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CHAPTER 7
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Trauma
1. A trauma patient arrives following a stab wound to the
left chest with systolic blood pressure (SBP) 85 mm Hg,
which improves slightly with intravenous (IV) fluid
resuscitation. Chest X-ray demonstrates clear lung fields.
What is the most appropriate next step?
A. Computed tomography (CT) scan of the chest
B. Pelvic X-ray
C. Focused abdominal sonography for trauma (FAST)
examination
D. Tube thoracostomy of the left chest
2. In which of the following patients is emergency department (ED) thoracotomy contraindicated?
A. Motor vehicle accident victim, cardiac tamponade
seen on ultrasound, systolic blood pressure (SBP)
decreasing to 50 mm Hg
B. Motor vehicle accident victim, became asystolic dur-
ing transport with 5 minutes of cardiopulmonary
resuscitation (CPR) with no signs of life
C. Patient with chest stab wound, SBP decreasing to
50 mm Hg
D. Patient with chest stab wound, became asystolic dur-
ing transport with 20 minutes of CPR with no signs
of life
Answer: C
During the circulation section of the primary survey, four lifethreatening injuries must be identified promptly: (1) massive
hemothorax, (2) cardiac tamponade, (3) massive hemoperitoneum, and (4) mechanically unstable pelvic fractures with
bleeding. In this patient, hemothorax is unlikely given normal
chest X-ray; thus, hemoperitoneum and cardiac tamponade
should be suspected. Cardiac tamponade occurs most commonly after penetrating thoracic wounds, although occasionally blunt rupture of the heart, particularly the atrial
appendage, is seen. Acutely, <100 mL of pericardial blood
may cause pericardial tamponade. The classic Beck’s triad—
dilated neck veins, muffled heart tones, and a decline in
arterial pressure—is usually not appreciated in the trauma
bay because of the noisy environment and associated hypovolemia. Diagnosis is best achieved by bedside ultrasound of
the pericardium, which is one of the four views of the FAST
examination. (See Schwartz 11th ed., Ch. 7, p. 188.)
Answer: D
The utility of resuscitative thoracotomy (RT) has been
debated for decades. Current indications are based on 30 years
of prospective data, supported by a recent multicenter prospective study. RT is associated with the highest survival rate
after isolated cardiac injury; 35% of patients presenting in
shock and 20% without vital signs (ie, no pulse or obtainable
BP) are salvaged after isolated penetrating injury to the heart.
For all penetrating wounds, survival rate is 15%. Conversely,
patient outcome is poor when RT is done for blunt trauma,
with 2% survival among patients in shock and <1% survival
among those with no vital signs. Thus, patients undergoing
CPR upon arrival to the ED should undergo RT selectively
based on injury and transport time. (See Schwartz 11th ed.,
Ch. 7, p. 189.)
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3. After an automobile accident, a 30-year-old woman is
CHAPTER 7
Trauma
discovered to have a posterior pelvic fracture. Hypotension and tachycardia respond marginally to volume
replacement. Once it is evident that her major problem
is free intraperitoneal bleeding and a pelvic hematoma in
association with the fracture, appropriate management
would be:
A. Application of medical antishock trousers with infla-
tion of the extremity and abdominal sections.
B. Arterial embolization of the pelvic vessels.
C. Celiotomy and ligation of the internal iliac arteries
bilaterally.
D. Celiotomy and pelvic packing.
E. External fixation application to stabilize the pelvis.
4. An 18-year-old man is admitted to the emergency
department (ED) shortly after being involved in an automobile accident. His Glasgow Coma Score (GCS) is 7.
His pulse is barely palpable at a rate of 140 beats per
minute, and BP is 60/0. Breathing is rapid and shallow,
aerating both lung fields. His abdomen is moderately
distended with no audible peristalsis. There are closed
fractures of the right forearm and the left lower leg. After
rapid intravenous (IV) administration of 2 L of lactated
Ringer solution in the upper extremities, his pulse is 130
and BP 70/0. The next immediate step should be to:
A. Obtain cross-table lateral X-rays of the cervical spine.
B. Obtain head and abdominal CT scans.
C. Obtain supine and lateral decubitus X-rays of the
abdomen.
D. Obtain an arch aortogram.
E. Intubate and proceed to the operating room (OR) to
explore the abdomen.
Answer: D
Severe pelvic bleeding is a major problem in the trauma
patient. Neither external fixation nor the use of medical antishock trousers control free intra-abdominal hemorrhage
regardless of its source. In the unstable patient, celiotomy is
mandatory. If there is a ruptured retroperitoneal hematoma
bleeding into the peritoneal cavity, control is a major problem. Internal iliac artery ligation has been abandoned as it
is rarely effective. Angiography and arterial embolization
may be effective with an arterial bleeding problem, but most
severe pelvic hemorrhage is venous in origin. If the hematoma is stable, it is best to leave it undisturbed. However, if
the hematoma has ruptured into the peritoneal cavity, pelvic
packing offers the best hope of control. (See Schwartz 11th ed.,
Ch. 7, p. 234.)
Answer: E
Ideally, a patient seriously injured in an automobile accident
should undergo X-rays of the cervical spine, the chest, and
the abdomen. When he has a GCS of 7, CT scans of the head
are certainly desirable. If the chest X-ray shows a widened
mediastinum, arch aortograms are indicated. However, this
patient has had no response to a rapid fluid challenge, and
if he is to survive, bleeding must be controlled immediately.
The head injury, although severe, is not responsible for his
hypotension and tachycardia. The most likely problem is
uncontrolled abdominal hemorrhage. Immediate abdominal
exploration offers the best chance for survival. (See Schwartz
11th ed., Ch. 7, p. 193.)
5. After sustaining a gunshot wound to the right upper
quadrant of the abdomen, the patient has no signs
of peritonitis. Her vital signs are stable, and CT scan
shows a grade III liver injury. What is the next step in
management?
A. Exploratory laparotomy with control of hepatic
parenchymal hemorrhage
B. Admission to surgical intensive care unit (SICU) with
serial complete blood count
C. Admission to SICU with repeat CT in 24 hours
D. Hepatic angiography
Answer: B
The liver’s large size makes it the organ most susceptible to
blunt trauma, and it is frequently involved in upper torso penetrating wounds. Nonoperative management of solid organ
injuries is pursued in hemodynamically stable patients who do
not have overt peritonitis or other indications for laparotomy.
Patients with more than grade II injuries should be admitted
to the SICU with frequent hemodynamic monitoring, determination of hemoglobin, and abdominal examination. The
only absolute contraindication to nonoperative management
is hemodynamic instability. Factors such as high injury grade,
large hemoperitoneum, contrast extravasation, or pseudoaneurysms may predict complications or failure of nonoperative
management. Angioembolization and endoscopic retrograde
cholangiopancreatography (ERCP) are useful adjuncts that
can improve the success rate of nonoperative management.
The indication for angiography to control hepatic hemorrhage is transfusion of 4 units of RBCs in 6 hours or 6 units
of RBCs in 24 hours without hemodynamic instability. (See
Schwartz 11th ed., Ch. 7, p. 225.)
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6. Which of the following statements is correct regarding
traumatic spleen injury?
A. An elevation in WBC to 20,000/mm3 and platelets to
300,000/mm3 on postoperative day 7 is a common
benign finding in postsplenectomy patients.
B. Delayed rebleeding or rupture will typically occur
within 48 hours of injury.
C. Common complications after splenectomy include
subdiaphragmatic abscess, pancreatic tail injury, and
gastric perforation.
D. Postsplenectomy vaccines against encapsulated bac-
teria are optimally administered preoperatively or
immediately postoperative.
Answer: C
After splenectomy or splenorrhaphy, postoperative hemorrhage may be due to an improperly ligated or unrecognized
short gastric artery, or recurrent bleeding from the splenic
parenchyma if splenic repair was used. An immediate postsplenectomy increase in platelets and WBCs is normal;
however, beyond postoperative day 5, a WBC count above
15,000/mm3 and a platelet/WBC ratio of <20 are associated
with sepsis and should prompt a thorough search for underlying infection. A common infectious complication after splenectomy is a subphrenic abscess, which should be managed
with percutaneous drainage. Additional sources of morbidity
include a concurrent or unrecognized iatrogenic injury to the
pancreatic tail during rapid splenectomy resulting in pancreatic ascites or fistula, or gastric perforation during short gastric vessel ligation. Enthusiasm for splenic salvage was driven
by the rare, but often fatal, complication of overwhelming
postsplenectomy sepsis. Overwhelming postsplenectomy
sepsis is caused by encapsulated bacteria, Streptococcus pneu-
moniae, Haemophilus influenzae, and Neisseria meningitidis,
which are resistant to antimicrobial treatment. In patients
undergoing splenectomy, prophylaxis against these bacteria
is provided via vaccines administered optimally at >14 days
postinjury. (See Schwartz 11th ed., Ch. 7, p. 227.)
CHAPTER 7
Trauma
7. At what pressure is operative decompression of an
extremity compartment mandatory?
A. 15 mm Hg
B. 25 mm Hg
C. 35 mm Hg
D. 45 mm Hg
8. Primary repair of the trachea should be carried out with:
A. Wire suture.
B. Absorbable monofilament suture.
C. Nonabsorbable monofilament suture.
D. Absorbable braided suture.
Answer: D
In comatose or obtunded patients, the diagnosis is more difficult to secure. A compatible history, firmness of the compartment to palpation, and diminished mobility of the joint
are suggestive. The presence or absence of a pulse distal to
the affected compartment is notoriously unreliable in the
diagnosis of a compartment syndrome. A frozen joint and
myoglobinuria are late signs and suggest a poor prognosis.
As in the abdomen, compartment pressure can be measured.
The small, hand held Stryker device is a convenient tool for
this purpose. Pressures >45 mm Hg usually require operative
intervention. Patients with pressures between 30 and 45 mm
Hg should be carefully evaluated and closely watched. (See
Schwartz 11th ed., Ch. 7, p. 237.)
Answer: B
Injuries of the trachea are repaired with a running 3-0 absorbable monofilament suture. Tracheostomy is not required in
most patients. Esophageal injuries are repaired in a similar
fashion. If an esophageal wound is large or if tissue is missing, a sternocleidomastoid muscle pedicle flap is warranted,
and a closed suction drain is a reasonable precaution. The
drain should be near but not in contact with the esophageal or
any other suture line. It can be removed in 7 to 10 days if the
suture line remains secure. Care must be taken when exploring the trachea and esophagus to avoid iatrogenic injury
to the recurrent laryngeal nerve. (See Schwartz 11th ed.,
Ch. 7, p. 224.)
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9. A patient with spontaneous eye opening, who is confused
CHAPTER 7
and localizes pain has a Glasgow Coma Score (GCS) of:
A. 9.
B. 11.
C. 13.
D. 15.
Answer: C
The GCS should be determined for all injured patients
(Table 7-1). It is calculated by adding the scores of the best
motor response, best verbal response, and eye opening. Scores
range from 3 (the lowest) to 15 (normal). Scores of 13 to 15
indicate mild head injury, 9 to 12 moderate injury, and <9
severe injury. The GCS is useful for both triage and prognosis.
Trauma
TABLE 7-1 Glasgow Coma Scale
Eye opening 4 Spontaneous Spontaneous
Verbal 5 Oriented Alert, normal vocalization
Motor response 6 Obeys commands Spontaneous, purposeful
a
Score is calculated by adding the scores of the best motor response, best verbal response, and eye opening. Scores range from 3 (the lowest) to 15 (normal).
a
3 To voice To voice
2 To pain To pain
1 None None
4 Confused Cries, but consolable
3 Inappropriate words Persistently irritable
2 Incomprehensible words Restless, agitated, moaning
1 None None
5 Localizes pain Localizes pain
4 Withdraws Withdraws
3 Abnormal flexion Abnormal flexion
2 Abnormal extension Abnormal extension
1 None None
(See Schwartz 11th ed., Ch. 7, p. 192.)
Adults Infants/Children
10. Neck injuries:
A. Less than 15% penetrating injuries require neck explo-
ration, a majority can be managed conservatively.
B. Divided into three zones, with zone I above the angle
of the mandible, zone II between the thoracic outlet
and angle of mandible, and zone III inferior to the
clavicles.
C. All patients with neck injury should receive com-
puted tomography angiogram (CTA) of the neck.
D. Patients with dysphagia, hoarseness, hematoma,
venous bleeding, hemoptysis, or subcutaneous
emphysema should undergo neck exploration.
Answer: A
Zone I is inferior to the clavicles encompassing the thoracic
outlet structures, zone II is between the thoracic outlet and
the angle of the mandible, and zone III is above the angle
of the mandible. Patients with symptomatic zone I and III
injuries should ideally undergo diagnostic imaging before
operation if they remain hemodynamically stable. Specific
symptoms which indicate further imaging include dysphagia,
hoarseness, hematoma, venous bleeding, minor hemoptysis,
and subcutaneous emphysema. Symptomatic patients should
undergo CTA with further evaluation or operation based
upon the imaging findings; <15% of penetrating cervical
trauma requires neck exploration. Asymptomatic patients are
typically observed for 6 to 12 hours. The one caveat is asymptomatic patients with a transcervical gunshot wound; these
patients should undergo CTA to determine the track of the
bullet. CTA of the neck and chest determines trajectory of the
injury tract; further studies are performed based on proximity to major structures. Angiographic diagnosis, particularly
of zone III injuries, can then be managed by selective angioembolization. (See Schwartz 11th ed., Ch. 7, p. 198.)
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11. The most appropriate treatment for a duodenal hematoma that occurs from blunt trauma is:
A. Exploratory laparotomy and bypass of the duodenum.
B. Exploratory laparotomy and evacuation of the
hematoma.
C. Exploratory laparotomy to rule out associated
injuries.
D. Observation.
12. Cerebral perfusion pressure (CPP):
A. Equals the systolic blood pressure (SBP) minus
increased intracranial pressure (ICP).
B. Should be targeted to be >100 mm Hg.
C. Is lowered with sedation, osmotic diuresis, paralysis,
ventricular drainage, and barbiturate coma.
D. Can be increased by lowering ICP and avoiding
hypotension.
Answer: D
The spectrum of injuries to the duodenum includes hematomas, perforation (blunt blow-outs, lacerations from stab
wounds, or blast injury from gunshot wounds), and combined pancreaticoduodenal injuries. The majority of duodenal hematomas are managed nonoperatively with nasogastric
suction and parenteral nutrition. Patients with suspected
associated perforation, suggested by clinical deterioration or
imaging with retroperitoneal free air or contrast extravasation, should undergo operative exploration. A marked drop in
nasogastric tube output heralds resolution of the hematoma,
which typically occurs within 2 weeks; repeat imaging to confirm these clinical findings is optional. If the patient shows
no clinical or radiographic improvement within 3 weeks,
operative evaluation is warranted. (See Schwartz 11th ed.,
Ch. 7, p. 229.)
Answer: D
The goal of resuscitation and management in patients with
head injuries is to avoid hypotension (SBP of <100 mm Hg)
and hypoxia (partial pressure of arterial oxygen of <60 or
arterial oxygen saturation of <90). Attention, therefore, is
focused on maintaining cerebral perfusion rather than merely
lowering ICP. Resuscitation efforts aim for a euvolemic state
and an SBP of >100 mm Hg. CPP is equal to the mean arterial
pressure minus the ICP, with a target range of >50 mm Hg.
CPP can be increased by either lowering ICP or raising mean
arterial pressure. Sedation, osmotic diuresis, paralysis, ventricular drainage, and barbiturate coma are used in sequence,
with coma induction being the last resort. (See Schwartz 11th
ed., Ch. 7, p. 218.)
CHAPTER 7
Trauma
13. A patient with penetrating injury to the chest should
undergo thoracotomy if:
A. There is >500 mL of blood which drains from the
chest tube when placed.
B. There is >200 mL/h of blood for 3 hours from the
chest tube.
C. There is an air leak that persists for >48 hours.
D. There is documented lung injury on CT scan.
14. A 19-year-old man fell off his skateboard, reporting
blunt injury to his upper abdomen. Abdominal CT and
magnetic resonance cholangiopancreatography (MRCP)
confirmed he suffered transection of the main pancreatic duct at the middle of the pancreatic body. Which of
the following would be the most appropriate next step in
management?
A. Nonoperative treatment
B. Endoscopic retrograde cholangiopancreatography
(ERCP) with stenting of pancreatic duct
C. Distal pancreatectomy with splenic preservation
D. Primary repair of pancreatic duct with closed suction
drainage
Answer: B
The most common injuries from both blunt and penetrating
thoracic trauma are hemothorax and pneumothorax. More than
85% of patients can be definitively treated with a chest tube.
The indications for thoracotomy include significant initial or
ongoing hemorrhage from the tube thoracostomy and specific
imaging-identified diagnoses. One caveat concerns the patient
who presents after a delay. Even when the initial chest tube output is 1.5 L, if the output ceases and the lung is re-expanded, the
patient may be managed nonoperatively, if hemodynamically
stable. (See Schwartz 11th ed., Ch. 7, p. 222.)
Answer: C
Optimal management of pancreatic trauma is determined by
where the parenchymal damage is located and whether the
intrapancreatic common bile duct and main pancreatic duct
remain intact. Patients with pancreatic contusions (defined
as injuries that leave the ductal system intact) can be treated
nonoperatively or with closed suction drainage if undergoing laparotomy for other indications. Patients with proximal
pancreatic injuries, defined as those that lie to the right of
the superior mesenteric vessels, are also managed with closed
suction drainage. In contrast, distal pancreatic injuries are
managed based upon ductal integrity. Pancreatic duct disruption can be identified through direct exploration of the
parenchymal laceration, operative pancreatography, ERCP,
or MRCP. Patients with distal ductal disruption undergo
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CHAPTER 7
Trauma
15. The most appropriate treatment for a gunshot wound to
the hepatic flexure of the colon that cannot be repaired
primarily is:
A. End colostomy and mucous fistula.
B. Loop colostomy.
C. Exteriorized repair.
D. Resection of the right colon with ileocolostomy.
distal pancreatectomy, preferably with splenic preservation.
An alternative, which preserves both the spleen and distal
transected end of the pancreas, is either a Roux-en-Y pancreaticojejunostomy or pancreaticogastrostomy. If the patient
is physiologically compromised, distal pancreatectomy with
splenectomy is the preferred approach. (See Schwartz 11th
ed., Ch. 7, p. 229.)
Answer: D
Numerous large retrospective and several prospective studies have now clearly demonstrated that primary repair is safe
and effective in the majority of patients with penetrating injuries. Colostomy is still appropriate in a few patients, but the
current dilemma is how to select them. Exteriorized repair is
probably no longer indicated since most patients who were
once candidates for this treatment are now successfully managed by primary repair. Two methods have been advocated
that result in 75% to 90% of penetrating colonic injuries
being safely treated by primary repair. The first is to repair all
perforations not requiring resection. If resection is required
due to the local extent of the injury, and it is proximal to the
middle colic artery, the proximal portion of the right colon up
to and including the injury is resected and an ileocolostomy
performed. If resection is required distal to the middle colic
artery, an end colostomy is created and the distal colon oversewn and left within the abdomen. The theory behind this
approach is that an ileocolostomy heals more reliably than
colocolostomy, because in the trauma patient who has suffered shock and may be hypovolemic, assessing the adequacy
of the blood supply of the colon is much less reliable than in
elective procedures. The blood supply of the terminal ileum
is never a problem. The other approach is to repair all injuries regardless of the extent and location (including colocolostomy), and reserve colostomy for patients with protracted
shock and extensive contamination. The theory used to support this approach is that systemic factors are more important than local factors in determining whether a suture line
will heal. Both of these approaches are reasonable and result
in the majority of patients being treated by primary repairs.
When a colostomy is required, regardless of the theory used
to reach that conclusion, performing a loop colostomy proximal to a distal repair should be avoided because a proximal
colostomy does not protect a distal suture line. All suture lines
and anastomoses are performed with the running single-layer
technique. (See Schwartz 11th ed., Ch. 7, p. 230.)
16. Which of the following statements is true of vascular
injuries of the extremities?
A. In the absence of hard signs of vascular injury, if the
difference between systolic blood pressure (SBP) in
an injured limb is within 15% of the uninjured limb,
no further evaluation is needed.
B. Occult profunda femoris injuries can result in com-
partment syndrome and limb loss.
C. All patients with significant hematoma should be
surgically explored.
D. Vascular injury repair should be performed prior to
realignment of bony fractures or dislocations.
Answer: B
Physical examination often identifies arterial injuries, and
findings are classified as either hard signs or soft signs of
vascular injury (Table 7-2). In general, hard signs constitute
indications for operative exploration, whereas soft signs are
indications for further testing or observation. Bony fractures
or knee dislocations should be realigned before definitive vascular examination. In management of vascular trauma, controversy exists regarding the treatment of patients with soft
signs of injury, particularly those with injuries in proximity
to major vessels. It is known that some of these patients will
have arterial injuries that require repair. The most common
approach has been to measure SBP using Doppler ultraso-
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nography and compare the value for the injured side with that
for the uninjured side, termed the A-A index. If the pressures
are within 10% of each other, a significant injury is unlikely
and no further evaluation is performed. If the difference is
>10%, computed tomography angiogram (CTA) or arteriography is indicated. Others argue that there are occult injuries,
such as pseudoaneurysms or injuries of the profunda femoris or peroneal arteries, which may not be detected with this
technique. If hemorrhage occurs from these injuries, compartment syndrome and limb loss may occur. Although busy
trauma centers continue to debate this issue, the surgeon who
is obliged to treat the occasional injured patient may be better served by performing CTA in selected patients with soft
signs. (See Schwartz 11th ed., Ch. 7, p. 206.)
TABLE 7-2 Signs and symptoms of peripheral arterial
injury
Hard Signs (Operation
Mandatory)
Pulsatile hemorrhage Proximity to vasculature
Absent pulses Significant hematoma
Acute ischemia Associated nerve injury
A-A index = systolic blood pressure on the injured side compared with that on the
uninjured side.
Soft Signs (Further Evaluation
Indicated)
A-A index of <0.9
Thrill or bruit
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CHAPTER 7
Trauma
17. Which of the following is a cause of cardiogenic shock in
a trauma patient?
A. Hemothorax
B. Penetrating injury to the aorta
C. Air embolism
D. Iatrogenic increased afterload due to pressors
Answer: C
In trauma patients, the differential diagnosis of cardiogenic
shock consists of a short list: (1) tension pneumothorax,
(2) pericardial tamponade, (3) myocardial contusion or
infarction, and (4) air embolism.
Tension pneumothorax is the most frequent cause of cardiac failure. Traumatic pericardial tamponade is most often
associated with penetrating injury to the heart. As blood
leaks out of the injured heart, it accumulates in the pericardial sac. Because the pericardium is not acutely distensible,
the pressure in the pericardial sac rises to match that of the
injured chamber. Since this pressure is usually greater than
that of the right atrium, right atrial filling is impaired and
right ventricular preload is reduced. This leads to decreased
right ventricular output and increased central venous pressure (CVP). Increased intrapericardial pressure also impedes
myocardial blood flow, which leads to subendocardial ischemia and a further reduction in cardiac output. This vicious
cycle may progress insidiously with injury of the vena cava
or atria, or precipitously with injury of either ventricle. With
acute tamponade, as little as 100 mL of blood within the pericardial sac can produce life-threatening hemodynamic compromise. Patients usually present with a penetrating injury in
proximity to the heart, and they are hypotensive and have distended neck veins or an elevated CVP. The classic findings of
Beck’s triad (hypotension, distended neck, and muffled heart
sounds) and pulsus paradoxus are not reliable indicators of
acute tamponade. Ultrasonography (US) in the emergency
department (ED) using a subxiphoid or parasternal view is
extremely helpful if the findings are clearly positive (Fig. 7-1);
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CHAPTER 7
Trauma
however, equivocal findings are common. Early in the course
of tamponade, blood pressure (BP) and cardiac output will
transiently improve with fluid administration. This may lead
the surgeon to question the diagnosis or be lulled into a false
sense of security. (See Schwartz 11th ed., Ch. 7, p. 193.)
FIG. 7-1. Subxiphoid pericardial ultrasound reveals a large pericardial
fluid collection. LV = left ventricle; RV = right ventricle.
18. In which of the following scenarios is emergent tracheostomy indicated?
A. Glasgow Coma Score (GCS) 6 and unable to protect
airway
B. Complex maxillofacial trauma
C. Chemical burn to the larynx
D. Laryngeal fractures
19. A 26-year old male patient presents to the emergency
department (ED) after being involved in a rollover motor
vehicle accident. He is awake and alert with GCS14. He is
tachypneic with labored breathing and hypotensive with
BP 80/palp. During primary survey you note distended
veins on the left neck and decreased breath sounds over
the left chest. The best next step in this patient’s care is:
A. Needle thoracostomy decompression with a 14-gauge
needle.
B. Obtain a chest X-ray and proceed to secondary
survey.
C. Tube thoracostomy in the midaxillary line.
D. Orotracheal intubation.
Answer: D
Emergent tracheostomy is indicated in patients who have
laryngotracheal separation or in those with laryngeal fractures because cricothyroidotomy may cause additional damage or result in loss of the airway. The remaining scenarios
are appropriately managed with orotracheal intubation or
cricothyroidotomy if intubation is unsuccessful. Emergent
tracheostomy is most safely accomplished in the operating
room. If there is complete tracheal transection, a penetrating
towel clip should be placed on the distal segment to prevent
retraction into the mediastinum. (See Schwartz 11th ed.,
Ch. 7, p. 185.)
Answer: C
Tension pneumothorax is presumed in any patient manifesting respiratory distress and hypotension in combination with
any of the following physical signs: tracheal deviation away
from the affected side, lack of or decreased breath sounds
on the affected side, and subcutaneous emphysema on the
affected side. Patients may have distended neck veins due to
impedance of venous return, but the neck veins may be flat
due to concurrent systemic hypovolemia. Tension pneumothorax and simple pneumothorax have similar signs, symptoms, and examination findings, but hypotension qualifies
the pneumothorax as a tension pneumothorax. Although
immediate needle thoracostomy decompression with a
14-gauge angiocatheter may be indicated in the field, tube
thoracostomy in the midaxillary line should be performed
immediately in the emergency department (ED) before a
chest radiograph is obtained (Fig. 7-2). In cases of tension
pneumothorax, the parenchymal tear in the lung acts as a
one-way valve, with each inhalation allowing additional air
to accumulate in the pleural space. The normally negative
intrapleural pressure becomes positive, which depresses the
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ipsilateral hemidiaphragm and shifts the mediastinal structures into the contralateral chest. Subsequently, the contralateral lung is compressed and the heart rotates about the
superior and inferior vena cava; this decreases venous return
and ultimately cardiac output, which culminates in cardiovascular collapse. (See Schwartz 11th ed., Ch. 7, p. 186.)
CHAPTER 7
Trauma
20. Patients who are conscious, without tachypnea, and have
a normal voice are unlikely to require air intervention.
Additional findings that should prompt airway intervention include all of the following EXCEPT:
A. Penetrating injury to the neck with expanding
hematoma.
B. Evidence of chemical or thermal injury to mouth,
nares, or hypopharynx.
C. Extensive subcutaneous air in the neck.
D. Right pneumohemothorax.
E. Airway bleeding.
FIG. 7-2. A. Tube thoracostomy is performed in the midaxillary
line at the fourth or fifth intercostal space (inframammary
crease) to avoid iatrogenic injury to the liver or spleen. B. Heavy
scissors are used to cut through the intercostal muscle into the
pleural space. This is done on top of the rib to avoid injury to the
intercostal bundle located just beneath the rib. C. The incision is
digitally explored to confirm intrathoracic location and identify
pleural adhesions. D. A 28Fr chest tube is directed superiorly and
posteriorly with the aid of a large clamp.
Answer: D
Patients who are conscious, without tachypnea, and have a
normal voice are unlikely to require early airway intervention. Exceptions are penetrating injuries to the neck with
an expanding hematoma; evidence of chemical or thermal
injury to the mouth, nares, or hypopharynx; extensive subcutaneous air in the neck; complex maxillofacial trauma; or
airway bleeding. Although these patients may initially have
an adequate airway, it may become compromised if soft tissue
swelling, hematoma formation, or edema progresses. In these
cases, preemptive intubation should be performed before airway access becomes challenging. Simple pneumohemotho-
rax is NOT an indication for airway intervention during
the primary survey.
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