ABSITE - Trauma – Questions And Answers All
Are Complete Test
A 34-year-old female presents after a high-velocity MVC with right flank pain and frank bright red
blood in her urine. Her primary survey is intact, and vital signs are HR 112 bpm, BP 86/59 mmHg, RR
20/min, and oxygen saturation is 98% on room air. CT scan demonstrates a Grade IV laceration to
the right kidney. The best choice for management is:
A. Renorrhaphy
B. Packing of the renal fossa, temporary abdominal closure, and return to the ICU.
C. Total nephrectomy
D. Observation in the intensive care unit with blood transfusion as needed
E. Gelfoam angioembolization Correct Answer: Renorrhaphy
Correct.
This patient is hemodynamically unstable, and therefore should be taken to the operating room for
laparotomy and renal exploration. Principles of operative repair for a Grade IV, and for some Grade V
kidney lacerations include renal preservation, when possible—debridement of non-viable tissue,
hemostasis using absorbable sutures in a figure-of-eight fashion with care taken to preserve arterial
supply to distal segments, closure of the collecting system with absorbable suture in a running
fashion, and reapproximation of the capsule. An omental flap can be substituted for large defects if
necessary. Damage control laparotomy is not indicated in this patient in the absence of coagulopathy,
hypothermia, or acidosis.
A 19-year-old male presents to the emergency room after a motorcycle crash. Digital rectal exam
including the prostate is normal, and there is no blood at the urethral meatus. He has a lateral
compression pelvis fracture and gross hematuria. The appropriate evaluation for this patient would
include:
A. Retrograde cystogram
B. Retrograde cystogram and contrast CT scan of the abdomen and pelvis
C. Contrast CT scan of the abdomen and pelvis
D. Retrograde urethrogram Correct Answer: Retrograde cystogram and contrast CT scan of the
abdomen and pelvis
Correct.
The combination of a cystogram and a contrast CT scan of the abdomen and pelvis will diagnose
potential bladder and renal injuries. No retrograde urethrogram (D) is needed as the patient did not
have a high-riding prostate on digital rectal exam and did not have blood at the urethral meatus. A
cystogram alone (A) would not evaluate for renal injuries which are possible with the given
mechanism and hematuria. A CT scan alone (C) would not evaluate for a potential bladder injury
which is possible with the given mechanism and hematuria.
A 30-year-old man presents to the Emergency Department after being struck by a motor vehicle; he
was found pinned under the vehicle and required 30 minutes of extrication. On arrival, his blood
pressure is 76/50 mmHg, pulse 132 beats/min, and he is slow to respond to stimuli. A massive
transfusion protocol is initiated. The FAST scan is positive. On exploration, he has a large zone I
retroperitoneal hematoma, a large volume of free intraperitoneal blood, several small bowel
lacerations, and a grade III liver laceration. After packing the four quadrants, exploration of the
hematoma demonstrates complete transection of the vena cava below the renal veins. The patient
, remains hemodynamically unstable despite transfusion. What is your next step in management of the
vena caval injury?
A. Perform a right medial visceral rotation, apply clamps proximally and distally on the cava, and
repair the injury primarily.
B. Insert a balloon through the laceration, occlude proximally and transfuse intraoperatively until the
patient becomes stable, and attempt repair.
C. Perform a left medial visceral rotation and attempt primary repair while auto-transfusing the
intraperitoneal blood.
D. Perform a left medial visceral rotation, and pack the injury.
E. Perform a right medial visceral rotation and ligate the vena cava. Correct Answer: Perform a right
medial visceral rotation and ligate the vena cava.
Correct.
In the setting of an unstable patient with complete transection of the vena cava, the best option is
ligation. Repair of the vena cava is usually the preferred option; however, this may not be feasible in
the setting of damage control laparotomy in an unstable patient with multiple injuries where
prolonging the operative time risks developing coagulopathy, acidosis, and hypothermia prior to
control of all major bleeding sources. A left medial visceral rotation is performed for aortic exposure
from the hiatus to the iliacs. A right medial visceral rotation is required for caval exposure.
A 55-year-old man presents with hemodynamic instability and severe abdominal pain after being
struck by a car. On exploratory laparotomy, he is found to have a grade 5 splenic injury and a 6-cm
left-sided zone II retroperitoneal hematoma that is not expanding. Microscopic hematuria was also
detected on urinalysis. After performing splenectomy, what is the next step in management?
A. Explore the zone II retroperitoneal hematoma.
B. Observe the zone II hematoma.
C. Perform a left nephrectomy.
D. Perform an on-table angiogram. Correct Answer: Observe the zone II hematoma.
Correct.
Zone 2 hematomas caused by penetrating injuries are routinely explored if encountered in the
operating room. Whether proximal control of the renal pedicle should be obtained before exploration
of a perinephric hematoma is controversial. In cases of severe ongoing hemorrhage, time should not
be taken to obtain proximal control, and the kidney should be mobilized directly. If time and the
degree of hemorrhage permit, however, it is acceptable to obtain vascular control before mobilization
of the kidney. Zone 2 hematomas caused by blunt trauma can be left alone if they are not expanding.
Microscopic hematuria is not an indication for exploration of zone II hematomas as it is a common
finding with such injuries. A nephrectomy or angiogram is not indicated in this setting.
A 27-year-old oilfield worker presents after falling from a 30-ft platform at his drilling site. A pelvic
binder was placed on scene by paramedics for pelvic instability, bruising and scrotal hematoma.
Attempted removal of the binder in the trauma bay results in hypotension despite blood transfusion.
The binder is reapplied and a CT scan performed which demonstrates a 4-cm left zone III hematoma
with blush on the arterial phase along with bilateral inferior and superior pubic ramus fractures and
left sacro-iliac widening. A cystogram shows no evidence of bladder injury. He is hemodynamically
stable after resuscitation. The most appropriate next step would be:
A. Immediate surgical exploration of the hematoma
B. Observation in the ICU and removal of the binder as soon as feasible to prevent decubitus
ulceration
C. Perform angioembolization of bleeding pelvic arteries followed by external fixation of the pelvis.
D. Immediate operative repair of the pelvic fractures
Are Complete Test
A 34-year-old female presents after a high-velocity MVC with right flank pain and frank bright red
blood in her urine. Her primary survey is intact, and vital signs are HR 112 bpm, BP 86/59 mmHg, RR
20/min, and oxygen saturation is 98% on room air. CT scan demonstrates a Grade IV laceration to
the right kidney. The best choice for management is:
A. Renorrhaphy
B. Packing of the renal fossa, temporary abdominal closure, and return to the ICU.
C. Total nephrectomy
D. Observation in the intensive care unit with blood transfusion as needed
E. Gelfoam angioembolization Correct Answer: Renorrhaphy
Correct.
This patient is hemodynamically unstable, and therefore should be taken to the operating room for
laparotomy and renal exploration. Principles of operative repair for a Grade IV, and for some Grade V
kidney lacerations include renal preservation, when possible—debridement of non-viable tissue,
hemostasis using absorbable sutures in a figure-of-eight fashion with care taken to preserve arterial
supply to distal segments, closure of the collecting system with absorbable suture in a running
fashion, and reapproximation of the capsule. An omental flap can be substituted for large defects if
necessary. Damage control laparotomy is not indicated in this patient in the absence of coagulopathy,
hypothermia, or acidosis.
A 19-year-old male presents to the emergency room after a motorcycle crash. Digital rectal exam
including the prostate is normal, and there is no blood at the urethral meatus. He has a lateral
compression pelvis fracture and gross hematuria. The appropriate evaluation for this patient would
include:
A. Retrograde cystogram
B. Retrograde cystogram and contrast CT scan of the abdomen and pelvis
C. Contrast CT scan of the abdomen and pelvis
D. Retrograde urethrogram Correct Answer: Retrograde cystogram and contrast CT scan of the
abdomen and pelvis
Correct.
The combination of a cystogram and a contrast CT scan of the abdomen and pelvis will diagnose
potential bladder and renal injuries. No retrograde urethrogram (D) is needed as the patient did not
have a high-riding prostate on digital rectal exam and did not have blood at the urethral meatus. A
cystogram alone (A) would not evaluate for renal injuries which are possible with the given
mechanism and hematuria. A CT scan alone (C) would not evaluate for a potential bladder injury
which is possible with the given mechanism and hematuria.
A 30-year-old man presents to the Emergency Department after being struck by a motor vehicle; he
was found pinned under the vehicle and required 30 minutes of extrication. On arrival, his blood
pressure is 76/50 mmHg, pulse 132 beats/min, and he is slow to respond to stimuli. A massive
transfusion protocol is initiated. The FAST scan is positive. On exploration, he has a large zone I
retroperitoneal hematoma, a large volume of free intraperitoneal blood, several small bowel
lacerations, and a grade III liver laceration. After packing the four quadrants, exploration of the
hematoma demonstrates complete transection of the vena cava below the renal veins. The patient
, remains hemodynamically unstable despite transfusion. What is your next step in management of the
vena caval injury?
A. Perform a right medial visceral rotation, apply clamps proximally and distally on the cava, and
repair the injury primarily.
B. Insert a balloon through the laceration, occlude proximally and transfuse intraoperatively until the
patient becomes stable, and attempt repair.
C. Perform a left medial visceral rotation and attempt primary repair while auto-transfusing the
intraperitoneal blood.
D. Perform a left medial visceral rotation, and pack the injury.
E. Perform a right medial visceral rotation and ligate the vena cava. Correct Answer: Perform a right
medial visceral rotation and ligate the vena cava.
Correct.
In the setting of an unstable patient with complete transection of the vena cava, the best option is
ligation. Repair of the vena cava is usually the preferred option; however, this may not be feasible in
the setting of damage control laparotomy in an unstable patient with multiple injuries where
prolonging the operative time risks developing coagulopathy, acidosis, and hypothermia prior to
control of all major bleeding sources. A left medial visceral rotation is performed for aortic exposure
from the hiatus to the iliacs. A right medial visceral rotation is required for caval exposure.
A 55-year-old man presents with hemodynamic instability and severe abdominal pain after being
struck by a car. On exploratory laparotomy, he is found to have a grade 5 splenic injury and a 6-cm
left-sided zone II retroperitoneal hematoma that is not expanding. Microscopic hematuria was also
detected on urinalysis. After performing splenectomy, what is the next step in management?
A. Explore the zone II retroperitoneal hematoma.
B. Observe the zone II hematoma.
C. Perform a left nephrectomy.
D. Perform an on-table angiogram. Correct Answer: Observe the zone II hematoma.
Correct.
Zone 2 hematomas caused by penetrating injuries are routinely explored if encountered in the
operating room. Whether proximal control of the renal pedicle should be obtained before exploration
of a perinephric hematoma is controversial. In cases of severe ongoing hemorrhage, time should not
be taken to obtain proximal control, and the kidney should be mobilized directly. If time and the
degree of hemorrhage permit, however, it is acceptable to obtain vascular control before mobilization
of the kidney. Zone 2 hematomas caused by blunt trauma can be left alone if they are not expanding.
Microscopic hematuria is not an indication for exploration of zone II hematomas as it is a common
finding with such injuries. A nephrectomy or angiogram is not indicated in this setting.
A 27-year-old oilfield worker presents after falling from a 30-ft platform at his drilling site. A pelvic
binder was placed on scene by paramedics for pelvic instability, bruising and scrotal hematoma.
Attempted removal of the binder in the trauma bay results in hypotension despite blood transfusion.
The binder is reapplied and a CT scan performed which demonstrates a 4-cm left zone III hematoma
with blush on the arterial phase along with bilateral inferior and superior pubic ramus fractures and
left sacro-iliac widening. A cystogram shows no evidence of bladder injury. He is hemodynamically
stable after resuscitation. The most appropriate next step would be:
A. Immediate surgical exploration of the hematoma
B. Observation in the ICU and removal of the binder as soon as feasible to prevent decubitus
ulceration
C. Perform angioembolization of bleeding pelvic arteries followed by external fixation of the pelvis.
D. Immediate operative repair of the pelvic fractures
