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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1232_Библиотеки_им_академика_М_И_Перельмана.pdf
296
J. Sadeh
Surgical Treatment
Rib xation is a controversial procedure, with literature both
advocating and against it. According to the EAST guidelines,
it is conditionally recommended to decrease mortality,
shorten duration under mechanical ventilation, decrease hospital and ICU length of stay. However, there is little to no
evidence that this decreases long-term pain. Thus, it is typically reserved for those with poor respiratory effort and several ail segments resistant to other methods of treatment.
Operative xation of rib fractures after blunt trauma
A practice management guideline from the Eastern
Association for the Surgery of Trauma
(https://journals.lww.com/jtrauma/fulltext/2017/03000/
operative_xation_of_rib_fractures_after_blunt.25.aspx)
Geriatric Population Considerations
As with all trauma, special consideration needs to be taken
with the geriatric population (dened as 65years or older)
due to their decreased physiologic reserves. Respiratory
physiologic changes include:
• Weakened respiratory muscles
• Reduced chest wall compliance
• Decreased inspiratory capacity
Extreme caution should be taken with those 65years or
older, especially those with a high frailty score. A low threshold for pan-scan imaging and early admission to the surgical/
trauma ICU should be considered.
Penetrating Neck Trauma
MargoCarlin
92
Concept
Penetrating neck trauma carries signicant rates of morbidity and mortality due to the region’s anatomy. The majority
of questions will be focused on the anatomy of injury, stabilizing the airway, and the operative exposure required for
hemorrhage control. You must keep in mind there is a high
rate of concomitant injuries to nerves and aerodigestive
structures, and injuries may not occur in isolation. Identifying
the trajectory of the injury, which may cross-dened anatomic zones, will help guide your workup and operative
strategy.
Way Question May BeAsked?
“A 21-year-old male presents to the emergency department
(ED) with stab wound to left neck with a non expanding
hematoma.” Your major focus in trauma scenarios is hemodynamic stability. In all trauma cases and in patients presenting in extremis in other scenarios, be sure to establish
bilateral IV access with large bore IVs. Proceed with ATLS
protocol for primary and secondary surveys in both stable
and unstable patients. In penetrating mechanisms, secondary
surveys should highlight junctional anatomy, such as the
neck, axilla, groin, and perineum.
How toAnswer?
Check Vital Signs
• Avoiding hypotension and hypoxia is important to minimize secondary brain injury in setting of carotid injury
M. Carlin (*)
Trauma, Emergency General Surgery, and Surgical Critical Care,
Newark, DE, USA
e-mail: margo.carlin@christianacare.org
Follow ATLS Workup
• Primary Survey
– Airway
10% arrive with compromised airway due to compression by hematoma
Assess for blood in the airway, palpable crepitus,
air leak through wound
Consider tracheal involvement: impending airway
loss, bleeding into the airway, compression by
hematoma
Intubate if necessary > may require cricothyroidotomy if unable to intubate
– Breathing
Assess for bilateral breath sounds
Zone 1 Neck Injuries can result in hemothorax or
pneumothorax, requiring chest tube placement
– Circulation
Assess for expanding and nonexpanding hematomas, dysphagia, changes in voice, hemoptysis, widened mediastinum
Absent peripheral pulses in upper extremities can
be secondary to subclavian artery injury
Temporary hemorrhage control with digital occlusion or Foley catheter balloon into tract
Note surface anatomy of the injury
• Zone 1:
Landmarks: Sternal notch to cricoid cartilage
Contents: great vessels, lung apices, esophagus, trachea, thoracic duct, thyroid
• Zone 2:
Landmarks: Cricoid cartilage to angle of the
mandible
Contents: carotid sheath, vertebral artery, esophagus, trachea, pharynx, recurrent laryngeal nerve
• Zone 3:
Landmarks: Angle of the mandible to the
base of the skull
Contents: distal carotid and vertebral arteries,
distal jugular veins
© 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_92
297
298
M. Carlin
– Indications for immediate operation:
Active bleeding
Expanding or pulsatile hematoma
Subcutaneous emphysema
Air bubbling from wound
– Disability
Assess GCS
Good preoperative neurologic assessment is crucial
in patients with devastating carotid injuries
Document neurologic decits
Motor assessment of upper extremities for ipsilateral brachial plexus injuries
– Exposure
Completely expose the patient
Roll the patient in the primary survey to assess for
injuries posteriorly
Blunt mechanism does not preclude penetrating
trauma
Be sure to focus on junctional areas (i.e., neck,
axilla, groins, perineum)
– Secondary Survey
Head-to-toe physical examination
Diagnostic Tests
• CXR
– Assess Trajectory
– Widened mediastinum
– Hematoma in superior mediastinum/base of neck/
supraclavicular area,
– Hemo- or Pneumothorax
– Tracheal deviation
• CT brain
– Carotid injuries may result in acute infarct
– Can help identify trajectory in Zone 3 Neck Injury
• CT neck with and without angiography
– Test of choice for penetrating neck trauma in respond-
ers, transient responders, and hemodynamically stable
patient
– Proximity of trajectory to major structures dened as
within 5mm anatomy of interest
• CT chest with and without angiography
– Can help with a trajectory in Zone 1 Neck Injury
• Esophagoscopy
• Laryngoscopy
• Bronchoscopy
Treatment
Internal Jugular Vein
• Lateral venography
• Bilateral injuries: repair at least one vein to prevent intracranial venous hypertension
• Ligate if the patient is unstable or primary repair narrows
lumen >50%
Carotid Artery
• Zone 1
– Landmarks: Sternal notch to cricoid cartilage
– Contents: great vessels, lung apices, esophagus, tra-
chea, thoracic duct, thyroid gland
– Incision: median sternotomy ±longitudinal extension
along the ipsilateral border of SCM
• Zone 2
– Landmarks: Cricoid cartilage to the angle of the
mandible
– Contents: carotid sheath, vertebral artery, esophagus,
trachea, pharynx, recurrent laryngeal nerve
– Incision: anterior border of ipsilateral SCM from the
sternal notch to the angle of the mandible
– Common carotid bifurcates into internal and external
carotid approximately 1–2 ngerbreadths below the
angle of the mandible
– Facial vein overlies bifurcation: divide and retract IJV
laterally to access common carotid. Protect the vagus
nerve in the sheath during this maneuver.
– Cephalad dissection along medial IJV identies ICA
and hypoglossal nerve.
• Zone 3
– Landmarks: Angle of the mandible to base of skull
– Contents: distal carotid and vertebral arteries, distal
jugular veins
– Incision: anterior border of ipsilateral SCM from the
sternal notch to the angle of the mandible
– Consider nonoperative vs endovascular repair, as
access is difcult
– Active hemorrhage: place #3 or 4 Fogarty balloon into
tract > continue hemorrhage > remove Fogarty and
attempt Foley catheter balloon ination>if this does
not work, perform oblique incision and perform transarterial placement of Fogarty balloon for internal
tamponade
– Ligate if there is no back bleeding
– Maneuvers to expose distal ICA
Divide occipital artery
Divide the posterior belly of the digastric muscle
(be careful to preserve glossopharyngeal and spinal
accessory nerves)
Anterior displacement of the mandible (requires nasotracheal airway, gives an extra 2–3cm to dissection)
• Repair:
– Transcervical injury=collar incision
– Obtain proximal and distal control
92 Penetrating Neck Trauma
299
– Debride edges
– Proximal and distal balloon thrombectomy with 2 or 3
French Fogarty
– Flush proximal and distal lumen with heparinized
saline (1000u/1L)
– Simple lateral defect: lateral arteriorrhaphy with inter-
rupted 6-0 prolene sutures
– Loss of one wall: patchy angioplasty (saphenous vein,
PTFE, bovine pericardium)
– Through-and-through or segmental disruption: seg-
mental resection and end-to-end anastomosis, interposition, or bypass graft
– Complex proximal ICA injury: external to internal
carotid artery transposition
Vertebral Artery
• First branch of the subclavian arteries
• 6% of left vertebral arises directly from arch of aorta
• 10% have unilateral hypoplasia
• Most can be managed with angioembolization
• Can present during exploration as brisk hemorrhage from
posterolateral neck
• Surgical access is difcult
• Consider nonoperative vs endovascular approaches
• Consider operative repair in active hemorrhage, failure of
endovascular management
• Segments
– V1
Subclavian artery to C6; external landmark: triangle between two heads of SCM
Medial transverse supraclavicular incision over two
heads of SCM
Expose carotid sheath by splitting heads of SCM
longitudinally
Open sheath
Retract carotid medially
Retract IJV and Vagus nerve laterally
Divide vertebral vein posteriorly to access subclavian and vertebral artery
– V2
C6 transverse foramen to C2 transverse process;
external landmark: cricoid cartilage
Requires exposure through transverse foramina
Continue with the same dissection as V1 exposure
Sweep longus coli muscle off bone in deep posterior aspect of the neck
Use bone rongeur to remove anterior rim of foramen
Do not injure cervical nerve roots posterior to the
artery
– V3
C2 transverse process to the base of skull
Requires posterior auricular approach (consider
intraoperative neurosurgery consult)
– V4
Intracranial joins contralateral vertebral artery to
form basilar artery
Exposed through craniotomy (consider intraoperative neurosurgery consult)
Subclavian Artery
• Most patients arrive in extremis and require ED
Thoracotomy
• Achieve temporary control with a Foley catheter into tract
• Left Subclavian Artery: third branch of aortic arch
• Right Subclavian Artery: arises from the innominate
artery
• Segments
– 1st: medial to anterior scalene; branches—vertebral
artery, mammary artery, thyrocervical trunk
Right SCA: median sternotomy ± supraclavicular
extension
Left SCA: third or fourth space anterolateral thoracotomy (+ median sternotomy + supraclavicular
extension=trap door incision)
– 2nd: posterior to anterior scalene
Supraclavicular incision
Proximal control may require a median sternotomy
– 3rd: lateral to scalene to rst rib (where it then transi-
tions to axillary artery)
Supraclavicular incision
Additional exposure is possible with resection of
medial half of clavicle
• Phrenic nerve: lies on or medial to anterior scale; take
care during dissection of rst segment of SCA
• Repair: primary repair, interposition grafts
• Ligation in complex injuries is possible due to extensive
collaterals around the shoulder.
• Consider endovascular options in hemodynamically stable patients.
Cervical Trachea
• Symptoms: hoarseness, stridor, hemoptysis, respiratory
distress
• Signs: crepitus, deep cervical tenderness, air bubbling
from penetrating wound, pneumothorax
• Imaging: paratracheal air or pneumomediastinum
• Diagnostics: laryngoscopy, beroptic tracheoscopy,
bronchoscopy
• Nonoperative management: hemodynamically stable,
absence of severe subcutaneous or mediastinal emphysema, injury <1/3 circumference of trachea, <4 cm in
length, wound edges well opposed, nondestructive injury/
no tissue loss
• Options for Airway Control: intubate through defect, intu-
bation perform over bronchoscope to help direct balloon
300
M. Carlin
of ETT past tracheal defect, cricothyroidotomy,
tracheostomy
– Get anaesthesiology involved early
– Airway best secured in operating room: sedation can
impede accessory muscle use, and patients can decompensate quickly
• Incisions: collar incision ± longitudinal extension
along SCM for associated injuries, directed over defect,
may need to perform median sternotomy if trachea
retracts
• Repair: debride devitalized tissue, primary repair with
simple, interrupted, absorbable suture
• Complex injuries: buttress with muscle ap, consider pro-
tective tracheostomy
• Limit dissection at 3 and 9 o’clock positions to avoid
devascularization of the trachea
• Gaps >5–6cm may require advanced procedures
Larynx
• Symptoms: dysphonia, neck pain, dysphagia, odynophagia, hemoptysis
• Signs: crepitus, ecchymosis, stridor, cannot lay at
• Goals of treatment: Recognize impending airway obstruc-
tion and maintain a safe airway
• Observe asymptomatic and minimally symptomatic
patients for 24hours, as airway edema can progress
• Secure airway with tracheostomy: avoid endotracheal
intubation and cricothyroidotomy to avoid laryngotracheal separation
• Surgical repair of larynx = tracheostomy in all
circumstances
• Indications for surgery:
– Large mucosal lacerations
– Lacerations involving the vocal cord
– Displaced/exposed/multiple cartilaginous fractures
– Recurrent laryngeal nerve transection
Cervical Esophagus
• External landmark of pharyngoesophageal junction: cricoid cartilage
• Symptoms: deep cervical pain, dysphagia, odynophagia,
hematemesis
• Signs: palpable crepitus
• Imaging: retropharyngeal or retroesophageal air in soft
tissues on CT; pneumomediastinum on CXR
• Diagnostic evaluation: contrast esophagram with gastro-
gran followed by thin barium and endoscopy (EGD
even if negative esophagram)
• Exposure:
– A left-sided oblique incision along anterior border of
SCM
– Retract SCM laterally
– Divide omohyoid
– Retract carotid sheath laterally
– Retract trachea and thyroid medially
– Ligate and divide middle thyroid vein and inferior thy-
roid artery if better exposure is needed
• To identify occult injury:
– Compress distal esophagus at thoracic inlet > ll
esophagus with 30–50 mL methylene blue > fullthickness staining=esophageal perforation
– Compress distal esophagus > ll 30–50 mL air into
proximal esophagus after lling operative eld with
saline and look for air bubbles
• Repair:
– Debride wound edges (mucosal injury extends beyond
muscular injury)
– Two-layer tension-free repair in transverse fashion:
inner layer with absorbable suture, outer layer with
nonabsorbable suture
– Use bougie or NGT when repairing outer layer to
avoid narrowing the esophagus
– Buttress repair with strap muscles to protect suture
line
– Place closed suction drain (remove POD5–7 after neg-
ative contrast study)
– Destructive injuries: drain, cervical esophagostomy,
delayed interposition graft, stent
Thyroid
• Primary repair
• Destructive injuries may require lobectomy
• Fractures of thyroid cartilage require ORIF
Thoracic Duct Injury
• Rare
• Left-sided Zone 1 Injuries at the base of the neck
• Usually manifest 3–7days after injury
• Symptoms: shortness of breath, malnourishment, and
immune deciencies are late signs
• Imaging: pleural effusion on CXR; most commonly right-
sided (injuries below T5 result in left pleural effusion);
chest tube drainage reveals milky or turbid uid
• Diagnostics:
– Pleural uid with WBC, triglycerides >110 mg/dL,
cholesterol <200mg/dL
– Lymphoscintigrahpy: technetium 99m-labeled CT
• Management:
– Conservative Therapy
Chest tube drainage
Maintaining nutrition: administration of mediumchain triglycerides
If drainage does not improve with the above > proceed with NPO/TPN
Consider octreotide if the output is <1L/day
92 Penetrating Neck Trauma
301
~50% close spontaneously within 2 weeks of
treatment
High output chylothorax (>1L/day) generally fails
conservative management
– Procedural Options:
Lymphatic embolization
VATS with duct ligation
Thoracic duct ligation by right thoracotomy
Isolate thoracic duct low in the chest between
aorta, esophagus, and azygous vein
Use nasogastric tube to help identify the
esophagus
Place downward retraction on the diaphragm to
help exposure
Ligate the duct with nonabsorbable suture
Common Curveballs
• Carotid arteries should be repaired even in the presence of
neurologic decits except if surgically inaccessible, delay
3–4h with coma, large radiographic infarcts, and absence
of retrograde bleeding during operation.
• Consider injuries to the vertebrae and spinal cord
• Monitor postoperative in ICU: cerebral edema and conversion to hemorrhagic stroke may be precipitated by
headache and/or deterioration in mental status
• Operating for platysmal violation has a 50% rate of negative exploration
• Coma and penetrating neck injury may be secondary to
cerebral ischemia, hypotension from hemorrhage, alcohol
intoxication, or illicit drug use > DO NOT ASSUME IT IS
DUE TO AN IRREVERSIBLE NEUROLOGIC INSULT
• Pack persistent hemorrhage from the vertebral artery with
bone wax, followed by post-op CTA and possible
embolization
• Revascularization after repair of carotid injury can covert
an ischemic stroke to a hemorrhagic stroke
• Postoperative hematoma can result in airway compression
• Complications from tracheal repairs include tracheal stenosis, tracheoesophageal stula, retropharyngeal abscess
• Combined injuries to the trachea, esophagus, and carotid
artery: buttress repairs with viable muscle to avoid breakdown, blowout, and/or stulization of suture lines
• Temporary intraluminal shunts are indicated for carotid
injuries in distal Zone II or Zone III with poor or absent
backow and/or an anticipated prolonged repair
• Major venous injuries risk air embolism: cover the wound
with gauze and place patient in reverse Trendelenburg
position with left side up
Clean Kills
• Failing to establish IV access
• Failure to identify concomitant aerodigestive injury
• Failure to identify postoperative cervical hematoma
resulting in airway compromise
• Not knowing to follow for compartment syndrome after
subclavian artery repair
• Multiple attempts at endotracheal intubation with clothesline injury (i.e., cricotracheal separation)
• Intubating a laryngotracheal injury causing complete separation of the airway
• Missing associated cardiac injury/hemopericardium/cardiac tamponade in a patient with Zone 1 injury
• Assuming coma/neurologic decit is due to an irreversible cerebral insult
• Failure to identify tension pneumothorax with tracheal
injury
• Missing transcervical injury
Summary
The neck is a region of high-stakes real estate, and injuries to this area can be quickly fatal due to uncontrolled
hemorrhage. In cases of penetrating trauma, the surgeon
must be able to rapidly demarcate the trajectory of the
injury. Identifying the pathway of the stab wound or bullet helps anticipate what structures may be involved and
the sequelae of the injury complex. Having a strong grasp
of the anatomy of the neck and the operative exposures
required to access these structures is paramount to optimizing outcomes in these patients.
Bibliography
Asensio J, Trunkey D.Current therapy of trauma and surgical critical
care, 2nd ed. Elsevier; 2016.
Demetriades D, Inaba K, Velmahos G.The atlas of surgical techniques
in trauma, 2nd ed. Cambridge University Press; 2020.
Dung LT, Van Sy T, Linh NT, Tuyen DT, Hung DT, Van Cuong V, Nhung
TH.Successful treatment of thoracic duct injury from blunt trauma.
Radiol Case Rep. 2023;18(6):2121–5. https://doi.org/10.1016/j.
radcr.2023.02.061. PMID: 37089973; PMCID: PMC10113754.
Feliciano D, Mattox K, Moore E.Trauma, 9th ed. McGraw Hill; 2021.
Pier JL, Rashid MA.Thoracic duct injury: an up to date. J Cardiothoracic
Trauma. 2021;6(1):15–21. https://doi.org/10.4103/jctt/jctt_19_21.
Rasmussen T.Rich’s vascular trauma, 3rd ed. Elsevier; 2016.
Venous Thromboembolism
OliviaW.Galloway andAnirudhKohli
93
Way Question May BeAsked?
A 46-year-old woman comes to the ofce to discuss an adenocarcinoma in her cecum found on a colonoscopy. She has
no evidence of metastatic disease. She has a past medical
history of hypertension and no past surgical history. Her
BMI is 35. She takes oral contraceptives. She is adopted and
her family history is unknown. What are her risk factors for
VTE?
How toAnswer?
• In this patient, her risk factors include malignancy and
estrogen exposure. She will also be at an elevated risk
postoperatively.
• Risk factors for VTE:
– Virchow triad- venous stasis, hypercoagulable state,
endothelial injury
– Increasing age
– Malignancy
– Prolonged immobilization
– Estrogen exposure
– Recent trauma or surgery
• Risk for thrombosis
– Caprini risk score is used to estimate the risk of post-
operative VTE. This is based on age, type of surgery,
BMI, oral contraceptives, malignancy, personal of
family history of VTE, inherited thrombophilia.
– This patient’s Caprini score is 6, which puts her at high
risk for VTE.
O. W. Galloway
Department of Surgery, Lankenau Medical Center,
Wynnewood, PA, USA
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
*)
– Thromboprophylaxis for this patient should include
pharmacologic prophylaxis. Low molecular weight
heparin is generally preferred.
Way Question May BeAsked?
The patient is now postoperative day 4 after a laparoscopic
right colectomy. You are called because she is complaining
of shortness of breath and chest pain. Upon arrival to her
room, you note that her heart rate is 120 and her blood pressure is 130/80. She is saturating 86% on room air and is
placed on a 2L nasal cannula with the improvement of saturation to 94%. How would you work up this patient?
How toAnswer?
• Symptoms of PE can overlap with other conditions. The
differential includes acute coronary syndromes, aortic
dissection, pneumonia, and pneumothorax.
• Rapid diagnosis of PE is important. The gold standard
for diagnosing a PE is a CT pulmonary angiogram.
• Electrocardiography is neither sensitive nor specic but
can be used to rule out myocardial infarction. The S1Q3T3
pattern is a sign of acute right ventricle overload.
• Echocardiograms can assess right heart strain.
• Chest x-ray is often nonspecic. A Hampton hump and
Westermark sign are rare but should raise suspicion for
PE.
• D-dimers in the postoperative patient are often elevated; a
negative D-dimer has a high negative predictive value.
• Arterial blood gas analysis will typically show hypoxemia, hypocapnia, increased alveolar-arterial oxygen difference (alveolar–arterial gradient), and respiratory
alkalosis.
– Some variations include hypercapnia in massive PE,
normal PaO2, normal alveolar–arterial gradient, combined respiratory and metabolic acidosis in massive
PE.
© 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_93
303
304
O. W. Galloway and A. Kohli
• Fifty percent of patients will have lower extremity deep
vein thrombosis (DVT). An ultrasound is performed to
identify lower extremity DVT.
Treatment After Diagnosis Conrms PE
• Begin with initial resuscitation focusing on oxygenating
and stabilizing the patient. This may range from supplemental oxygen to ventilatory and hemodynamic support.
• Anticoagulation should be started for all patients unless
there is an absolute contraindication to anticoagulation.
– Subcutaneous low molecular weight heparin or
fondaparinux
– Direct oral anticoagulants (DOACs)- rivaroxaban and
apixaban are the only DOACs that have been studied
and approved by regulatory agencies as monotherapy.
Duration of Therapy
• Patients with an acute VTE and an identied major transient risk factor should have a 3-month treatment period
with anticoagulation.
• Patients with VTE diagnosed in the absence of transient
risk factor (unprovoked), indenite anticoagulation is
recommended.
Thrombolysis
• Recommended for high-risk patients with massive PE and
hypotension (systolic Blood pressure less than 90) within
48h.
• Catheter-directed thrombolysis may be considered in
patients with a high risk for bleeding.
• Catheter-based thrombectomy can be performed as an
adjunct to catheter-directed thrombolysis.
• Surgical thrombectomy is reserved for patients with central PE resulting in cardiogenic shock.
Way Question May BeAsked?
Key Steps of IVC Filter Placement
• Local anesthesia at the site of percutaneous puncture
• Use of Seldinger technique to access vein (femoral or
internal jugular)
• Guidewire placement into IVC under uoroscopic guidance, sequential dilation of the tract
• Venogram to identify renal veins and assess the diameter
of IVC.
• Placement of sheath at the level of the left renal vein,
insertion of lter into sheath with tip of lter distal to left
renal vein.
• Withdrawal of sheath to expose lter and deployment of
lter under uoroscopy.
• Final venogram, removal of sheath, check for
hemostasis.
IVC Filter Retrieval
• The longer the IVC lter is in place, the more difcult it
is to remove and more likely to have complications.
• An Endo snare catheter or retrieval cone is used to hook
the top of the lter and apply tension as the retrieval
sheath is advanced over the lter to collapse it. Completion
venography conrms the removal of the IVC lter.
• Complications of long-term placement of IVC lters
include inferior caval wall penetration, erosion into adjacent structures, lter migration, lter thrombosis, and lter fracture or embolization.
Clean Kills
• Inability to work up and identify VTE.
• Inability to treat VTE with anticoagulation.
• Inability to identify contraindications for anticoagulation
and indications for IVC lter placement.
• Inability to identify indications for thrombectomy.
The previously described patient is diagnosed with a pulmonary embolus on the left lower lobe segmental branch. She is
started on low molecular weight heparin. However, she
begins to have multiple bloody bowel movements requiring
multiple blood transfusions. What is your next step?
How toAnswer?
Indications for Inferior Vena Cava (IVC) Filter Placement
• Anticoagulation is contraindicated, or the risk of bleeding
is unacceptably high.
• Recurrence despite therapeutic anticoagulation
• Prophylaxis in high-risk trauma patient
• Protection during venous thrombolytic therapy
Bonus Points
Anticoagulation considerations for special patient
populations
• Renal disease—preferred anticoagulant is vitamin K
antagonist (warfarin). Dosing of some DOACs can be
renally adjusted.
• Liver disease and coagulopathy—preferred anticoagulant
is low molecular weight heparin. DOACs are contraindicated if the INR is raised because of liver disease, warfarin
is difcult to control, and INR may not reect the antithrombotic effect.
• Pregnancy—preferred anticoagulant is low molecular
weight heparin.
93 Venous Thromboembolism
305
• Anticipated need for discontinuation or reversal—IV
unfractionated heparin has a short half-life and a known
reversal agent (protamine sulfate.)
• Malignancy—low molecular weight heparin is
preferable.
• Anti-phospholipid syndrome—vitamin K antagonists
preferred.
Words ofWisdom
Early recognition of high-risk patients and timely initiation
of VTE prophylaxis helps mitigate the risk of venous thromboembolism. If the patient is manifesting signs/symptoms
suggestive of pulmonary embolism, then consider a CT PE
study if the renal function is normal as that will be the most
sensitive and specic study to help you manage the patient
most effectively.
Further Reading
Score. https://www.surgicalcore.org/modulecontent.aspx?id=133538.
Score. https://www.surgicalcore.org/modulecontent.aspx?id=134647.
Score. https://www.surgicalcore.org/modulecontent.aspx?id=1000909.
Stevens SM, Woller SC, Baumann Kreuziger L, Bounameaux H,
Doerschug K, Geersing GJ, Huisman MV, Kearon C, King CS,
Knighton AJ, Lake E, Murin S, Vintch JRE, Wells PS, Moores
LK. Executive summary: antithrombotic therapy for VTE disease: second update of the CHEST guideline and expert panel
report. Chest. 2021;160(6):2247–59. https://doi.org/10.1016/j.
chest.2021.07.056. Epub 2021 Aug 2. PMID: 34352279.
Splenic Trauma
MadisonHarris andJosephA.Sciacca
94
Concept
The spleen is one of the most injured organs in abdominal
trauma. These injuries can occur with both blunt and penetrating mechanisms. The approach to a traumatically injured
spleen is based on the degree of injury and the patient’s stability. Advancements in computed tomography (CT) and
angiographic intervention have made nonoperative management of splenic injuries increasingly more feasible as a rstline option.
Way Questions May BeAsked?
A 30-year-old male presents to the emergency department
after a motor vehicle collision. He is tachycardic to 120, with
a systolic blood pressure of 116. His chest X-ray shows fractures of ribs 10–12 on the left. What do you want to do?
How toAnswer?
• Always start with ABCs:
– Airway and C-spine control
– Breathing and Ventilation
– Circulation and IV access
– Disability (neuro status)
– Environment/Exposure
• Don’t skip the secondary survey; this may clue you into
key physical exam ndings such as a diffusely tender
abdomen, peritonitis, or open wounds.
History (AMPLE)
• Allergies
• Medications
• Anticoagulants, Antiplatelets
• Past medical history
• Last meal
• Events leading to presentation
• Assessment of trauma patient begins at the scene
• Mechanism of injury, degree of damage, loss of consciousness, speed of travel, etc.
Physical Examination
• Vital Signs (tachycardia, hypotension)
• Secondary survey includes head-to-toe physical exam
• Seatbelt sign
• Peritonitis
• Trauma to the left upper quadrant, left rib cage, or left
ank should increase suspicion
• Referred pain to left shoulder (Kehr’s sign)
• Digital rectal exam
Labs/Tests
Labs
• CBC, BMP
• TEG
• PT/INR
Imaging
• Chest X-ray (look for concomitant injuries such as rib
fractures)
M. Harris (*) · J. A. Sciacca
General Surgery, Christiana Care Health System,
Newark, DE, USA
e-mail: Madison.Harris@christianacare.org;
Joseph.Sciacca@christianacare.org
© 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_94
• Pelvis X-ray (pelvic fractures may clue you into the
degree of injury/force)
• FAST Exam (hemoperitoneum)
• Has largely replaced DPL
• CT abdomen/pelvis with IV contrast if stable
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