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88 Genitourinary Trauma
283
– Diagnosed on a CT urogram, which is a CT abdomen/
pelvis with a delayed excretory phase, or by direct
examination during an exploratory laparotomy (Lewis
2023)
• What are the three segments of the ureter?
– Proximal includes the portion of the ureter above the
iliac bifurcation (Lewis 2023).
– Mid portion includes the ureter located between the
iliac bifurcation and pelvic brim (Lewis 2023).
– Distal includes the portion of the ureter below the pel-
vic brim (Peitzman etal. 2020).
• What is the management of ureteral injury?
– Management of a ureteral injury is dependent upon the
segment of the ureter that is injured, the amount of the
ureter that is injured, and the condition of the patient
(Lewis 2023).
– Operative repair is usually indicated and there is a lim-
ited role for nonoperative management (Lewis 2023).
– If the patient is unstable and undergoing a damage
control laparotomy, then you can ligate the ureter or
create a cutaneous ureterostomy, and denitive management can be deferred (Peitzman etal. 2020). The
patient can undergo percutaneous nephrostomy diversion or retrograde ureteropyelography and stenting
when the patient is more stable (Lewis 2023).
• Basics of repair include (Peitzman etal. 2020):
– Debridement of devitalized tissue
– Proximal and distal mobilization
– Spatulation of the ureter
– Tension-free repair
– Stenting the ureter
– A watertight anastomosis
– Bladder drainage
• Proximal injuries (Peitzman etal. 2020):
– <2cm injury—primary repair (ureteroureterostomy)
– Larger injuries may require more complex
reconstruction
• Mid portion injuries (Peitzman etal. 2020):
– <2cm injury—primary repair
– Longer segment injuries may require Psoas Hitch and
Boari ap
• Distal injuries:
– Ureteral reimplantation into the bladder
– Longer segment injuries may require Psoas hitch and/
or Boari ap
• What is a helpful adjunct to detect GU injuries if not obvi-
ous during laparotomy injecting methylene blue may help
identify injuries
Clean Kills
• Not systematically completing your trauma assessment
• Missing other injuries, including outside the abdominal
cavity or within the abdominal cavity
• Placing a urinary catheter in a patient with an intraperitoneal injury
• Taking the time to repair a ureteral injury in an unstable
patient.
• Managing a patient with a low-grade kidney injury who is
hemodynamically unstable in the ICU and not taking
them to the operating room.
Bonus Points
• Remember to study the extraperitoneal urinary bladder
injury after placement of a foley catheter with a CT cystogram in 10–14days.
• If you have a urethral injury with disruption, the standard
recommendation is to surgically place a suprapubic cystostomy tube. Attempts can initially be made at early
endoscopic or non-endoscopic urethral realignment, and
Foley catheter placement, but such attempts should not be
overly prolonged to avoid contamination and extravasation. If unsuccessful, a suprapubic tube should be placed
with the expectation that a delayed urethroplasty will
likely be needed.
Words ofWisdom
Although the incidence of mortality is low with GU trauma,
it is important to have a high index of suspicion of injury to
be able to order adequate studies and interpret them to further guide management. Initial treatment and early recognition of injuries will decrease the incidence of sepsis and will
lower the incidence of morbidity.
Bibliography
Leslie SW, Nelson Q, Baker J.Urethral injury [Updated 2023 Jul 24].
In: StatPearls [Internet]. Treasure Island: StatPearls Publishing;
2023. https://www.ncbi.nlm.nih.gov/books/NBK554575/.
Lewis M. Genitourinary trauma. 2023. https://www.surgicalcore.org/
modulecontent.aspx?id=1000738. Accessed 27 Aug 2023.
Peitzman AB, Yealy DM, Fabian TC, Schwab CW. Trauma and acute
care surgery. 5th ed. Philadelphia: Wolters Kluwer; 2020.
Liver Trauma
DevonPace andGeorgeJ.Koenig Jr
89
Way Questions May BeAsked?
A 33-year-old man with no known medical history presents
to the trauma bay after a high-speed motor vehicle accident
as a restrained driver. His blood pressure on arrival is 80/60,
with a heart rate of 125. What would you like to do?
Way toAnswer?
• Initiate the evaluation with Advanced Trauma Life
Support (ATLS) primary survey (ABCDEs)
– Be sure to evaluate for injuries requiring urgent man-
agement (i.e., pneumothorax, hemothorax, etc.).
• Ensure adequate access with at least two large bore IVs
(18 gauge or larger at the antecubital or above) and resuscitate with blood products.
– Key step: you will be faced with a decision on deter-
mining whether the patient is a responder, transient
responder, or nonresponder to resuscitation.
• Responder
– Continue the evaluation, including a secondary survey
with a head-to-toe exam highlighting specic regions
of interest based on the history, including the neck,
chest, abdomen, and pelvis.
For example, you do not want to miss a concomitant cervical spine injury or open-book pelvic
fracture.
Be sure to obtain your laboratory (CBC, CMP, lactate, lipase, coags, and type and screen) and imaging (CXR, pelvic XR, FAST) adjuncts.
FAST assists with cavitary triage in patients with
hemodynamic instability.
– Proceed with secondary imaging studies based on
injury patterns as well as cross-sectional imaging (CT
D. Pace · G. J. Koenig Jr (*)
Department of Surgery, Sidney Kimmel Medical College at
Thomas Jefferson University, Philadelphia, PA, USA
e-mail: Devon.Pace@jefferson.edu; George.Koenig@jefferson.edu
head, cervical spine, chest, abdomen, and pelvis) to
evaluate the extent of injuries.
– If solid organ injury is identied and there is no evi-
dence of active extravasation or blush of contrast, then
you should consider non-operative management.
• Transient responder
– Continue the evaluation, including a secondary survey
with a head-to-toe exam.
– Be sure to obtain your laboratory and imaging adjuncts.
– Ensure continued response to resuscitation and con-
sider obtaining cross-sectional imaging to identify the
type of injury.
– If solid organ injury with active extravasation or blush
of contrast, then we may consider interventional radi-
ology for angioembolization.
• Non-responder
– The operative strategy will be based on the type of
injury (laparotomy for patients with positive eFAST,
peritonitis, or penetrating abdominal injuries).
– Be sure to obtain your laboratory and imaging adjuncts.
Management Options
• Non-operative management
– Indicated for patients with low-grade liver injuries or
those who respond to resuscitation without active
extravasation on CT.
– Admit these patients to a monitored bed (ICU versus
step-down), bedrest for at least 24h, NPO, IV uids
versus blood products, and trend serial hemoglobins
until stable.
– May additionally perform serial abdominal exams and
have a low threshold to explore the patient operatively
or consider angiography with evolving vitals, hemoglobins, product requirement, or exams.
• IR (Interventional Radiology) angiography management
– Depending on the scenario, it may not be an available
option but should still be mentioned if the patient meets
the criteria.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_89
285
286
D. Pace and G. J. Koenig Jr
– However, may consider angiography and embolization
in patients with signicant liver injuries (active extravasation, large injuries, and/or pseudoaneurysms) who
are transient responders to resuscitation.
• Operative management
– Indicated for patients not responsive to resuscitation,
those with signicant injuries, and those without IR
availability.
Surgical Management
To reiterate, it is unlikely you will encounter an isolated liver
injury scenario but a scenario requiring a laparotomy with
multiple intra-abdominal injuries that need to be managed
including a liver injury requiring hemostatic management
techniques.
1. Prep the patient from chin to knees
2. Make a generous midline incision from the xiphoid to
the pubis
3. Upon opening the abdomen, pack all four quadrants
with laparotomy/trauma pads to allow anesthesia to
catch up in resuscitation attempts
4. Perform a rapid abdominal survey and be sure to control
any intestinal spillage by quick transection of injured
bowel or primary repair for minor injuries (more specic
to penetrating abdominal injuries)
5. Carefully remove pads from quadrants in a clockwise
fashion and control bleeding
(a) For penetrating injuries, evaluate the specic quad-
rant of interest last
6. For more complex injuries, may consider asking for a
transplant surgeon or hepatobiliary surgeon for assistance, although this will likely be unavailable
7. May require mobilization of the liver by division of the
falciform and triangular/coronary ligaments
8. Always place drains to control for a bile leak
9. Pay specic attention to patient stability intraoperatively
and the possibility of transitioning to a “damage control”
procedure if the patient remains hypothermic, acidotic,
and coagulopathic
10. Place a temporary abdominal closure device with the
intentions to re-explore the patient in 24 h once
resuscitated
ponade bleeding (sandwich the liver). Typically
requires 8–10 laparotomy pads.
2. Simple laceration
(a) Direct pressure
(b) Topical hemostatic agents (i.e., brin glue, brillar,
nu-knit)
(c) Monopolar electrocautery (Bovie), bipolar electro-
cautery (Aquamantys), or argon beam plasma
coagulation
3. Deep laceration
(a) Finger fracture and ligation of individual vessels
(b) Suture hepatorrhaphy to injured area with a large
blunt-tipped liver needle
(c) Pack laceration with a vascularized tongue of omen-
tum and suture in place to Glisson’s capsule
4. Extensive injuries (bilobar, hepatic vein injury, retrohepatic vena cava)
(a) Decide early to utilize a “damage control” strategy
with the placement of a temporary abdominal closure
device
5. Maneuvers
(a) Pringle—access the lesser sac and place a straight
vascular clamp across the hepatoduodenal ligament
to control bleeding or identify a hepatic/vena cava
bleeding source. One can also use a Rumel tourniquet for the Pringle maneuver.
• If bleeding stops, it indicates a hepatic artery or
portal venous source (or both)
• If bleeding continues, it indicates a hepatic venous
or retrohepatic inferior vena cava (IVC) source
(b) Atriocaval (Shrock) shunt—insertion of a 36-French
chest tube in the right atrium (secured with a purse
string) and down to the suprarenal inferior vena cava
(IVC) (secured with a Rumel tourniquet). One can
also use an endotracheal tube, although it needs to
have a side hole cut in it.
• Requires a median sternotomy and opening of the
pericardium for access to the right atrium
(c) Total vascular isolation—placement of vascular
clamps across the hepatoduodenal ligament, infrahepatic/suprarenal IVC, and suprahepatic IVC
• Generally, not well tolerated in trauma patients
due to lack of venous return and limited cardiac
output
Operative Hemostatic Techniques
1. General
(a) Mobilize the liver (falciform and triangular liga-
ments) and pack anteriorly and posteriorly to tam-
Post-operative Management
• Admit to the ICU and continue balanced resuscitation
efforts with serial labs and monitoring of hemodynamics
• Return to the OR in 12–36h, depending on the patient’s
responsiveness to resuscitative efforts or lack thereof
89 Liver Trauma
287
• Consider initiation of broad-spectrum antibiotics if there
is a concomitant bowel injury
• Once the patient is determined to be stable for abdominal
closure, place drains in the perihepatic space to prevent
biloma formation and infection
• Proactively obtain a hepatobiliary iminodiacetic acid
(HIDA) scan at 72h post-injury for high-grade liver injuries to evaluate for bile leaks. If present, you should manage with an endoscopic retrograde cholangiography
(ERC), and stent placement and IR drain placement
• Consider transferring the patient to a higher level of care
or a level 1 trauma center for further management once
stable with an open abdomen and temporary closure
device in place
Sample Scenario Dialogue
A 33-year-old man with no known medical history presents
to the trauma bay after a high-speed motor vehicle accident
as a restrained driver. His blood pressure on arrival is 80/60,
with a heart rate of 125. What would you like to do?
“I’m concerned that the patient was involved in a major
accident and is at risk of numerous injuries in the head, chest,
and abdomen. I’m going to start by initiating ATLS protocol
and conrm the patient has a patent airway by asking them
their name. If they respond appropriately then I would listen
for breath sounds on both sides and if they were absent, then
I would place a chest tube on the appropriate side. I would
then evaluate for proximal and distal pulses while simultaneously ensuring proper IV access for resuscitation which
would include two large bore IVs at the antecubital or higher.
During placement of IVs, I would obtain a full set of labs
including a CBC, CMP, lactate, and coags. Given the patient’s
mechanism of injury and hemodynamic status, I would start
by resuscitating the patient with 2 units of whole blood. I
would then assess the patient’s Glasgow Coma Scale score
and completely expose the patient to assess for stigmata of a
major injury, such as a seatbelt sign. Lastly, I would turn the
patient to evaluate their back while maintaining cervical
spine precautions to assess their back and then follow up on
the patient’s response to resuscitation.”
Okay, the patient’s airway was patent. You noted there
were absent breath sounds on the left side and placed a chest
tube, which put out 200mL of blood upon placement. The
patient has both central and distal pulses, but their distal
pulses feel weaker. You give the patient 2 units of blood, and
their blood pressure improves to 90/65 and heart rate 115.
You note a seatbelt sign is present on the chest and
abdomen.
“I am still concerned that the patient may not have ade-
quately responded to resuscitation and I would continue
resuscitating the patient with blood products while obtaining
imaging adjuncts to assess for injuries requiring immediate
management. I would obtain a CXR to evaluate for pneumo-
thorax or residual hemothorax after placement of the chest
tube. I would obtain a pelvic x-ray to assess for a pelvic fracture that may require placement of a pelvic binder. I would
perform a FAST exam to assess for intra abdominal free uid
that may indicate an intra abdominal injury. If the adjuncts
were negative and the patient was hemodynamically stable,
then I would proceed with a secondary head-to-toe exam to
assess for other injuries. If the FAST exam was positive for
free uid in the abdomen and the patient remained nonresponsive to resuscitation, then I would proceed to the operating room for an exploratory laparotomy. If the FAST exam
was positive but the patient was responsive to resuscitation,
then I would obtain cross-sectional imaging including a CT
head, cervical spine, chest, abdomen, and pelvis to assess for
injuries. If at any point, the patient became unstable or I was
concerned about their hemodynamics despite resuscitation,
then I would proceed to the operating room.”
The patient remains hemodynamically unstable despite
resuscitative attempts. The CXR demonstrates your chest
tube is adequately in place without any evidence of pneumothorax or residual hemothorax. There is no pelvic fracture
identied. On the FAST exam, you note uid in the hepatorenal, splenorenal, and perivesicular spaces. You administer
another 2 units of blood and the patient’s heart rate remains
120 and the blood pressure 90/60. How would you like to
proceed?
“I’m concerned that the patient has an intra abdominal
solid organ injury that requires operative management and
would proceed to the operating room emergently for an
exploratory laparotomy. I would ensure that the patient has
adequate access and prep the patient from xiphoid to pubis
with the groins exposed. I would make a generous midline
laparotomy to enter the abdomen, and upon entry, I would
sequentially pack all four quadrants with laparotomy pads.
After packing the abdomen, I would allow time for anesthesia to catch up in resuscitation based on the patient’s response
while evaluating the bowel for any injuries that may be amenable to suturing or transection, although bleeding would be
my priority. I would then sequentially remove the packs from
the lower quadrants rst to evaluate for any source of active
hemorrhage. I would then remove the packs from the upper
quadrants to assess for any injuries to the liver or spleen. If
there was active bleeding from either of these organs, I would
attempt to hold pressure rst, followed by topical hemostatic
agents if this were to be unsuccessful. If there was continued
bleeding from the liver, then I would take down the triangular ligaments to mobilize the liver and sandwich the liver
with laparotomy pads. If there is a signicant deep liver laceration with continued bleeding, I would consider nger
fracturing and ligating any bleeding vessels present within
the parenchyma. Meanwhile, I would continually assess the
patient’s response to resuscitation and understand the
potential that I may need to convert to a damage control lapa-
288
D. Pace and G. J. Koenig Jr
rotomy and place a temporary abdominal closure device to
allow for time to resuscitate the patient.”
You perform an exploratory laparotomy and identify signicant injuries to the spleen and liver. The spleen remains
hemostatic after the placement of topicals, but the liver continues to bleed despite local hemostatic attempts. What are
some more advanced techniques you can use to identify the
source of bleeding?
“If the liver continued to bleed despite attempts at local
control, I would perform a Pringle maneuver to triage
between the portal vein and hepatic vein or retrohepatic IVC
as sources of bleeding. I would do this by placing a Rumel
tourniquet around the hepatoduodenal ligament to occlude
the portal vein. If the bleeding stops, then this indicates
bleeding from a portal venous source. If the bleeding continues, then this indicates a hepatic venous or retrohepatic IVC
source of bleeding.”
Alternative Scenario Dialogue
The patient responds to initial resuscitation during the primary survey.
Okay, the patient’s airway was patent. You noted there
were absent breath sounds on the left side and placed a chest
tube, which put out 200mL of blood upon placement. The
patient has both central and distal pulses, but their distal
pulses feel weaker. You give the patient 2 units of blood, and
their blood pressure improves to 110/80 and heart rate 95.
You note a seatbelt sign is present on the chest and
abdomen.
“Given the patient is responsive to resuscitation, I would
rst proceed with imaging adjuncts including a CXR and
pelvic x-ray to assess for any additional injuries that may
require immediate interventions, including a missed pneumothorax or hemothorax and an open book pelvic fracture
requiring placement of a pelvic binder. I would then proceed
with the secondary survey and perform a head-to-toe exam to
assess for additional injuries. If the patient remained stable
or responsive to resuscitation, I would proceed with crosssectional imaging including a CT head, cervical spine, chest,
abdomen, and pelvis to evaluate all injuries. If a high-grade
solid organ injury was identied, then I would prioritize nonoperative management and consider angiography with
embolization if the patient were transiently responsive to
resuscitation or if a pseudoaneurysm was present.”
You take the patient to CT and identify a grade III splenic
injury and a grade IV liver injury with hemoperitoneum and
possible intrahepatic extravasation of contrast. After CT, the
patient’s blood pressure is 100/70 and heart rate is 110.
“Given the patient’s slight worsening in hemodynamics, I
would administer another 2 units of blood products and con-
sult the interventional radiology team for angiography and
embolization of any pseudoaneurysms or areas of active
extravasation in either the spleen or liver.”
You take the patient to IR, and they identify and successfully embolize a branch of the right hepatic artery that had
active extravasation. How would you like to proceed?
“I would admit the patient to the intensive care unit and
perform serial hemoglobin checks every 6h to ensure the
patient’s blood counts remain stable. I would keep them
NPO as they are resuscitated in the ICU.I would plan to perform a HIDA scan 72h after injury to evaluate for a bile leak
given the signicance of the liver injury. If a leak were present, I would again consult interventional radiology for drain
placement and consult our gastroenterologists for endoscopic retrograde cholangiography (ERC) with stent
placement.”
Common Curveballs
• Hepatic pseudoaneurysm
– Development of large volume bright red rectal bleed-
ing or hematemesis
– CTA may demonstrate pseudoaneurysm, or ERC may
demonstrate hemobilia
– Managed with angiographic embolization
• Abdominal compartment syndrome
– Development of worsening urine output and/or dif-
culty ventilating the patient while intubated status post
exploration with the placement of a temporary abdominal closure device while aggressively resuscitating
– Consider re-exploration of the abdomen to evaluate for
other causes and decompress the abdomen
Clean Kills
• Failure to identify concomitant injuries prior to going to
the operating room (i.e., unidentied pneumothorax/
hemothorax, open book pelvic fracture, cervical spine
injury, etc.)
• Performing a CT scan in an unstable patient (do FAST
and if/when positive, take directly to surgery)
• Attempting nonoperative management when not indi-
cated (i.e., hemodynamically unstable patient or nonre-
sponder to resuscitation)
• Lack of knowledge of intraoperative hemorrhage control
techniques
• Lack of recognition of when to transition to a “damage
control” management strategy
89 Liver Trauma
289
Words ofWisdom
The oral board exam will likely focus on a few key management decisions when faced with a traumatic liver injury,
which are rooted in the recognition of when it is appropriate
to perform nonoperative versus operative management. Nonoperative management will focus on the critical care management of patients who are post-injury. Operative
management will address key decisions focusing on the least
invasive to the most invasive strategies to control liver hemorrhage intraoperatively. It is unlikely that you will face a
scenario based on the isolated management of liver injury
but a combination of injuries. Remember that this is overall
a trauma scenario, therefore, you should adhere to ATLS protocol algorithms in the initial workup and management.
Bibliography
Singer G, Neville A, Feinman M.Abdominal exploration for trauma.
The SCORE Portal. https://www.surgicalcore.org/modulecontent.
aspx?id=1000552. Published July 2023.
Stassen NA, Bhullar I, Cheng JD, Crandall M, Friese R, Guillamondegui
O, et al. Nonoperative management of blunt hepatic injury: an
Eastern Association for the Surgery of Trauma practice management
guideline. J Trauma Acute Care Surg. 2012;73(5 Suppl 4):S288–93.
https://doi.org/10.1097/TA.0b013e318270160d. PMID: 23114483.
Pelvic Fractures
AymenIbrahim andAnirudhKohli
90
Way Question May BeAsked
A 30-year-old male presents to the trauma bay after being
involved in an MVC.He is found to have a GCS of 13 upon
arrival to the bay. He is noted to be tachycardic to the 110s
and blood pressure is noted to be in the 90s/50s. What is your
next step?
How toAnswer
• In any trauma scenario, prioritization of the ABCDEs will
always be the rst step.
– Airway: Ensure that there is a patent airway and that
patient is able to protect their airway
– Breathing: Are there bilateral breath sounds? If yes,
move on. If no, consider placing a chest tube on the
side of the chest with concern for either a hemothorax
or pneumothorax.
– Circulation: Is there a pulse? Do you have palpable
distal extremity pulses? Any active bleeding? And if so
employ means to temporarily stop active bleeding. Do
you have adequate intravascular venous access?
– Disability: What is their GCS? What is their quick neu-
rological assessment? (Are they moving their upper
and lower extremities?)
– Environment/Exposure: Look for any signs of trau-
matic injuries on the axillary/perineal and torso/
extremities and control the environment by optimizing
room temperature, warm blankets, and warm uids.
A. Ibrahim
Department of Surgery, Lankenau Medical Center,
Wynnewood, PA, USA
e-mail: ibrahimay@mlhs.org
A. Kohli (
Department of Surgery, Lankenau Medical Center,
Wynnewood, PA, USA
Division of Acute Care Surgery, Department of Surgery, Thomas
Jefferson University Hospital, Philadelphia, PA, USA
e-mail: anirudh.kohli@jefferson.edu
*)
• Ensure there are two large bore peripheral IVs (18 gauge
or lower) and give the patient blood or start massive transfusion protocol (MTP) if there is ongoing concern for
hemorrhagic shock and/or signicant bleeding.
• With any trauma scenario involving a high-impact mechanism of injury, obtaining a chest and pelvic X-ray to
assess for injuries is a crucial adjunct to the primary
survey.
• If the pelvic X-ray shows an anterior–posterior fracture
pattern or an obvious open book fracture of the pelvis and
the patient is hypotensive, place the pelvic binder to compress the pelvic space.
– It is important to remember how to place the pelvic
binder: make sure to line up the binder on the greater
trochanters; higher on the body will not provide adequate compression.
Way Question May BeAsked
A 35-year-old male presents after an MVC.He is intubated
in the eld and brought in by EMS.His vital signs are stable.
A primary survey is completed, with a pelvic X-ray demonstrating a pelvic fracture. FAST is negative. Pelvic binder is
placed prophylactically, and secondary survey is completed.
How do you proceed?
How toAnswer
• Next step in this scenario should be a CT scan as the
patient is hemodynamically stable, and there may be other
organs that could be injured.
– Remember to mention that other organs in the pelvis
may be injured, such as the bladder and urethra. Hence,
do not forget to ask about blood at the meatus or about
high-riding prostate. If that piece of information is not
provided, one can add RUG/CT Cystogram to the
workup.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_90
291
292
A. Ibrahim and A. Kohli
– If there is blood at the meatus, then one must perform
a retrograde urethrogram (RUG).
– If there is gross hematuria, then a CT Cystogram
should be strongly considered.
– Bladder injuries that are intraperitoneal require opera-
tive intervention.
– Bladder injuries that are extraperitoneal are treated
with a Foley catheter placement and decompression
for at least 7–10days with a follow-up CT Cystogram
typically at day 7 of injury.
• If an intra-abdominal source is found requiring surgery,
perform exploratory laparotomy.
• If there is a source of major active bleeding from the pelvis that is accessible via angiography, direct the patient to
IR angiography for potential embolization.
Way Question May beAsked
An 85-year-old female presents to the bay after a fall from
standing. She is hemodynamically stable, has a GCS 15 but
is complaining of lower abdominal and leg pain. Primary
and secondary survey is completed, and the patient is taken
to CT scan. CT scan demonstrates retroperitoneal hematoma. Patient remains stable and Hgb remains stable, how
do you manage this hematoma?
How toAnswer
• Stable retroperitoneal hematomas can be observed with
serial abdominal exams and checking serial complete
blood counts (CBCs) to ensure stability.
• If the scenario mentions the presence of an active extravasation, then consider IR angiography and embolization.
• If the scenario describes peritonitis and an expanding
hematoma, then one should strongly consider either preperitoneal packing in addition to angiography and embolization, preferably in a hybrid operating room (if
available).
Way Questions May BeAsked
A 65-year-old female presents to the bay after MVC.She was
intubated in the eld due to a GCS of 6. She is currently
hemodynamically unstable. Primary survey is completed,
and secondary survey is notable for ecchymosis along the
pelvis and a pelvic binder is placed, a FAST (Focused
Assessment of Sonography in Trauma) is performed, which is
negative for any intra-abdominal uid. Chest X-ray does not
show a large pneumothorax or hemothorax, and the pelvic
X-ray shows a small vertical shear fracture pattern. Patient
is currently still hemodynamically unstable despite resuscitation and cannot proceed to CT scan. What would you do
next?
How toAnswer
• This is a situation in which DPL (diagnostic peritoneal
lavage) should be considered to rule in the abdominal
cavity as the source of bleeding to help in proceeding to
the operating room next.
• DPL can be used to assess bleeding into the abdomen that
would require laparotomy in a patient who is too unstable
to go to CT scan.
– There are multiple techniques for DPL, such as open
(all layers opened), semi-open (fascia opened and then
needle inserted), and closed (skin opened and then
needle inserted). The safest choice is open using direct
visualization.
– Open DPL in a pelvic fracture patient is performed
by making an incision above the umbilicus (supraumbilical), going through all layers of abdominal wall
and through peritoneum. A DPL catheter is placed,
and the rst aspiration is performed. If there is >10cc
of gross blood or succus, then it is positive, and laparotomy should be performed. If the initial aspiration
is not grossly positive, then 1 L of sterile normal
saline is instilled and the uid is allowed to passively
drain out.
– To summarize DPL ndings and responses:
If gross blood is aspirated, proceed to laparotomy.
If clear uid is aspirated, send it to lab for analysis.
If analysis shows >100,000 RBC/mm
WBC/mm3, the DPL is positive and laparotomy
should be performed.
If negative, look for another source of bleeding.
• When faced with a hemodynamically unstable pelvic
fracture patient who has a negative FAST and negative
DPL, perform preperitoneal packing.
– Take the patient from the trauma bay to the OR; prep
and drape in a trauma manner from chin to knees.
– Perform a lower midline incision (can use Pfannenstiel
as well)
– Dissect through abdominal wall with incision of the
abdominal fascia and leave the peritoneum intact until
hematoma/bleeding located (pre-peritoneal space usually dissected free by hematoma) or remember the
retro-rectus muscle plane (typically used for laparoscopic or robotic inguinal hernia repair) to help guide
you in a hostile plane.
– Once in the preperitoneal plane, sequentially pack 3
laparotomy sponges on each side, beginning posterior,
then middle, then anterior on either side of the urinary
bladder.
3
or >500
90 Pelvic Fractures
293
– Close the fascia with 0 PDS and the skin with
staples.
– Come back in 24–48h after hemodynamic stability to
remove the sponges.
Common Curve Balls
A challenging problem is the hemodynamically unstable pelvic fracture patient with a negative FAST exam. Diagnostic
Peritoneal Lavage (DPL) can help ensure there is not a false
negative FAST result. Be able to describe how to perform a
DPL.
For patients who are too unstable to transport to a CT scan
or await the Interventional Radiology team, extraperitoneal
pelvic packing can provide compression and assist in hemostasis and resuscitation of the unstable pelvic fracture patient.
Clean Kills
• Not assessing stability of the pelvis during secondary
survey.
• Not placing a pelvic binder when there is a pelvic fracture
with unstable vital signs.
• Operatively exploring stable retroperitoneal hematomas.
Words ofWisdom
Pelvic fracture patients present in a variety of ways, including presenting with hemodynamic instability from lifethreatening internal hemorrhage. Such cases present
diagnostic and therapeutic challenges. Consider obtaining a
pelvic X-ray as an adjunct to the primary survey with a
mechanism of injury to the lower abdomen/pelvis or in a
hypotensive patient to perform cavitary triage. Consider
placement of a pelvic binder with suspicion of a pelvic fracture and hypotension. If the patient is normotensive or a transient responder with resuscitation, then consider
cross-sectional imaging with intravenous contrast to look for
ongoing bleeding. Extraperitoneal pelvic packing can provide a rapid stabilizing and temporizing measure while the
logistics of other treatment modalities (e.g., interventional
radiology) are brought into play. Angiography with or without preperitoneal packing is an effective means of controlling ongoing bleeding.
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Rib Fractures
JohnathanSadeh
91
Flail chest is dened as three or more consecutive displaced
rib fractures in two separate locations along each rib leading
to varying degrees of chest wall instability. The pathophysiology of hypoxia and ineffective ventilation stems from both
the underlying pulmonary contusions and the paradoxical
motion of the chest wall during inspiration/expiration.
During inspiration, the affected side of the chest collapses
inwards due to the negative intrathoracic pressure, collapsing
the airways, and increasing dead space.
Work Up
1. All trauma scenarios should be worked up in a similar
manner and should start with the ABCs of trauma:
(a) Airway
(b) Breathing
(c) Circulation
(d) Disability
(e) Exposure
Many patients in trauma will have other concomitant
injuries, and those will need to be addressed as well.
These patients are also more likely to be categorized
under blunt trauma and should have C-collars placed.
Special consideration at this point for intubation and
chest tube placement for impending respiratory
instability.
2. A thorough head-to-toe secondary survey should be performed to rule out any other major injuries.
3. Adjuvants such as E-FAST and imaging (Chest/pelvic
X-rays) can be performed in the trauma bay.
(a) Address any large visible pneumothorax/hemotho-
rax/hemopneumothorax with a chest tube
J. Sadeh (*)
General Surgery, Jefferson Einstein Hospital,
Philadelphia, PA, USA
e-mail: Johnathan.Sadeh@jefferson.edu
4. If there is no reason to bring the patient directly to the
operating room, CT imaging should be performed if
appropriate.
(a) Non-contrast CT head
(b) IV contrast CT Chest-Abdomen-Pelvis
(c) CT maxillofacial for concerns of facial fractures
(d) CT angiography of head and neck if
• 1st rib fractures
• Denver or Memphis criteria
Non-Surgical Treatment
1. The primary treatment of those with rib fractures is multimodel pain control using both non-narcotic and narcotic
medications. Options include:
(a) Acetaminophen
(b) NSAIDs
(c) Oral narcotics
(d) I.V narcotics
(e) Gabapentin or Pregabalin
(f) Muscle relaxants (i.e., Cyclobenzaprine)
• If pain remains uncontrolled, patient-controlled
analgesics, epidurals, local nerve blocks (i.e.,
erector spinae block, intercostal blocks), and
nerve block catheters.
2. Aggressive pulmonary toilet
3. Close monitoring of respiratory status
(a) ABGs
(b) Daily chest X-rays
4. Non-invasive ventilation
(a) Hi-Flow nasal Cannula
(b) CPAP
(c) Bipap/Bilevel
5. Invasive ventilation
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_91
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