Chapter 22: Care of the Surgical Patient

A 40 year old male patient with type 2 diabetes calls your office because he is having difficulty urinating and quite a bit of pain in the perineal area. He has not felt well for several days and was running a low-grade fever. He went to his chiropractor 2 days ago when he only had pain and swelling in the scrotum and the chiropractor adjusted his … well, we won't go there …. He is now noting that his temperature is higher (he doesn't have a thermometer and is reading his temperature via his old mood ring from the 90s). You suggest that he presents to your office.

Examination reveals an obese male who is waddling into the office because of pain in his scrotal area. Vitals: blood pressure 150/100 mm Hg, pulse 112 bpm, respirations 20 bpm, and temperature 39.0°C. Other significant findings include a swollen scrotum that is bright red, exquisitely tender to touch, and without crepitus. You do not have extended laboratory access in your office, but a urine dipstick is negative for blood and leukocyte esterase. His blood sugar, which is usually fairly well controlled, is elevated at 320 mg/dL.

Question 22.1.1 Your next step for this patient will be which of the following?

A) Start the patient on cephalexin (Keflex) for methicillin-sensitive Staphylococcus aureus and Streptococcus coverage and follow-up with the patient in the morning

B) Emergent surgical referral

C) Begin trimethoprim/sulfamethoxazole (Bactrim) for methicillin-resistant S. aureus (MRSA) coverage and follow-up with the patient in the morning

D) Admit the patient and start him on IV vancomycin, piperacillin/tazobactam, and metronidazole for coverage of MRSA, Streptococcus, Pseudomonas, anaerobes

Answer 22.1.1 The correct answer is "B." This likely represents Fournier gangrene. The erythematous, swollen scrotum with pain out of proportion to examination and associated signs of fever, tachycardia, and elevated blood sugar make Fournier gangrene the most likely diagnosis. While crepitus is common with Fournier gangrene due to presence of gas-forming anaerobic bacteria, its absence is not sensitive enough to rule out gangrene. Without early surgical debridement and IV antibiotics, infection can progress rapidly causing sepsis and multiorgan failure. Therefore, "B," emergent surgical referral is the best option for this patient. Antibiotics, particularly oral (options "A" and "B"), are inappropriate as a sole therapy. "D" has the right intent with broad-spectrum coverage but is incorrect because the patient needs adjunct surgical debridement to remove the necrotic tissue.

Question 22.1.2 Fournier gangrene can best be described as:

A) Necrotizing fasciitis

B) Necrotizing cellulitis

C) Caused by aerobic bacteria

D) Secondary to streptococci

E) A mathematical function that can be written as an infinite sum of harmonics

Answer 22.1.2 The correct answer is "A." Fournier gangrene is a form of necrotizing fasciitis. This is termed "Type I" necrotizing fasciitis and is caused by mixed aerobic and anaerobic bacteria. "B" is incorrect. Necrotizing cellulitis is isolated to the superficial skin. Fournier gangrene involves deep tissues including the fascia. "C" is incorrect because, as noted above, Fournier gangrene is caused by mixed aerobic and anaerobic bacteria. "D" is incorrect. There is necrotizing fasciitis secondary to streptococci (see below); however, it has different causative agents than Fournier gangrene. Fournier gangrene is typically caused by coliforms, Clostridia, Bacteroides, Klebsiella, Staphylococcus, and Streptococcus. If you used "the-longest-answer-is-always-right" method and chose "E," you are way off base and also a math nerd; "E" describes Fourier's transform.

Question 22.1.3 Which of the following is NOT a risk factor for Fournier gangrene?

A) Diabetes

B) Immunosuppression

C) Varicella infection

D) End-stage renal disease

E) Advanced age

Answer 22.1.3 The correct answer is "C." All the other options are risk factors for Fournier gangrene. Varicella infection is a risk factor for Type II necrotizing fasciitis, which is a different entity. Type II necrotizing fasciitis is caused by group A Streptococcus. Generally, patients with Type II necrotizing fasciitis are not diabetic or otherwise immunocompromised. Other risk factors for Type II necrotizing fasciitis include IV drug use, penetrating trauma, and blunt trauma.

The surgeon evaluates the patient and asks for your opinion on the antibiotic regimen. You nearly fall over in shock that your advice was solicited.

Question 22.1.4 What do you recommend for this patient with necrotizing fasciitis?

A) Penicillin and clindamycin

B) Clindamycin and metronidazole

C) Meropenem, vancomycin and clindamycin

D) Piperacillin/tazobactam (Zosyn), vancomycin and metronidazole

E) C or D

Answer 22.1.4 The correct answer is "E." As noted above, Fournier gangrene is a mix of aerobic and anaerobic bacteria. The first two choices ("A" and "B") will cover anaerobes and some Gram-positive organisms. However, Gram-negative coverage is lacking. More broad-spectrum antimicrobial coverage is needed in this situation. Most experts and guidelines recommend a broad-spectrum antibiotic with anaerobic and Gram-negative coverage (e.g., piperacillin/tazobactam, ampicillin/sulbactam, or a carbapenem) plus MRSA coverage (usually vancomycin) plus anaerobic coverage (e.g., clindamycin, metronidazole). Although MRSA is not usually the causative agent, these infections are polymicrobial, and empiric MRSA coverage is required. Clindamycin deserves a special mention. Clindamycin blunts the adverse effects of Staphylococcal and Streptococcal toxins so is especially helpful in Staphylococcal and Streptococcal toxic shock syndromes and toxin-related shock.

The patient has a wide excision of necrotic tissue. After surgery, he becomes hypotensive and tachycardic (blood pressure 85/50, pulse 128), and his serum lactate is 8 mg/dL (very high).

Question 22.1.5 What is the most appropriate next step in his management?

A) Start IV dopamine to stabilize his blood pressure

B) Start IV norepinephrine to stabilize his blood pressure

C) Start IV 0.9% normal saline boluses to stabilize his blood pressure

D) Start IV albumin boluses to stabilize his blood pressure

E) Read him the hospital charges he has accumulated thus far

Answer 22.1.5 The correct answer is "C." This patient is likely hypovolemic secondary to third spacing and/or is in septic shock and needs volume. The lactate of 8 mg/dL suggests that he has hypoperfusion with poor tissue oxygenation (although it could also be secondary to necrotic tissue). Just giving dopamine (or other vasopressors) will not increase peripheral circulation and, in fact, may decrease tissue oxygenation by increasing vascular tone and decreasing perfusion. Albumin has not been shown to have any advantage over crystalloids in almost any circumstance—post large-volume paracentesis (>5 L) being the exception. Mortality of necrotizing fasciitis approaches 30% even with the best care.

Objectives: Did you learn to…

• Diagnose and treat Fournier gangrene?

• Differentiate between types of necrotizing fasciitis?

• Prescribe appropriate fluids and vasopressors to treat sepsis and septic shock?

Which of the following drugs will give you the most rapid pain control when given intravenously

A) Fentanyl (Sublimaze)

B) Hydromorphone (Dilaudid)

C) Meperidine (Demerol)

D) Morphine

The correct answer is "A." Fentanyl has a peak effect at 3 to 5 minutes. This is followed by meperidine at 5 to 7 minutes, morphine at 20 minutes, and hydromorphone at 15 to 30 minutes. Thus, to get rapid control of pain, fentanyl is the preferred agent. Meperidine is the least preferred agent because of drug interactions (MAO inhibitors, SSRIs) and toxic metabolites (normeperidine that can cause agitation and seizures).

Which of the following organisms is/are not generally covered by trimethoprim/sulfamethoxazole (TMP/SMX)?

A) S. aureus

B) Streptococcal species

C) Escherichia coli

D) Enterococcus

E) B and D

The correct answer is "E." Neither Streptococcus nor enterococcus species are sensitive to TMP/SMX. This has implications for the treatment of MRSA. Cellulitis (one of the manifestations of MRSA) can be from either staphylococcal or streptococcal species. So, unless you are confident that you have MRSA (abscess formation, etc.), TMP/SMX is not a great single agent for cellulitis. If there is an abscess, treat for MRSA (drainage, TMP/SMX, doxycycline). If there is a superficial cellulitis, treat for Streptococcus (cephalexin, amoxicillin/clavulanate). If you are not sure, one option would be clindamycin as a single agent, though resistance rates are on the rise.

You are working in a rural ED when you get a call that a 62-year-old farmer has been trapped between a tractor and a silo while loading silage. It seems to have pinned his legs and pelvis, but from the waist up he is fine. Nonetheless, the ambulance crew places the patient in a collar and on a backboard and transports him to the ED.

The patient is in significant pain from his lower extremities and pelvis (of course, since he is a stoic farmer, he denies this and just wants to go back to planting corn). His blood pressure is initially 100/65 mm Hg with a pulse of 118 bpm. Primary survey is unremarkable, although he is still boarded and collared.

Question 22.2.1 Which of the following most clearly reflects the best approach to this patient's pain?

A) Use IV meperidine (Demerol) for pain control

B) Use IV morphine for pain control

C) Use IV fentanyl (Sublimaze) for pain control

D) Pain medications are contraindicated at this point given the patient's overall condition

E) Since he's so tough, just offer him some useless platitudes like "no pain, no gain"

Answer 22.2.1 The correct answer is "C." Fentanyl generally has a negligible effect on blood pressure (although one should never say "never"). Both morphine and meperidine tend to drop a patient's blood pressure, so they are relatively contraindicated in this patient with a marginal blood pressure or hypotension. Those who chose "D" or "E" have been hanging around old-time surgeons too long. It is unconscionable to withhold pain medication.

Further examination, by gentle inward pressure on the anterior superior iliac spines bilaterally, shows that the patient's pelvis is unstable. As you recall, a fractured pelvis can lead to significant blood loss into the retroperitoneal space.

Question 22.2.2 In the short term, what is the best way to temporize the underlying pathology?

A) Vasopressors (e.g., dopamine) plus fluids

B) Pelvic binder

C) Fluids (normal saline)

D) Activated factor VIIa (NovoSeven)

E) Embolization by interventional radiology (45-minute delay)

Answer 22.2.2 The correct answer is "B." A pelvic binder will significantly reduce bleeding in most unstable pelvis fractures. "A" is incorrect because in trauma dopamine is not indicated when the problem is hypovolemia. In fact, vasopressors increase mortality in hypovolemic shock. "C" is incorrect. While normal saline is a good choice for resuscitation fluids, we want to tamponade the bleeding and not just chase our tails with fluids. "D" is incorrect. Recombinant activated factor VIIa has not been shown to improve outcomes after trauma (J Trauma. 2010;69:353–359). Additionally, it has a number of adverse effects including increased thromboembolic phenomenon (pulmonary embolism [PE], deep venous thrombosis [DVT], etc.). Finally, interventional radiology will likely be needed at some point. They are quite good at stopping bleeding vessels. However, the delay time during which you are watching the patient bleed is unacceptable.

You appropriately place a pelvic binder that tamponades the bleeding. The patient's blood pressure stabilizes. You now turn to other issues. This patient will clearly need a Foley catheter.

Question 22.2.3 Relative contraindications to placement of a Foley catheter include which of the following?

A) Blood at the urethral meatus

B) Gross hematuria

C) High-riding prostate

D) Gross blood from the rectum

E) A and C

Answer 22.2.3 The correct answer is "E." Both blood at the meatus and a "high-riding prostate" (ever wonder what it is riding on?) signify the possible disruption of the urethra. Thus, since one does not want to place the catheter in the wrong place—like the peritoneal space—catheterization is relatively contraindicated. "B," gross hematuria, can be from the kidney and is not a contraindication to catheterization.

You find blood at the urethral meatus. The patient complains that he really needs to void.

Question 22.2.4 Your options at this point include which of the following?

A) Urethrogram to document an intact urethra

B) Performance of suprapubic cystostomy using ultrasound guidance

C) Use a Coudé catheter to catheterize the urethra

D) Placement of a bladder catheter via the urethra but using a wire guide (such as with a central line)

E) A and B

Answer 22.2.4 The correct answer is "E." One could perform a urethrogram using a water-soluble dye (e.g., Gastrografin) to document that the urethra is intact and if so place a standard Foley. One could also do a suprapubic cystostomy using ultrasound guidance. "C" and "D" are both incorrect. A Coudé catheter is used to bypass a stricture (prostate or otherwise) and would be no safer than a regular catheter in this patient. Likewise, a wire could end up anywhere and should not be used in this case.

Objectives: Did you learn to…

• Treat acute traumatic pain?

• Recognize and treat pelvic trauma and intrapelvic hemorrhage?

• Describe contraindications to bladder catheter placement?

A 55-year-old gentleman with history of smoking and diabetes presents to your office for a mass in his right groin. He works as a night stocker in a local supermarket. He first noticed the mass after lifting a 60 lb box from the floor to the shelf several nights ago. Since then, he notices that the mass is painful and "pulses" when he coughs. He has not been able to work since he first noted the mass due to pain; in fact, he wonders if you should just fill out disability papers for him now (never happens, right?). He endorses a history of chronic constipation for which he takes over-the-counter medications. He denies weight loss, nausea, vomiting, and urinary symptoms.

On examination, the patient is afebrile with a blood pressure of 135/86 mm Hg and a pulse of 84 bpm. Abdominal examination demonstrates a mildly obese gentleman with no scars of prior surgeries. Bowel sounds are normal. He denies tenderness with palpation of all four quadrants. There is no guarding. With standing, examination of the groin demonstrates an enlarged scrotum on the right side. On coughing the mass becomes more prominent and you can feel something protruding from the inguinal canal.

Question 22.3.1 Based on the information above what is the next step in this patient's overall care?

A) Get CT scan of the abdomen to evaluate for etiology of the mass

B) Refer the patient to a surgeon

C) Have the patient monitor the mass over the next couple of months for changes

D) Have the patient cut back on his constipation medication

E) Place the patient in an inguinal binder

Answer 22.3.1 The correct answer is "B." The patient has an inguinal hernia. History and physical examination are typically sufficient to make the diagnosis, so no further imaging is warranted ("A"). Because the hernia is relatively large and affecting his ability to work, surgical repair is recommended rather than watchful waiting ("C"). For small, asymptomatic, or mildly symptomatic hernias, surgical repair can be deferred with expectant management and counseling on signs and symptoms of strangulation that would warrant emergent evaluation. Because constipation is a risk factor for hernias, advising him to cut back on his constipation medication is probably not recommended ("D"). Finally, "E" sounds like a medieval torture device rather than a therapeutic intervention.

You refer the patient to a general surgeon within the month and he undergoes a laparoscopic hernia repair with mesh placement. He is discharged to home the following day. He is relieved that he doesn't need that disability paperwork filled out after all and already 2 days postoperative is wondering when he can go back to work. He is unable to reach his surgeon who is in the OR (or maybe on the golf course) and calls your office asking when he can return to work … lifting 60-lb boxes.

Question 22.3.2 How do you counsel him about when he can return to work?

A) He may return to work once he is no longer requiring any pain medications and can drive

B) Return to work is typically permitted within 2 to 4 weeks for laborers and within 10 days as tolerated for professionals

C) Return to work at his current job is not recommended, as it requires too strenuous activity and heavy lifting. He should seek another line of work

D) Return to work is typically permitted within 6 weeks for all professions

Answer 22.3.2 The correct answer is "B." Hernia repair is a fairly low-risk surgery and patients are typically able to return to work within 2 to 4 weeks, primarily based on their surgeon's preference. For professionals with more sedentary jobs, return to work may be as early as 10 days as long as no heavy lifting or straining will take place; therefore "D" is not the best answer. While patients should be off all their pain medications prior to return to work or driving, "A" is not the best answer as the surgical wound needs at least 2 to 4 weeks to heal to a reasonable strength. "C" is not correct as he should be able to resume his prior job activities once the surgical wound heals to maximum strength. However, the patient should be counseled on safe lifting techniques and possibility or recurrence of his hernia.

The patient is able to successfully return to work about 4 weeks postoperatively. He is feeling so well that he forgets to return to his follow-up appointments with you. Two years later, the patient returns after he has initiated a running regimen to lose weight. Unfortunately, he is now having groin pain on the left after he runs and is worried that he now has an inguinal hernia on the left (his prior hernia was on the right). He denies any nausea, vomiting, constipation (you cured him with the Miralax!), urinary symptoms, or masses in the groin area. Pain is an aching sensation and worsened with changing positions from sitting to standing or going up stairs. He denies any injury.

On examination, the patient is afebrile with a blood pressure of 120/78 mm Hg and a pulse of 84 bpm. Abdominal examination demonstrates a normal-weight gentleman with well-healed laparoscopic incisions on the right. Bowel sounds are normal. He denies tenderness with palpation of all four quadrants. There is no guarding or rebound. Pain is reproducible with palpation of the inguinal ligament on the left. There is no inguinal lymphadenopathy. With standing, examination of the groin demonstrates a normal-sized and symmetric scrotum bilaterally without any palpable masses. With palpation of the affected area, there is no mass when the patient coughs.

Question 22.3.3 What is the most common diagnosis for this patient's symptoms?

A) Osteoarthritis of the left hip

B) Femoral adenitis

C) Left direct inguinal hernia

D) Osteitis pubis

E) Ligamentous strain

Answer 22.3.3 The correct answer is "E." While all of the above should be considered in the differential for groin pain, the most likely diagnosis for this patient's symptoms with his new running regimen is a ligamentous strain. Without a bulge detected on Valsalva maneuver (coughing) or a palpable abdominal wall defect, a hernia is unlikely ("C"). There are no palpable inguinal lymph nodes and patient does not have clinical signs of a fever, so "B" is unlikely. Hip osteoarthritis ("A") can be a cause of groin pain, particularly in people with good old wear-and-tear. However, the type of pain with hip osteoarthritis tends to be a deep and aching sensation within the groin area that is not reproducible on palpation. Of particular note is "D." Osteitis pubis, an inflammatory process of the symphysis pubis, is a very common overuse syndrome causing groin pain in athletes; it manifests as pain over the pubic symphysis, not the inguinal ligament. Other causes include childbirth, urologic or gynecologic surgery, and rheumatologic conditions. Treatment includes rest, NSAIDs, and, in rare cases, injection of the symphysis pubis with a steroid mixture (for athletes). Other causes of groin pain that should be considered within the differential and should be based on your clinical history and findings include epididymitis, referred pain, ectopic testes, stress fractures, and tendinopathies. If the pain had been localized to the right, adhesions and mesh complications from prior hernia repair must also be considered.

You treat your patient conservatively and he goes on to complete his first half-marathon a year later.

Objectives: Did you learn to…

• Diagnose a hernia based on clinical history and physical examination?

• Appropriately manage treatment for hernias?

• Counsel patients on recommended return to activities postoperatively?

• Identify other potential causes of groin pain?

A 60-year-old female presents to your office for severe abdominal pain … at 4:45 PM … on a Friday. She reports that she developed vague left lower quadrant abdominal pain yesterday. This morning she awakened from her sleep with severe, diffuse abdominal pain, anorexia, and vomiting.

On examination, she is lying very still. Temperature is 38.4°C, pulse 106 bpm, respirations 16 bpm, blood pressure 100/62 mm Hg. She has dry mucous membranes. Her abdomen has diminished bowel sounds and is rigid with involuntary guarding and rebound tenderness greatest in the left lower quadrant. On pelvic examination, she is exquisitely tender on the left abdomen. There is no cervical motion tenderness or adnexal fullness. There are no masses on rectal examination, and her stool is negative for occult blood.

Laboratory tests include a negative urine pregnancy (she's 60 after all—but can you be too careful?!), WBC 25,500/mm³, HCT 32%, platelets 450,000/mm³, Na 142 mEq/L, K 3.2 mEq/L, BUN 24 mg/dL, and Cr 1.0 mg/dL. Abdominal x-ray demonstrates free air under the diaphragm. Based on the information you decide that she has diverticulitis.

The patient undergoes surgery with a partial bowel resection and primary re-anastomosis. Two months following your patient's surgery, she presents complaining of abdominal pain. The pain is crampy and intermittent. Further history reveals a 24-hour history of vomiting, abdominal bloating, and low-grade fever. She reports her last bowel movement was 2 days ago and denies any flatus over the last 24 hours. On examination, her temperature is 37.1°C, pulse 105 bpm, respirations 12 bpm, and blood pressure 158/60 mm Hg. Her abdomen is slightly distended, diffusely tender to palpation without rebound or guarding, and has hyperactive bowel sounds. On flat plate and upright views of the abdomen, there are dilated loops of small bowel and multiple air fluid levels.

Question 22.4.1 Which of the following is true regarding this patient's current disease process?

A) She most likely has a closed-loop small bowel obstruction (SBO)

B) She most likely has an extramural source of obstruction

C) Dilated loops of small bowel are defined as being >5 cm in diameter on plain film

D) Both partial and complete bowel obstructions reveal no colonic gas on plain film

Answer 22.4.1 The correct answer is "B." This patient most likely has an external source of obstruction. Bowel obstructions are divided into two classes: mechanical and functional (also known as pseudo-obstruction, ileus, or neurogenic obstruction). Mechanical obstructions are further classified by both their location and etiology. Possible etiologies include intraluminal bodies (e.g., gallstone ileus or foreign body), intramural lesions (e.g., tumor or intussusception), and extramural lesions (e.g., adhesions). Obstructions can further be divided into open and closed loop. Open-loop obstructions have an outlet for gas and secretion relief (e.g., vomiting) whereas closed-loop obstructions block both inflow and outflow to an area. Closed-loop obstructions, like bowel torsion or volvulus, cause acute, severe abdominal pain, and generally require urgent surgical intervention.

Bowel obstruction presents with crampy, intermittent abdominal pain, vomiting, distention, and obstipation. History often includes previous abdominal surgery. Depending on the degree of obstruction and its duration, there may be hyperactive bowel sounds, high-pitched bowel sounds, or decreased/absent bowel sounds. An upright abdominal plain film or lateral recumbent abdominal film confirms diagnosis with findings of dilated loops of small bowel (bowel >3 cm in diameter) on the flat plate and air fluid levels on the upright or decubitus film. However, the sensitivity, specificity, and accuracy of plain radiographs are 79% to 83%, 67 to 83%, and 64% to 82%, respectively. CT scan is more sensitive and specific (93% and 100%) for obstruction than are plain films and will often reveal the source of the obstruction. However, CT should be reserved for patients in whom the diagnosis is unclear. Patients with a complete SBO will lack air in the colon on plain film; but remember that air can be introduced into the rectum during a rectal examination.

Question 22.4.2 Which of the following cause ileus?

A) Burns

B) Spinal cord injury

C) Hypokalemia

D) Pneumonia

E) All of the above can cause an ileus

Answer 22.4.2 The correct answer is "E." All of the above can cause an ileus. Additional causes include peritonitis, pancreatitis, uremia, surgery, and narcotics.

You diagnose a SBO, which you believe is most likely related to adhesion formation after hemicolectomy.

Question 22.4.3 Which of the following is INCORRECT regarding the management of bowel obstruction?

A) Initial treatment orders should include maintaining the patient NPO, IV fluid resuscitation, and electrolyte replacement as needed

B) This patient should undergo emergent surgical intervention

C) If she has fever or leukocytosis, she should undergo surgical intervention

D) If she requires surgery, broad-spectrum antibiotics to cover anaerobes and Gram-negative aerobes should be administered perioperatively

Answer 22.4.3 The correct answer is "B." Peritoneal adhesions account for more than half of all SBOs. Up to 80% of episodes of SBO caused by adhesions resolve without surgical intervention. Initial treatment includes restricting oral intake, IV fluid resuscitation with normal saline, and electrolyte correction. The goal is to prevent small bowel strangulation. Patients can be safely observed if there is no evidence of strangulation. Indications of strangulation include rapidly progressing abdominal pain or distention, development of peritoneal findings, fever, diminished urine output, leukocytosis, hyperamylasemia, metabolic acidosis, and persistent obstruction. Complete bowel obstruction, and closed-loop obstructions, should always be treated surgically. Also, patients with de novo obstruction (e.g., no history of laparotomy) usually require surgical intervention. If surgery is necessary, broad-spectrum antibiotics that cover anaerobes and Gram-negative aerobes should be administered perioperatively to reduce wound infection and abdominal sepsis rates.

Objectives: Did you learn to…

• Assess abdominal pain and recognize an acute abdomen?

• Provide appropriate perioperative management for gastrointestinal (GI) surgery?

• Identify and treat small bowel obstruction after abdominal surgery?

Mr. and Ms. Biggs have always been "big boned." They have decided that weight reduction surgery is the thing for them. However, they are concerned that, for the first time in their lives, they may not be big enough.

Question 22.5.1 Which of the following is NOT a necessary condition for weight loss surgery?

A) BMI ≥40 kg/m² regardless of the presence of weight-related disease

B) BMI ≥35 kg/m² without the presence of weight-related disease

C) BMI ≥35 kg/m² plus other weight-related disease such as sleep apnea, diabetes, severe joint disease, or weight-related cardiomyopathy

D) Failure to control weight with diet and other medical interventions

Answer 22.5.1 The correct answer is "B." A BMI of ≥40 kg/m² (not ≥35 kg/m²) alone is considered an appropriate weight for surgical intervention in the absence of other comorbidities. As noted above, a BMI of ≥35 kg/m² with weight-related comorbidities is considered an indication for bariatric surgery. "D" is worthy of comment. Most weight control drugs are fairly useless. However, failure of medical therapy is considered a necessary condition for bariatric surgery, as is an acceptable operative risk.

Much to their chagrin, they do meet the criteria for weight loss surgery. There are several surgeons in town who perform different techniques, including a Roux-en-Y and laparoscopic banding.

Question 22.5.2 Which of the following is NOT true?

A) Roux-en-Y is associated with greater weight loss at 1 year

B) Laparoscopic banding is associated with a greater need for recurrent surgery compared with Roux-en-Y

C) Mortality is higher with Roux-en-Y and there are more hospital admissions for complications

D) Vertical banded gastroplasty leads to sustained weight loss and few complications

Answer 22.5.2 The correct answer is "D." Vertical banded gastroplasty does not lead to sustained weight loss and has many complications including disruption of the staple line, GERD, vomiting, and erosion of the band into the stomach. For this reason, it has (or should have) fallen out of favor. The rest are true. Roux-en-Y results in the best weight loss and requires fewer recurrent surgeries when compared with laparoscopic banding. However, the mortality rate is higher (0.06% vs. 0.17%) for Roux-en-Y and there are more perioperative complications. It also requires longer hospital stays.

Mr. and Ms. Biggs are wondering if this is worth the trouble at all.

Question 22.5.3 You can tell them that:

A) Although they may lose weight, weight loss surgery does nothing for their underlying diabetes, hypercholesterolemia, and coronary artery disease (CAD)

B) There is no psychological or quality-of-life benefit to weight loss surgery: they will have the same existential crisis before and after the surgery

C) NSAIDs are relatively contraindicated after weight loss surgery

D) Dumping syndrome is more common after laparoscopic banding than with Roux-en-Y

E) There is rarely a need for supplemental vitamins after bariatric surgery

Answer 22.5.3 The correct answer is "C." The rate of gastric ulcers from NSAIDs is higher after bariatric surgery. The rest are not true. Weight loss does improve cholesterol, CAD, DM, etc., so "A" is incorrect. Additionally, there is both a psychological and quality-of-life benefit ("B"). Finally, dumping syndrome is commonly seen after a Roux-en-Y but not with laparoscopic banding ("D") and most patients will need supplemental vitamins ("E"). Vitamin deficiencies after bariatric surgery are common, especially folic acid, and deficiencies are more of a concern with Roux-en-Y procedures. However, supplementation is recommended for all post bariatric surgery patients.

After their operations, they return to see you. Mr. Biggs (who opted for the Roux-en-Y procedure and who is changing his name to Mr. Little) complains of recurrent postprandial colicky abdominal pain, diaphoresis, nausea, diarrhea, and tachycardia. His wife, who went for the laparoscopic banding, has no such symptoms. You make the diagnosis of "dumping syndrome."

Question 22.5.4 Your advice is to:

A) Start an anticholinergic to reduce stomach emptying

B) Increase the content of simple sugars to quickly raise the blood sugar with meals

C) Increase the size of feedings a bit in order to increase the amount of food available for digestion

D) Separate solid from liquid intake for at least 30 minutes (no beer with that pizza!)

E) None of the above

Answer 22.5.4 The correct answer is "D." Separating liquid from solid intake by 30 minutes may help to reduce dumping syndrome. The others are incorrect. While theoretically plausible, anticholinergics have not been shown to be of benefit in dumping syndrome (nor has octreotide). Additionally, small and frequent meals devoid of simple sugars are the way to go. The symptoms seem to be related to the rapid transit of simple sugars into the bowel. Smaller volume meals without simple sugars mitigate the problem.

Objectives: Did you learn to…

• Recognize the indications for bariatric surgery?

• Describe some different techniques for bariatric surgery and their pros and cons?

• Provide long-term management of the bariatric surgery patient and dumping syndrome?

A 24-year-old male presents to your clinic with a 5-day history of rectal bleeding. For several years, he has had hard stools but has developed rectal bleeding in the last few days. In addition, he has severe, intermittent, and crampy abdominal pain that he thinks is due to constipation. He reports a mild fever.

On examination, temperature is 37.9°C, pulse 95 bpm, respirations 12 bpm, and blood pressure 108/78 mm Hg. His abdomen is nontender and without guarding or rebound tenderness. Anoscopy reveals gross blood and two internal hemorrhoids.

Question 22.6.1 Regarding hemorrhoids in general, which of the following is true?

A) Patients with hemorrhoids most commonly present for perianal burning, itching, swelling, and pain

B) A grade III hemorrhoid can be reduced manually

C) If a patient under the age of 50 with rectal bleeding is found to have hemorrhoid on examination, further studies are not indicated

D) Because they are above the dentate line, strangulated internal hemorrhoids are not painful

Answer 22.6.1 The correct answer is "B." Grade III hemorrhoids can be reduced manually. Hemorrhoids are normal vascular structures in the anal canal; however, the venules can become engorged and symptoms such as pain, bleeding, and itching may result. Two types of hemorrhoids exist: external hemorrhoids derived from the inferior hemorrhoidal plexus below the dentate line and internal hemorrhoids derived from the anal cushions above the dentate line. Internal hemorrhoids occur on the left lateral, right anterior, and right posterior anal walls and are classified into grades I to IV. Grade I hemorrhoids slide below the dentate with straining but not through the anus. Grade II hemorrhoids protrude the anus but spontaneously reduce, whereas Grade III hemorrhoids must be manually reduced. Grade IV internal hemorrhoids cannot be reduced. "A" is incorrect because most patients with symptomatic hemorrhoids present with painless rectal bleeding. "C" is incorrect. You should consider further evaluation (e.g., flexible sigmoidoscopy and colonoscopy) in patients under the age of 50 presenting with rectal bleeding, even if hemorrhoids are present and are the likely source of bleeding. In patients older than 50 with rectal bleeding, a full colonoscopy is routinely recommended to rule out any cancerous process. "D" is incorrect. Although most internal hemorrhoids do not cause pain, strangulated internal hemorrhoids are very painful and can become necrotic and gangrenous, requiring emergent surgery. Note that strangulated is different from thrombosed.

Question 22.6.2 Which of the following would you NOT consider as a treatment of this patient's hemorrhoids?

A) Psyllium

B) Dicyclomine

C) Warm sitz baths

D) Short course of topical hydrocortisone

E) Increased water intake

Answer 22.6.2 The correct answer is "B." Dicyclomine (Bentyl, Antispas) is not indicated. Dicyclomine is an anticholinergic and will contribute to constipation—exactly what you want to avoid in hemorrhoids. "A" and "E" are the primary modes of treatment. Psyllium, as well as a diet high in fiber and water, will reduce straining and thus reduces intra-abdominal pressure. "C," warm baths or showers (40°C), have been shown to reduce anal canal pressures. "D," a short course of topical hydrocortisone (e.g., Anusol HC), may be of benefit. Long-term topical steroids are contraindicated. Finally, good hygiene and analgesia should be prescribed as needed.

Question 22.6.3 Which of the following is true about treating hemorrhoids surgically?

A) Irritable bowel syndrome is a relative contraindication to hemorrhoid surgery

B) It is best to ligate all hemorrhoids in a single office visit

C) Band ligation results in sloughing of hemorrhoid in about 1 to 2 weeks

D) Following excision, thrombosed external hemorrhoids should be closed to prevent bleeding

Answer 22.6.3 The correct answer is "C." Rubber-band ligation generally results in the sloughing of the hemorrhoid in 1 to 2 weeks. "A" is incorrect. Inflammatory bowel disease (IBD)—not irritable bowel syndrome (IBS)—is a relative contraindication to the surgical treatment of hemorrhoids. Other contraindications to office-based hemorrhoidectomy procedures include bleeding diathesis, pregnancy and the period immediately postpartum, anorectal fissures, active anorectal infections, AIDS or other immunodeficient states, portal hypertension, rectal wall prolapse, and anorectal tumors. Complications of hemorrhoidectomy include pain, significant bleeding with sloughing, thrombosis of external hemorrhoids, and very rarely sepsis with pelvic cellulitis. "B" is incorrect. Although evidence is scarce, standard of care dictates that only one hemorrhoid be ligated in a single office visit (due to concerns about excessive tissue necrosis). "D" is incorrect. Patients who present with external hemorrhoids that are painful, tender, swollen, with bluish discoloration have thrombosis. If the patient presents within 48 hours of thrombosis, the thrombus should be expressed. It is important not to close the hemorrhoid once the clot is expressed. In fact, a small ellipse of the hemorrhoid should be removed to facilitate continued drainage and prevent re-accumulation of clot.

You prescribe conservative treatment for your patient's hemorrhoids, and since he does not return for his next scheduled appointment, you assume he is doing well. You see him again 6 months later. He reports that he had indeed healed. Although he still takes psyllium, he began having painful bowel movements with blood-streaked stool 2 days ago. Upon examination of the anus, you find a fissure.

Question 22.6.4 All of the following findings would lead you to consider Crohn disease EXCEPT:

A) Posterior midline fissure

B) Painless fissure

C) Multiple fissures

D) Nonhealing fissure

Answer 22.6.4 The correct answer is "A." The posterior (dorsal) midline is where solitary fissures, unrelated to IBD, are typically located. Fissures in any other location should raise suspicion for Crohn disease. "B," "C," and "D" are also suggestive of Crohn disease.

Question 22.6.5 In a patient with an uncomplicated, initial anal fissure, what do you recommend for first-line therapy?

A) Lord dilation

B) Botulinum toxin injections

C) Topical nitroglycerin

D) Oral psyllium

E) Oral nifedipine

Answer 22.6.5 The correct answer is "D." All of the options are employed for treating anal fissures. However, in patients with an uncomplicated, initial anal fissure, it seems prudent to initiate conservative therapy (e.g., psyllium, dietary fiber, water, and warm soaks) prior to proceeding to more invasive measures. Most fissures will respond to conservative measures. Generally, healing takes 2 to 4 weeks. In addition to the treatments listed, topical diltiazem and topical nifedipine are also useful as are various surgical approaches. Lord dilation deserves special mention as a relatively arcane procedure for stretching the anal sphincter muscle (under anesthesia, we hope!).

You note that this patient's fissure is deep, ulcerating, and located at the left lateral aspect of the anus. Given this examination, you are concerned about Crohn disease. You briefly consider what you know about IBD.

Question 22.6.6 Which of the following is true of IBD?

A) Ulcerative colitis is primarily a diagnosis of young males

B) Crohn disease can be isolated to the colon

C) Ulcerative colitis is generally associated with deep colonic ulcerations and transmural inflammation while those of Crohn disease are more superficial

D) Crohn disease is more common in African Americans, while ulcerative colitis is more common in Caucasians

Answer 22.6.6 The correct answer is "B." Although often thought of as a disease of the entire GI tract, Crohn disease can be isolated to the colon. "A" is incorrect because ulcerative colitis is evenly distributed between men and women with a similar incidence in each. "C" is incorrect. Crohn disease is associated with deeper ulcerations and transmural inflammation leading to fistulae and strictures, etc. "D" is incorrect. In general, IBD is more common in Caucasians than other races. See Chapter 7 for more questions about Crohn disease.

Objectives: Did you learn to…

• Characterize hemorrhoids based on location?

• Grade internal hemorrhoids based on severity?

• Manage hemorrhoids with conservative and surgical treatments?

• Treat an uncomplicated anal fissure?

• Recognize anal fissures as potential signs of Crohn disease?

A 58-year-old female presents to your clinic for a lump found on routine breast self-examination. Her older sister died from breast cancer, and she is very concerned about the possibility of breast cancer in herself. She never misses her monthly breast examination and notes she has never felt this lump before. She first noticed the lump 2 weeks ago, and it has not changed in size or consistency since that time. Consistent with her personal health care goals but totally inconsistent with any current guidelines, she has had yearly mammograms since age 40 that have always been normal. She denies any weight loss or fatigue and reports being postmenopausal for the last 5 years. She previously took combination hormone replacement therapy, which she discontinued last year.

On examination, her breasts appear symmetrical with no skin abnormalities. The nipples are symmetric in size, shape, and color without retraction or discharge. You palpate a small, pea-sized thickening in upper outer quadrant of the right breast. This is the lump that she noticed 2 weeks ago. It is fixed to the deep aspect of the chest wall, so you have a hard time delineating whether the borders are smooth.

Question 22.7.1 Regarding breast lumps, which one of the following is FALSE?

A) Abnormal screening mammography is the most common presentation of breast carcinoma

B) Cysts are more common in premenopausal women than postmenopausal women

C) A history of fibroadenoma is associated with an increased risk of breast cancer

D) A radiographic oil cyst is pathognomonic for fat necrosis

Answer 22.7.1 The correct answer is "A." The most common presentation of breast carcinoma is a breast lump felt by the patient. Breast masses can be cysts, fibroadenomas, thickened areas with fibrocystic change, fat necrosis, and carcinoma. "B" is true. Cysts primarily present when women are premenopausal and are uncommon in the postmenopausal state, unless the woman is taking hormone replacement. Cysts are well-demarcated, mobile, and firm. The diagnosis is confirmed with aspiration of nonbloody fluid followed by complete resolution of the mass. Fibroadenomas occur between the ages of 20 and 50 and are described as firm, rubbery, and mobile. They can be confirmed by characteristic findings on ultrasound and fine needle aspiration (FNA) if necessary. "C" is also true. While historically believed to be entirely benign, fibroadenomas are associated with a small but significant increased risk for breast cancer. "D" is true. A radiographic oil cyst (a circumscribed mass of mixed soft-tissue density and fat with a rim that is often calcified) is due to fat necrosis, which occurs in areas of the breast that have been subject to trauma, surgery, infection, or radiation therapy. About half of the time, fat necrosis has no precipitant. Oil cysts are most common in the superficial aspects of pendulous breasts of obese women. When an oil cyst is seen radiographically, no further evaluation is needed.

Your patient is concerned about her family history of breast cancer. She asks about genetic testing.

Question 22.7.2 You are able to tell her that the BRCA 1 gene is associated with which of the following?

A) Breast cancer

B) Uterine cancer

C) Ovarian cancer

D) A and B

E) A and C.

Answer 22.7.2 The correct answer is "E." The BRCA (BReast CAncer) 1 and 2 genes are related to familial breast cancer, and BRCA 1 is also associated with an increased risk of ovarian cancer. They are not associated with uterine cancer. The usefulness of testing for these genes in primary care is questionable, and they cannot be relied upon for general screening or diagnostic purposes.

You are suspicious that this patient's mass may be cancer, and you order mammography and ultrasound. However, these studies show no mass. When your patient returns to discuss her test results, you examine her again. The mass is still palpable and essentially unchanged.

Question 22.7.3 The next best step in management of this patient is:

A) Breast examination and mammogram every 6 months

B) Breast examination and mammogram every 3 months

C) Referral to a surgeon to consider excisional biopsy

D) Ultrasound-guided needle biopsy

E) Return to normal screening

Answer 22.7.3 The correct answer is "C." A palpable mass that is suspicious for cancer cannot be ignored even in the presence of negative radiologic studies. No other option is acceptable, nor would any other option be defensible if this patient were to develop overt breast cancer. "D" would be a viable option if a mass were identified on ultrasound, but none was.

When making diagnostic decisions regarding breast masses, age matters.

Question 22.7.4 Which of the following is NOT TRUE about how a diagnostic evaluation should proceed?

A) In women <40 years of age, lesions that appear benign on ultrasound may be followed simply by a repeat examination in 3 months

B) In women >40 years of age, lesions that appear benign on ultrasound and cytological analysis need no follow-up

C) In women >40 years of age where a lesion is palpated but not seen on mammogram or ultrasound, excision should follow if clinical suspicion dictates

D) In women >40 years of age who have a palpable lesion and desire definitive removal, no further testing is necessary prior to excisional biopsy

Answer 22.7.4 The correct answer is "B." Women over the age 40 should be followed up in 3 months even with negative cytology. Clinical diagnosis of carcinoma has accuracy of 60% to 85%. Extent of evaluation, however, is driven by clinical suspicion. Radiologic studies should be ordered as indicated. A needle biopsy either by FNA or core needle biopsy is the next step in evaluation of solid tumor masses. Needle diagnosis offers the advantages of being simple, quick, inexpensive, relatively noninvasive, highly available, and an accurate way of diagnosing atypical cells.

Because of the risk for carcinoma, algorithms for evaluation of solid tumors differ between women <40 years versus those 40 years and older. Women <40 years who desire observation should be evaluated by ultrasound and/or FNA. If either is suspicious, surgical excision should be performed. If there is a negative FNA, the patient can be followed up in 3 months.

In women 40 years of age or older, palpable masses should further be evaluated by ultrasound and mammography. If the lesion cannot be identified radiographically, it should be removed by excision if clinical suspicion dictates. If the lesion appears benign by radiography, it can be followed by FNA. Those with atypia on FNA should be referred for excision. If the lesion appears benign both radiographically and cytologically, it still warrants further follow-up in 3 months by clinical examination. "D" is correct. All women with a palpable breast mass who desire an excisional biopsy can proceed directly to definitive removal, regardless of age.

You perform an FNA, which the cytopathologist reads as "probable malignancy." You recall from previous visits that the patient's older sister had breast cancer. Additionally, your patient went through menopause at age 53, and used hormone replacement therapy for 5 years. You obtain further history, including a history of menarche at 14 years of age and the fact that the patient has never been pregnant.

Question 22.7.5 Which of these factors DOES NOT contribute to an increased risk of breast cancer in THIS patient?

A) Her nulliparity

B) Her age at menarche

C) Her family history

D) Her age at menopause

E) Her history of hormone replacement

Answer 22.7.5 The correct answer is "B." The risk of breast cancer is roughly associated with the lifetime exposure to estrogen. This patient's age at menarche is in the mid-to-late age range and is thus not a risk factor for breast cancer. Younger age at menarche (e.g., 10 years old) is associated with an increased risk of breast cancer. Nulliparity and greater age at first pregnancy are associated with an increased risk, as is greater age at menopause. A history of a first-degree relative with breast cancer is a strong risk factor. Finally, as demonstrated in the Women's Health Initiative, estrogen/progesterone replacement therapy (HRT) is associated with an increased risk of breast cancer (an excess of about 8 breast cancers per 10,000 women treated with HRT).

While you wait for definitive pathology results, you consider the different types of breast cancer that this patient might have.

Question 22.7.6 Regarding various types of breast cancer, all of the following are true EXCEPT:

A) Cystosarcoma phyllodes tumors are not always malignant

B) Infiltrating lobular carcinoma is the most common histological type of invasive breast carcinoma

C) Paget disease of the breast clinically appears eczematous

D) Sarcomas, lymphomas, melanomas, and angiosarcomas are all possible causes of cancer in the breast

Answer 22.7.6 The correct answer is "B." Infiltrating ductal (not lobular) carcinoma is the most common histological type of invasive breast cancer. Invasive breast carcinoma includes a wide variety of histological diseases. Infiltrating ductal carcinoma accounts for 65% to 80% of breast cancers, whereas infiltrating lobular carcinoma is the second most frequent, accounting for 10% of breast cancers. "A" is true. Cystosarcoma phyllodes tumors, which have a clinical presentation similar to fibroadenomas but are more rapidly growing, may be either malignant or benign. Yet the malignant nature of cystosarcoma phyllodes is sometimes difficult to determine on cytology, and the lesions may require a wide excision. "C," Paget disease of the breast, is a rare form of breast cancer with eczematous changes of the nipple, including itching, erythema, and nipple discharge. "D" is true as well. Many other malignancies may occur in the breast, including sarcomas, lymphomas, melanomas, and angiosarcomas.

The pathology results are final and show infiltrating ductal carcinoma. Your patient will see a breast surgeon next week. As you await the results of surgery, you consider her prognosis.

Question 22.7.7 All of the following are favorable prognostic indicators in breast cancer EXCEPT:

A) Hormone receptor negative

B) Absence of axillary nodal involvement

C) Low-grade tumor

D) Pure tubular, mucinous, or medullary histological types

E) Tumor size <1 cm

Answer 22.7.7 The correct answer is "A." Patients whose tumors are hormone receptor negative have worse outcomes than do patients whose tumors are hormone receptor positive. "B," absence of axillary nodal involvement, is obviously a better prognostic factor than the presence of nodal involvement. In fact, axillary lymph node status is the single most important predictor of overall survival in breast cancer. "C," low tumor grade, is also a good prognostic factor. "D," patients with a single cell type have a better prognosis as well. "E" is true. A very useful predictor of tumor behavior is tumor size, and tumor size <1 cm is a positive prognostic sign.

Objectives: Did you learn to…

• Generate a differential diagnoses for breast masses?

• Evaluate a patient with a breast mass?

• Identify risk factors for breast cancer?

• Describe several types of breast cancers?

• Describe factors that are used to establish prognosis in breast cancer?

A 50-year-old female presents for a routine physical. She wants to know her risk of developing breast cancer. You want to give her a more accurate picture, and you decide to use the Gail model.

When taking her history, you must ask about all of the following EXCEPT:

A) Number of first-degree relatives with breast cancer

B) Age at first menstrual period

C) Number of breast biopsies

D) Age at first live birth

E) Number of live births

The correct answer is "E." The Gail model is a computer program that estimates a woman's chance of developing breast cancer. Factors that affect the score include the number of first-degree relatives with breast cancer, current age, age of first menstrual period, number of breast biopsies, BRCA gene status, age at first live birth, race, and history of atypia in a biopsy. This tool may be useful in patients who are candidates for tamoxifen for breast cancer prophylaxis. However, the Gail score is much better at predicting the likelihood of breast cancer in populations than in any individual. So, realize that it has limitations. The National Cancer Institute maintains a website for the Gail model calculation, located at http://bcra.nci.nih.gov/brc/q1.htm.

An orthopedic colleague asks you to consult on a 64-year-old male prior to an elective total hip replacement. The surgery is scheduled for 3 months from now. The patient is a smoker with diabetes mellitus type 2 and has recently had a cardiac catheterization that showed significant, but nonbypassable, coronary disease. He is asymptomatic and is able to walk stairs without dyspnea or chest pain. The surgeon would like some perioperative recommendations.

Question 22.8.1 You would recommend all of the following EXCEPT:

A) The patient should stop smoking 4 weeks before surgery

B) The patient should have preoperative and postoperative β-blockers if the pulmonary status allows it

C) The patient should have a ECG done

D) The patient should have his hemoglobin/hematocrit drawn

E) The patient should have his creatinine measured

Answer 22.8.1 The correct answer is "A." Paradoxically, unless patients stop smoking 8 weeks or more before surgery, the risk of adverse pulmonary outcomes is increased. The cause of this phenomenon remains unclear but may occur because the cilia are able to mobilize material in the lungs. "B" is true. The use of pre-, intra-, and postoperative β-blockers is well supported for patients with CAD. One of the most serious intraoperative events is a myocardial infarction. β-Blockers have been shown in multiple studies to reduce this risk and to improve outcomes if the patient has an elevated risk for a myocardial infarction. Note, however, that a β-blocker should be started well in advance of the surgery and not just on the day of surgery. It is critical to assure that the patient is on a stable dose of a β-blocker at the time of surgery. Starting the β-blocker too close to surgery may increase the risk of stroke, likely secondary to intraoperative hypotension. While "C," "D," and "E" are true, a lot of other routine preoperative assessments are not supported in the literature. See Table 22-1 and Table 22-2 for the appropriate evaluation of the preoperative patient.

Question 22.8.2 Which of the following is effective for the prevention of postoperative DVT?

A) Early mobilization

B) Enoxaparin 30 mg subcutaneously every 12 hours

C) Enoxaparin 40 mg subcutaneously every 24 hours

D) Heparin 5,000 Units subcutaneously every 12 hours

E) All of the above

Answer 22.8.2 The correct answer is "E." All of the modalities listed above can prevent the development of DVT. Aspirin and low-dose warfarin (target INR 1.5) are also effective but less so than heparin or enoxaparin. Sequential compression devices (SCDs) may also be used. Subcutaneous heparin may require TID dosing in larger patients.

The patient undergoes his hip replacement, and his postoperative ECG is normal. Four hours after surgery, he develops mild respiratory distress, a fever, and cough. On chest x-ray, there is a right lower lobe infiltrate. There is no evidence of fluid overload.

Question 22.8.3 Which of the following is the most likely cause of this patient's fever and infiltrate?

A) Pneumococcus

B) Gram-negative organisms

C) Atelectasis

D) Aspiration pneumonitis

E) Aspiration pneumonia

Answer 22.8.3 The correct answer is "D." In the hours after surgery, an aspiration pneumonitis would be the most likely cause of this patient's current findings. Aspiration pneumonitis occurs when there is aspiration of gastric contents with a pH of less than 2.5. In order for aspiration pneumonitis to develop, the volume of aspirate needs to be at least 1 to 4 mL/kg of stomach contents. Aspiration pneumonitis develops over a matter of hours. In contrast, pneumococcal and Gram-negative pneumonias generally develop several days after surgery (unless a subclinical pneumonia was present at the time of surgery). Aspiration pneumonia is caused by anaerobes and mixed flora and develops slowly over days to a week. Atelectasis warrants special mention. Atelectasis does not cause fever. Both atelectasis and fever occur frequently in the postoperative period, but their occurrence together is most likely due to chance. The old adage about atelectasis and fever has been shown to be untrue. Thus, in the postsurgical patient with fever, look for another cause besides atelectasis.

Question 22.8.4 Of the following, which generally IS NOT a cause of postoperative fever in the first 48 hours?

A) Malignant hyperthermia

B) Surgical "trauma" (e.g., cutting through muscle)

C) Wound infection

D) Hyperthyroidism

E) Drug fever

Answer 22.8.4 The correct answer is "C." Wound infections generally are not found in the first 48 hours after surgery. All of the rest can be found either immediately after surgery (malignant hyperthermia, hyperthyroidism, drug fever, etc.) or soon thereafter (fever from surgical trauma secondary to the release of cytokines). Table 22-3 summarizes the time course and causes of postoperative fever.

The patient's chest radiograph is consistent with aspiration pneumonitis (infiltrate in the right lower lobe … yes, lower lobe is more common).

Question 22.8.5 Which of the following is NOT TRUE with regard to aspiration pneumonitis?

A) It can progress to ARDS

B) Patients with aspiration pneumonitis present with fever, dyspnea, bronchospasm, and hypoxia

C) It should be treated with antibiotics that cover for anaerobes

D) It tends to resolve in about 7 days

Answer 22.8.5 The correct answer is "C." Aspiration pneumonitis is a chemical process that is unrelated to infection. Thus, aspiration pneumonitis does not need to be treated with antibiotics at all (although it usually is as a practical matter—since we are chicken). The rest of the options are true.

You treat the patient with fluids and tracheal suction. However, he remains febrile and tachycardic at about 128 bpm. There is no evidence of dehydration at this point and he seems euvolemic.

Question 22.8.6 Which of the following would be the most appropriate first step in the treatment of tachycardia in this postsurgical patient?

A) Oral or rectal aspirin

B) Oral or rectal acetaminophen

C) IV β-blockers

D) IV fluids

Answer 22.8.6 The correct answer is "B." The initial treatment of this patient is acetaminophen. Reducing the fever and metabolic stress will result in a reduction in the heart rate. "A" is not the best choice since this patient is postsurgical. Giving aspirin, an antiplatelet agent, may result in increased postoperative bleeding. "C," IV β-blockers, can be used and would be appropriate if the patient was having ischemic symptoms and needed an immediate reduction in pulse. "D," IV fluid, is incorrect in this patient who is already well hydrated (as stipulated in the question). Note that IV fluids are appropriate in postoperative tachycardia if the patient is dehydrated.

The patient's pulmonary status has improved. The surgeon notices that the patient has hyperkalemia and thrombocytopenia. The patient is on a number of drugs postoperatively. She is wondering which of these drugs is causing the problem.

Question 22.8.7 You let her know that the most likely cause is:

A) β-Blockers

B) Albuterol

C) Aspirin

D) Morphine

E) Heparin

Answer 22.8.7 The correct answer is "E." Heparin can cause both hyperkalemia and thrombocytopenia (HITTS, or heparin-induced thrombocytopenia and thrombosis syndrome). Hyperkalemia is caused by heparin's ability to block the aldosterone system and usually requires prolonged heparin use (although in diabetics and those with renal failure it may occur more rapidly because of poor reserve). Thrombocytopenia is caused by the development of antiplatelet antibodies and occurs 5 to 10 days after the start of heparin therapy and is associated with thromboembolic phenomenon. Platelets can get as low as 30,000 platelets/μL. Stop the heparin and anticoagulate with a nonheparin agent (e.g., bilivarudin). A non–immune-mediated thrombocytopenia also occurs in up to 20% of individuals who receive heparin. This mild thrombocytopenia occurs within the first 4 days of heparin administration, resulting in a nadir of 100,000 platelets/μL and no clinical consequences. "A," β-blockers, may result in hyperkalemia at high doses (via a β1-receptor effect inhibiting renin release) but do not cause thrombocytopenia. "B," albuterol, can cause hypokalemia (as can other catecholamines) by driving potassium intracellularly. However, albuterol does not cause hyperkalemia or thrombocytopenia. Likewise, "D" is incorrect because morphine is not associated with hyperkalemia or thrombocytopenia.

After you stop the patient's heparin, the thrombocytopenia and hyperkalemia begin to resolve.

You start the patient on intermittent leg compression with SCDs.

Question 22.8.8 Which of the following is TRUE about the use of heparin in patients with a history of heparin induced thrombocytopenia?

A) A low-molecular-weight heparin (LMWH) should be used in patients with a history of HITTS

B) Heparin can be re-introduced once the HITTS has been treated with steroids

C) The use of lepirudin and argatroban are contraindicated in the treatment of HITTS

D) Unfractionated heparin can be used during cardiopulmonary bypass despite a previous history of a thrombocytopenic reaction to heparin if the patient is HIT antibody negative

E) None of the above

Answer 22.8.8 The correct answer is "D." Heparin can be used during cardiopulmonary bypass despite a previous history of HITTS. The theory is that the development of enough antibodies to reproduce thrombocytopenia takes several days and patients will generally be on cardiopulmonary bypass for only a matter of hours. Thus, heparin can be used during cardiopulmonary bypass even if there is a history of prior heparin-induced thrombocytopenia. "A" is incorrect. LMWH should be avoided in patients with strongly suspected (or confirmed) HITTS. It is recommended to consider an alternative, nonheparin anticoagulant (e.g., danaparoid, lepirudin, argatroban, fondaparinux, bivalirudin) over the further use of unfractionated heparin or LMWH. "C" is incorrect. In fact, the treatment of patients who need anticoagulation after HITTS includes lepirudin and argatroban. These two agents are direct thrombin inhibitors that do not cross-react with heparin. Note that there are now a number of oral alternatives to heparin including dabigatran, apixaban, and rivaroxaban. Any of these would also be appropriate although dabigatran requires 7 days of overlap with heparin so would not be the best choice here….

Objectives: Did you learn to…

• Perform a preoperative medical evaluation?

• Generate a differential diagnosis for postoperative fever?

• Diagnose and treat aspiration pneumonitis?

• Recognize some complications of heparin use?

• Employ appropriate DVT prophylaxis measures?

• Manage a patient with heparin-induced thrombocytopenia?

Regarding anesthesia evaluation both preoperatively and intraoperatively, which one of the following is FALSE?

A) Therapeutic β-blockade should be administered preoperatively in vascular surgery patients who have underlying cardiac disease in order to reduce perioperative and long-term risks of cardiac events.

B) Minimum potassium before proceeding with elective coronary artery bypass graft (CABG) surgery should be 3.5 mEq/L.

C) American Society of Anesthesiologists (ASA) Class IV designation includes patients who have well-controlled major systemic disease.

D) Risks of anesthesia include allergic drug reactions, failure to intubate and provide adequate oxygenation and ventilation, nerve damage, and malignant hyperthermia.

The correct answer is "C." ASA Class IV includes patients who have a systemic disease that is life threatening and NOT well controlled. All the other options are true. "A" is true, but the β-blocker should be started well in advance of the surgery and the patient should be on a stable dose at the time of the surgery. Starting the β-blocker at the time of the surgery worsens outcomes as noted above. "B" is a correct statement. There are increased perioperative arrhythmias and need for cardiac resuscitation in patients with serum potassium levels <3.5 mEq/L. "D" is also a correct statement. Anesthesia risks include allergic drug reactions, failure to intubate and provide adequate oxygenation and ventilation, nerve damage, and malignant hyperthermia, among others. Mortality rate from anesthesia is surmised to be about 1 to 2 per 10,000 patients. The ASA classification system is outlined in the Table 22-4.

A 60-year-old male patient of yours is planning to undergo CABG. After you perform a physical examination and laboratory tests, you discuss his case with the surgeon. She asks if you will help to manage him postoperatively, and you agree. She then asks if you are aware of his risk of arrhythmia during the postoperative period.

You correctly reply:

A) "His risk for atrial fibrillation is less than it would be if he were undergoing valve replacement simultaneously with CABG."

B) "Of the potential arrhythmias, he is most likely to encounter bradycardia, which is the most common postoperatively."

C) "Nonsustained ventricular tachycardia is highly unlikely in this setting."

D) "Keep his potassium low, around 3.0 mEq/L, and he will be less likely to experience tachyarrhythmias."

The correct answer is "A." With CABG, the risk of postoperative atrial flutter or fibrillation is around 30%. That risk almost doubles when valve replacement is accomplished simultaneously with CABG. "B" is incorrect because bradyarrhythmias occur less frequently than tachyarrhythmias. "C" is incorrect. Nonsustained ventricular tachycardia is extremely common in the immediate postoperative period. "D" is also incorrect. Plasma potassium levels <3.5 mEq/L are associated with an increased risk of tachyarrhythmias.

A 15-year-old male presents to your office with a 3-day history of diarrhea and right lower quadrant abdominal pain. He has tenderness in the right lower quadrant with guarding and rebound. He remains afebrile and has been hungry, scarfing down five bacon-wrapped waffles for breakfast (but less than his usual 6…). The patient has no other significant history. You decide that this patient might have appendicitis, so you draw some labs. The white blood cell count is normal (7,500/mm³), as is the urinalysis.

Question 22.9.1 Which of the following is true about appendicitis?

A) A normal white count effectively rules out the diagnosis of appendicitis.

B) The majority of patients with appendicitis present with fever.

C) The absence of anorexia effectively rules out appendicitis.

D) A fecalith is found on radiograph in the majority of patients with appendicitis.

E) None of the above.

Answer 22.9.1 The correct answer is "E." None of the above is true. Taking these in order, 10% of patients with appendicitis have a normal white count, a minority of patients with appendicitis present with fever (15% in one study), only 75% of patients with appendicitis complain of anorexia, and a radiographic fecalith is found in only a small minority of patients.

Question 22.9.2 Which of the following is specific for appendicitis?

A) Obturator sign

B) Psoas sign

C) Rovsing sign

D) Tenderness at McBurney's point

E) None of the above is specific for appendicitis

Answer 22.9.2 The correct answer is "E." None of the above is specific for appendicitis. An obturator sign is present if there is pain on internal and external rotation of the hip. The obturator sign can be seen with any pelvic abscess that is in contact with the hip area, but is more commonly seen with a retrocecal abscess. The psoas sign is pain on use of the psoas muscle (e.g., lifting the leg at the hip), and it can be seen with any inflammatory process that is in contact with the psoas muscle, including a psoas abscess. Rovsing sign is when pain increases in an area of peritonitis when the abdomen is palpated elsewhere. For example, in a patient with appendicitis, right lower quadrant pain will be increased with palpation of the left lower quadrant. This is indicative of peritonitis in the area that has increased pain, but it is not specific for appendicitis. Tenderness at McBurney's point can be seen in a number of processes including appendicitis, ileitis, any process in the cecum, and urinary tract infection.

Question 22.9.3 Which of the following is true about the treatment of pain in the acute abdomen?

A) Early treatment with morphine will obscure the proper diagnosis

B) Treatment with pain medication invalidates informed consent

C) Early treatment of pain with morphine is safe except in children

D) Ketorolac is preferred for patients who may undergo a surgical procedure

E) None of the above is true

Answer 22.9.3 The correct answer is "E." None of the above is correct. Early treatment of pain in the acute abdomen actually improves diagnostic accuracy in both children and adults. Ketorolac is not a good choice because of its antiplatelet effects, which increase the risk of bleeding intraoperatively. Pain medication does not inherently invalidate informed consent (but obviously can if the patient is hardly arousable).

Although you have thought a lot about his potential problem, you have not actually done anything more to evaluate this 15-year-old with abdominal pain!

Question 22.9.4 The BEST test to help you arrive at a diagnosis in this patient is:

A) Erythrocyte sedimentation rate (ESR)

B) C-reactive protein (CRP)

C) Abdominal ultrasound

D) Abdominal CT scan

E) Colonoscopy

Answer 22.9.4 The correct answer is "D." The test most likely to arrive at a diagnosis in this patient is a CT scan of the abdomen looking at the appendix. "A" and "B" are incorrect. Both the CRP and the ESR are nonspecific markers of inflammation and are not helpful in the diagnosis of appendicitis. "C," an ultrasound, can be used and is often recommended as the first test in pediatric patients to avoid the ionizing radiation associated with CT. The specificity for ultrasound is high (95–99%). However, it is not as sensitive as a CT scan (as varied as 60–85% depending on the study). Although "D" is the textbook answer, it would be reasonable to start with an ultrasound, and if equivocal, one can then move on to CT or surgical consultation for serial abdominal examinations depending on institutional preference. Finally, ultrasound can also be useful in the female patient in whom other diagnoses need to be ruled out, such as ovarian pathology. "E," colonoscopy, is not particularly useful in the diagnosis of appendicitis but could be used for other purposes such as looking for IBD once appendicitis is ruled out by CT.

Question 22.9.5 If this patient's CT scan is positive for appendicitis, the likelihood that he will have a normal appendix removed at appendectomy is:

A) 0%

B) 10%

C) 20%

D) 30%

E) 50%

Answer 22.9.5 The correct answer is "B." With the advent of CT scanning, the false positive rate (of taking normal patients to the OR) has improved, but perhaps not as much as you would think. The negative laparotomy rate is still about 10%. The negative laparotomy rate has gone down in men and the young but has increased in the elderly and in women. There is evidence that CT scanning changes the treatment plan in more than half of cases of suspected appendicitis. The sensitivity of CT for appendicitis is 91% to 98%, but the specificity is as low as 75% depending on the radiologist and the population tested (range 75–93%).

Question 22.9.6 In general, which of the following is true about appendicitis?

A) Pain is in the right upper quadrant in the majority of pregnant women with appendicitis

B) Atypical presentations are more common in the elderly patient than in other groups

C) Patients with a retrocecal appendix generally present with well-localized tenderness and signs of peritoneal irritation

D) An appendicitis is great way to postpone your board examination—get one soon!

Answer 22.9.6 The correct answer is "B." Symptoms tend to be atypical in the elderly. In fact, elderly patients may have appendicitis with a normal white count, poorly localized pain, and absence of fever. So, maintain a high index of suspicion. "A" is incorrect. Despite classic teaching, patients who are pregnant tend to have "typical" symptoms with right lower quadrant pain. This is especially true in the first half of pregnancy. Certainly the appendix can be displaced cephalad, but the majority will still have right lower quadrant pain. "C" is incorrect. Patients with retrocecal appendicitis will commonly complain of a dull ache. However, signs of peritoneal irritation may be minimal or absent.

Objectives: Did you learn to…

• Describe the findings in acute appendicitis?

• Diagnose appendicitis and determine how ancillary tests are best used in the patient presenting with signs and symptoms of appendicitis?

• Manage a patient with appendicitis?

A 72-year-old male presents to your office for a 3-month history of episodic abdominal pain. It is primarily located in the epigastric region and radiates to the back. It occurs both during the night and day and lasts about 1 hour. His past medical history is significant for a 5-year history of diabetes. He takes glyburide, atorvastatin, and aspirin (he clearly isn't your patient … he is not on metformin, the drug of choice in type 2 diabetes). He has no previous surgical history. You order an ultrasound. The ultrasound reveals a normal aorta, but the technician notes several stones in the gallbladder. You are concerned that this patient may have symptomatic cholelithiasis.

Question 22.10.1 Which of the following is true of his risk for gallstones?

A) This patient has an increased risk of cholesterol stones because he is diabetic

B) This patient's risk of gallstones would have peaked in his fourth decade of life

C) This patient's risk of gallstones is increased because of his atorvastatin use

D) This patient's risk for cholesterol stones is lower because of his advanced age

E) This patient's risk of gallstones is increased because he's male

Answer 22.10.1 The correct answer is "A." Patients with diabetes have an increased risk of gallstones when compared with the general population. Other associations include female gender (not male, so "E" is wrong), family history, obesity, and certain medical illnesses including hyperlipidemia, cystic fibrosis, short bowel syndrome, parenteral nutrition, hemolytic anemia (e.g., sickle cell), and history of terminal ileum resection. "B" and "D" are incorrect because the risk of gallstones increases linearly with age. "C" is incorrect. Atorvastatin and other "statins" are not associated with an increased risk of gallstone formation, but clofibrate and other fibrates are. "D" is also incorrect.

Question 22.10.2 Which of the following statements is FALSE regarding the evaluation of the gallbladder?

A) Ultrasound will find pericolic fluid in only 50% of patients with cholecystitis

B) An HIDA scan can be abnormal/positive (e.g., no tracer in the duodenum) in patients with common bile duct obstruction and/or cholecystitis

C) Endoscopic retrograde cholangiopancreatography (ERCP) has an attendant risk of pancreatitis

D) The absence of disease on ultrasound effectively rules out gallbladder disease

Answer 22.10.2 The correct answer is "D." While ultrasound is highly sensitive for stones (95% or greater), it will miss some. "A" is a correct statement as are "B" and "C." An HIDA (hepatic iminodiacetic acid) scan can be abnormal (e.g., no tracer in the duodenum) in cholecystitis but also in any other condition in which the common duct is blocked including a common duct stone or tumor. Additionally, if there is liver disease (which may prevent the uptake of HIDA into the gallbladder), a full gallbladder, gallbladder dysfunction, or spasm of the sphincter of Oddi, one can have a false positive scan (e.g., no tracer in the duodenum). MRCP (magnetic resonance cholangiopancreatography) or ERCP can be used to identify stones in the common duct prior to surgery.

Question 22.10.3 Regarding different types of gallstones, all of the following are true EXCEPT:

A) Cholesterol stones are associated with obesity and hyperlipidemia

B) Black pigment stones are associated with cirrhosis

C) Brown pigment stones are associated with liver fluke infection

D) Blue pigment stones are associated with being an avid fan of the St. Louis Blues hockey team and/or the Blue Man Group

Answer 22.10.3 The correct answer is "D." While we have noticed that beer-swilling hockey fans might be prone to developing gallstones, there are no studies that show this. Besides, blue pigment stones do not exist. All the other options are true. Stone types include cholesterol, black pigment, and brown pigment stones. Cholesterol stones are associated with advancing age (due to decreased synthesis of bile salts from cholesterol), hyperlipidemia, diabetes, obesity, and living in the Western Hemisphere (thank you, fast food industry!). Black pigment stones contain calcium bilirubinate, calcium carbonate, and calcium phosphonate. They are associated with hemolytic diseases, Crohn disease, ileal resection, cirrhosis, and total parental nutrition (TPN). Brown stones are observed more often in East Asia and are associated with liver fluke infection.

You refer the patient to your favorite surgical consultant, Dr. Hugh Jeego (or his partner, I. M. Agodd), for evaluation of cholecystectomy. However, before his surgery appointment, you see him again in the ED. He presents with fever, nausea, vomiting, and anorexia for the last 48 hours. His examination is significant for temperature 38.9°C, mild tachycardia and tachypnea, and a normal blood pressure. He is tender in the right upper quadrant and has a positive Murphy sign. He has no jaundice or palpable right upper quadrant mass. Laboratory values include WBC 14,800/mm³, ALT 58 IU/L, AST 64 IU/L, alkaline phosphatase 45 IU/L, total bilirubin 1.5 mg/dL (mildly elevated liver enzymes and bilirubin), amylase 95 IU/L, and lipase 52 IU/L (normal amylase and lipase).

Question 22.10.4 At this point in time, your working diagnosis is:

A) Acalculous cholecystitis

B) Acute calculous cholecystitis

C) Pancreatitis

D) Ascending cholangitis

E) Myocardial infarction

Answer 22.10.4 The correct answer is "B." The clinical presentation, examination, and laboratory data point toward acute cholecystitis. "A" is incorrect because acalculous cholecystitis occurs more often in critically ill hospitalized patients, and you already know that this patient has stones, so his cholecystitis is by definition calculous in nature. There must be no gallstones detected on ultrasound to diagnose acalculous cholecystitis (thus the name). "C" is incorrect. His pancreatic enzymes are normal; and although one can certainly have pancreatitis with a normal amylase and lipase, you have a better explanation with cholecystitis. "D" is incorrect. Patients with ascending cholangitis usually have markedly elevated transaminases and an obstructive laboratory pattern (e.g., elevated bilirubin, alkaline phosphatase, and pancreatic enzymes). "E" is very unlikely in this patient who has findings more consistent with intra-abdominal pathology, but you should always consider cardiac (and other thoracic organ) etiologies in older patients presenting with abdominal complaints.

Question 22.10.5 Regarding the differential diagnosis of complicated cholelithiasis, which of the following is true?

A) Empyema of the gallbladder is primarily a disease of the elderly and carries a high mortality rate due to associated Gram-positive sepsis

B) Emphysematous cholecystitis occurs primarily in elderly diabetics as a late complication of miliary tuberculosis (TB)

C) The most common consequence of gallbladder perforation is generalized peritonitis

D) Charcot's triad (jaundice, fever, and right upper quadrant pain) is associated with cholangitis

Answer 22.10.5 The correct answer is "D." The classic Charcot's triad (jaundice, fever, and right upper quadrant pain) is associated with cholangitis, but it is not seen in the majority of cases, probably due to early detection of cholangitis. Nonetheless, it can be helpful if present. "A" is incorrect because patients generally develop a Gram-negative sepsis. "B" is incorrect because emphysematous cholecystitis is not a complication of miliary TB, but it can occur with anaerobic cholecystitis. Miliary TB rarely affects the gallbladder. "C" is incorrect. The most common consequence of gallbladder perforation is a localized, walled off abscess. Additionally, a cholecystoenteric fistula may form between the gallbladder and the duodenum or jejunum. Stones can then pass into the bowel. Stones larger than 2 cm in diameter are likely to lodge in the terminal ileum, a process termed gallstone ileus.

Generally, patients with cholecystitis have a prior history of biliary colic. Pain with acute cholecystitis is similar to that of cholelithiasis except is more often severe, longer lasting (>24 hours), and associated with anorexia, nausea, vomiting, fever, elevated white count (12,000–15,000/mm³), right upper quadrant guarding, and a positive Murphy sign (arresting inspiration when palpating the gallbladder). However, Murphy sign is only 65% sensitive (less in the elderly). Additionally, 38% with confirmed cholecystitis have neither leukocytosis nor fever. About 15% of the time there is associated jaundice and 20% of the time there is a palpable mass in the right upper quadrant. Biliary pancreatitis can occur when there is blockage of the ampulla of Vater, and cholangitis occurs when there is ductal stone obstruction and biliary infection. Emphysematous cholecystitis occurs primarily in elderly male diabetics: gas producing bacteria, most commonly C. perfringens, result in gas in the gallbladder and can cause a severe sepsis.

Given the physical findings, leukocytosis, and mild elevation of transaminases, you conclude that this patient has cholecystitis.

Question 22.10.6 Which of the following should NOT be considered in the management of this disease?

A) Initial treatment includes hospitalization with IV fluid resuscitation

B) Select an antibiotic regimen to include a third-generation cephalosporin ± metronidazole, piperacillin/tazobactam (Zosyn), or fluoroquinolone + metronidazole

C) Choose a narrow-spectrum antibiotic to treat enterococcus (e.g., vancomycin)

D) If early cholecystectomy is not chosen as treatment, it should be performed late (at least 6 weeks after diagnosis)

Answer 22.10.6 The correct answer is "C." This answer is incorrect for two reasons. First, just over 50% of episodes of cholecystitis are sterile; as a matter of course they are treated with antibiotics because of our inability to determine which are infected. Second, while enterococcus is frequently encountered, it is rarely a solitary pathogen and does not require specific targeted antimicrobial therapy. The initial treatment of cholecystitis includes hospitalization, broad-spectrum IV antibiotics, and IV fluid resuscitation. Definitive therapy for cholecystitis is cholecystectomy. Controversy surrounds whether cholecystectomy should be performed acutely or be delayed. Generally, shorter hospitalizations and better outcomes are found with early cholecystectomy.

Objectives: Did you learn to…

• Identify risk factors for gallstones?

• Recognize complications of gallbladder disease?

• Manage a patient with symptomatic gallstones and cholecystitis?

A 28-year-old male who was the restrained front passenger of a vehicle traveling in excess of 60 mph is brought to the ED via ambulance. The driver of the vehicle was found dead at the scene. Ambulance personnel report it took 5 to 10 minutes to extricate the patient. On arrival, he is mumbling incoherently. He is initially able to give his name, but he is slurring his words. He denies any medical problems, medications, or allergies. Vitals signs include temperature 35.5°C, pulse 148 bpm, respirations 35 bpm, blood pressure 65/30 mm Hg, and oxygen saturation 81% on 100% oxygen by facemask. On examination, he is in severe respiratory distress. Lung sounds are absent on the right and diminished on the left. Heart sounds are muffled. You determine that this patient needs immediate treatment of a pneumothorax.

Question 22.11.1 Which of the following is most appropriate at this time?

A) Perform needle decompression on the left

B) Perform needle decompression on the right

C) Place a chest tube on the left

D) Place a chest tube on the right

E) Perform a chest radiograph and act on the basis of the results

Answer 22.11.1 The correct answer is "B." The combination of hypotension, hypoxia, and absent breath sounds suggests a tension pneumothorax. Immediate decompression of the affected hemithorax should be performed by placing a large-bore (14- or 16-gauge) needle through the chest wall to relieve intrathoracic pressure. Per Advanced Trauma Life Support guidelines, the correct placement is in the second intercostal space at the mid-clavicular line. However, due to risk of mediastinal vascular injuries, some experts recommend placing the needle in the traditional location for chest tube—that is the fifth or sixth intercostal spaces at the mid-axillary line. Either site is acceptable if the pleural space can be reached (it may be more difficult in the midaxillary line given increased subcutaneous tissue). Of particular note is "E." If tension pneumothorax is suspected, you should never wait for confirmation of the diagnosis by a chest radiograph. It is a true emergency that requires treatment on the basis of clinical examination.

His vital signs and oxygen saturation improve with needle decompression. You place a chest tube and give boluses of normal saline through two peripheral IVs. Then, the patient is placed in external fixation device for his femur fracture. Operating room fixation is deferred secondary to unstable medical status. He is ultimately intubated for continued increased work of breathing. He is admitted to the intensive care unit (ICU) on a ventilator with a cervical collar following negative FAST examination (focused assessment with sonography for trauma—a sonographic evaluation to rule out fluid in perihepatic, perisplenic, pelvic, and pericardial spaces).

Repeat chest x-ray in the ICU shows the endotracheal (ET) tube and chest tube in appropriate positions. Several rib fractures are noted. There are "fluffy infiltrates" in the left chest that were not present on initial trauma chest series.

Question 22.11.2 Which of the following is true of pulmonary contusions?

A) They occur in less than 25% of patients with significant blunt trauma to the chest

B) Treatment includes aggressive IV steroid and fluid administration

C) The condition starts to resolve in 48 to 72 hours

D) Treatment includes appropriate antibiotics

Answer 22.11.2 The correct answer is "C." Pulmonary contusions begin to resolve in 48 to 72 hours. However, 2 to 3 weeks may be required for complete resolution. "A" is incorrect. Pulmonary contusions occur in up to 70% of trauma patients with significant blunt chest trauma. It is usually, but not always, associated with fractured ribs. There may also be a flail segment noted. Chest x-ray changes are usually evident within 1 hour post-trauma but may not appear for up to 6 to 7 hours. Pulmonary contusions result in a ventilation–perfusion mismatch, hypoxemia, and an increased A-a gradient. If a patient is able to maintain oxygenation and ventilation, intubation is not required. "B" and "D" are incorrect. Treatment currently only involves intubation as necessary, observation, and tincture of time.

You elect to proceed with pulmonary artery catheter placement due to the severity of this patient's condition. Overnight, he begins to decompensate. The nurse pages you with his vital signs and Swan–Ganz readings: temperature 37.0°C, pulse 100 bpm, respirations 20 bpm (ventilator set at 14 bpm), blood pressure 82/30 mm Hg, PCWP 24 mm Hg (normal 5–15), cardiac index 2.0 L/min/m² (normal 2.5–3.5), systemic vascular resistance 2,000 dyne-sec/cm² (normal 1,000–1,500), and oxygen delivery of 700 mL/min (normal 900–1,200).

Question 22.11.3 What is the cause of shock at this time?

A) Hypovolemic shock

B) Neurogenic shock

C) Cardiogenic shock

D) Septic shock

Answer 22.11.3 The correct answer is "C." This patient appears to be in cardiogenic shock (elevated pulmonary capillary wedge pressure, decreased cardiac index). Cardiogenic shock may be caused by myocardial failure, valve failure, dysrhythmias, and tamponade. Treatment is directed at the underlying disorder. See Table 22-5 for more on the categories of shock.

Part of the injuries sustained by this patient includes burns to the abdomen and back.

Question 22.11.4 Which of the following is FALSE regarding burn wound management in general?

A) The Parkland formula for fluid resuscitation calls for 2 to 4 mL/kg/% body surface area burned with half of the volume in the first 8 hours and the other half over the next 16 hours

B) Escharotomy should be performed on all partial-thickness burns

C) Patients with chemical burns should be treated first with tap water irrigation

D) Prevention of wound infection via topical antimicrobial agents, such as silver sulfadiazine cream, or via silver-coated dressings is the standard of care

Answer 22.11.4 The correct answer is "B." Any time you see "all," it is probably the wrong answer. Escharotomy is not necessary unless there is a full-thickness wound that is circumferential and compromising vascular supply. The thinking about this is changing and some suggest escharotomy of all full-thickness burns. "A" is a correct statement about the Parkland formula. "C" is also correct with the addendum that any particulate matter should be brushed off prior to irrigation. Water may activate some substances such as sodium hydroxide. "D" is also a correct statement although thinking is changing. Silver delays wound healing and bacitracin is being used with increasing frequency.

Question 22.11.5 Which of the following is TRUE regarding fluid administration in burn and dehydrated patients?

A) A peripheral line will deliver fluid more rapidly than a central line of an equivalent gauge

B) Albumin is the fluid of choice in the treatment of burns and should be considered for all patients with significant fluid deficits

C) D5W-½ NS (D5W-0.45%NS) is the preferred fluid for resuscitation in all nonburn patients

D) All of the above are true

Answer 22.11.5 The correct answer is "A." A peripheral line will deliver fluid more rapidly than a central line of an equivalent gauge, according to Poiseuille's law (flow is directly proportional to tube radius and inversely proportional to tube length). The shorter the catheter, the more quickly fluid is delivered (think of a short traffic jam as opposed to a longer one on the same sized road). The largest port on a traditional triple lumen catheter will give the same flow rates as a 20 gauge peripheral IV. Consider a "cordis" catheter if placing a central line in a patient who may also require rapid fluid resuscitation. This is a larger diameter, shorter central line. "B" is incorrect. Albumin is not helpful and may increase adverse outcomes in trauma. "C" is also incorrect. Normal saline (0.9% NS), or Lactated Ringer's if you are a surgeon, are the fluids of choice for resuscitation. Remember that Lactated Ringer's is actually slightly hypotonic and thus may worsen cerebral edema. There is no evidence favoring Lactated Ringer's over normal saline.

Objectives: Did you learn to…

• Approach a trauma patient with an understanding of advanced trauma life support principles?

• Identify and manage a patient with a tension pneumothorax?

• Describe various types of shock and how they are differentiated?

• Treat a patient in shock?

• Manage a patient with significant burns?