaments. In about 80% of these
cases, the patients will present with complete spinal cord injuries. Nerve root injuries
are common as well. Unilateral locked facets are more stable than bilateral, and
these patients are usually neurologically intact. Patients in either of these groups
should be treated initially with closed reduction using cervical traction. Once
reduction of the cervical spine is achieved, patients may be stabilized by
immobilization in a halo vest or by internal fixation and fusion. Surgical management
is often preferred given the high incidence of unsatisfactory fusion when using a halo
vest alone. Surgical management should be used if attempts at closed reduction are
unsuccessful. MRI is helpful in evaluating for a herniated disc and determining the
extent of damage to the spinal cord (Fig. 9-17). It is also useful for preoperative
planning. Perched facets refer to facets that have just reached the point of locking
without actually doing so. These injuries are treated in a similar manner to locked
facets.
29-year-old male restrained passenger is brought to the ER in stable condition following
a motor vehicle accident. He is admitted for observation following an abdominal CT
demonstrating a moderate amount of free fluid in the pelvis. Within 48 h, patient
develops worsening abdominal pain and undergoes exploratory laparotomy. A small
bowel perforation is identified (Fig. 10-4). Which of the following statements regarding
small bowel injuries is not correct?

(A) thought to occur when bowel is crushed against
spine

(B) frequently associated with lumbar spine fractures

(C) decreased incidence since the mandatory seat belt
laws

(D) believed result of closed loop of bowel under high
intraluminal pressure


Explanation:
Small bowel injuries secondary to blunt abdominal trauma are
increasing in incidence because of high velocity motor vehicle
accidents and mandatory seat belt laws (Moore, Feliciano, and
Mattox, 2004). The "seat belt" syndrome is the complex of injuries,
which includes lumbar fractures and small bowel injuries. Physical
finding of ecchymoses along the anterior abdominal wall is referred
to as the "seat belt sign" and may indicate underlying small bowel
injuries (Appleby and Nagy, 1989).
The proposed mechanisms of injury include (1) crushing of bowel
against spine, (2) tearing of bowel from mesentery by sudden
deceleration, and (3) rupture of a closed loop of bowel under high
intraluminal pressure (Guarino, Hassett, and Luchette, 1995).
An ER thoracotomy should not be performed in what setting?

(A) a patient in shock with a penetrating anterior chest wound

(B) a patient who sustained a penetrating chest wound and
develops precipitous shock after endotracheal intubation and
positive-pressure ventilation

(C) a pulseless patient with a penetrating chest wound suspected to
have a massive hemothorax

(D) a patient arriving with no electrocardiogram (ECG) rhythm with
known blunt trauma to the chest
E) C and D

Explanation:
The primary objectives of resuscitative thoracotomy are (a) release of percardial tamponade; (b)
control of intrathoracic vascular or cardiac bleeding; (c) eliminate massive air embolism or
bronchopleural fistula; (d) perform open cardiac massage; and (e) temporarily occlude the
descending thoracic aorta. A left anterolateral thoracotomy incision is preferred. A right
thoracotomy is reserved for hypotensive patients with penetrating injuries to the right chest in
need of direct access to massive blood loss or air embolism. An ER thoracotomy is initiated at the
level of fourth to fifth intercostal space with the proper level corresponding to inferior border of
pectoralis major muscle. The incision is made through the intercostal muscle and parietal pleura
is divided along superior margin of the rib. The rib retractor is inserted with the handle toward
the axilla. Key resuscitative maneuvers are then initiated.
A pericardiotomy incision is made in the presence of cardiac tamponade and incised widely,
anterior and parellel to the phrenic nerve. Blood clots are evacuated from the pericardium and
cardiac bleeding sites should be controlled immediately with digital pressure on the surface of the
ventricle and partially occluding vascular clamps placed on atrium or great vessels. In beating
hearts, efforts at cardiorrhapy should be delayed until initial resuscitation measures have been
completed. In the nonbeating heart, suturing should be performed prior to defibrillation.
Temporary control of the bleeding can be accomplished with a skin-stapling device. Cardiac
wounds are best repaired with 3-0 nonabsorbable horizontal mattress sutures in the operating
room.
In cardiac arrest, bimanual internal massage of the heart should be instituted. If internal
defibrillation does not restore vigorous cardiac activity, the descending thoracic aorta should be
incompletely cross-clamped at the level inferior to the left pulmonary hilum to maximize coronary
perfusion. Cardiopulmonary collapse from suspected intraabdominal hemorrhage should be
temporized by occlusion of the descending thoracic aorta. Air embolism should be suspected in a
patient with penetrating chest trauma who develops precipitous shock after endotracheal
intubation and positive-pressure ventilation. Treatment involves pulmonary hilar cross-clamping,
vigorous cardiac massage, along with aortic root and left ventricle air aspiration (Moore,
Feliciano, and Mattox, 2004).
Trauma patients arriving in extremis with cardiopulmonary resuscitation (CPR) being initiated
following blunt injury should undergo thoracotomy only if they show electrical cardiac activity on
ECG, cardiac activity or pericardial effusion visualized via ultrasound. Patients exhibiting ECG
cardiac activity or who have sustained penetrating thoracic wounds should undergo resuscitative
thoracotomy (Cogbill et al., 1983).

An unrestrained 23-year-old male drag racer involved in high-speed motor vehicle
accident presents to ER with intense pain in right chest. The primary survey
demonstrates decreased breath sounds over the right hemithorax with noted paradoxical
motion of the right chest wall during respiration (Fig. 10-5). The major pathologic
sequela of this injury is
A) disruption of ventilation because of paradoxical
motion of the chest wall

(B) bleeding from disruption of intercostal vessels

(C) underlying pulmonary contusion

(D) pneumothorax

(E) splinting from chest wall pain

Explanation:
A flail chest consists of segmental fractures of three or more adjacent ribs, or one or more rib fractures with associated
costrochondral separation or fracture of sternum (Fig. 10-5). This causes an unstable or floating
segment of chest wall that moves paradoxically during respiration (ATLS, 1997). A pneumothorax
or hemothorax may be present. A more significant injury, however, is associated with pulmonary
contusion leading to hemorrhage and edema of the injured lung. A chest wall injury of this
magnitude is also associated with significant pain, and respiratory efficiency is reduced.
Treatment is directed toward reversing hypoventilation caused by the pain, and hypoxia caused
by the associated pulmonary contusion. Careful monitoring of ventilation and oxygenation is
required, and often time intubation and ventilatory support may be indicated in 2040% of
patients. Control of pain because of multiple rib fractures by using regional anesthetic techniques
such as intercostal nerve block, insertion of intrapleural catheter, or insertion of an epidural
catheter is important to improve respiratory mechanics. Rarely is physical stabilization of chest
wall necessary (Moore, Feliciano, and Mattox, 2004).

BibliographyMoore E, Feliciano D, Mattox K. Trauma, 5th ed. New York, NY: McGraw-Hill, 2004.

American College of Surgeons Committee on Trauma. American Trauma Life Support, 6th ed.
Chicago, IL: American College of Surgeons, 1997.