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Author34 Posts
  #21

Tuscani wrote:
where is this question from?


A similar case is found in UW...



Edited by romano on Aug 24, 2008 - 9:51 PM



  #22

It is A

because the patient doesnot have clear and definite symptoms of peritonitis to go streightly for laparatomy , Just mild distention of abdomen without tenderness , so DPL is the best choice for unstable patient and CT for stable one.



  #23

A

what would happens if you don't find anything with laparotomy? stuck

a simple procedure to be precise in treating such an emergent condition is required

-t


  #24

he can be bleeding from scalp laceration

ans: DPL


  #25

read surical vignette carefully



  #26

i vote for A
because a is for alaska and sara palin
not only that: why is the blood not causing peritoneal signs?

also ans can be Ct if they have a CT in the emergency room


  #27

C right answer


  #28

:nogrinPL and sonography are done quickly in OR or ER....they ll tell if its bleeding in abd or not then laparotomy shud b done ...kaplan page 7 surgey ...and also there are no signs of rib fracture given to suspect spleen rupture...


  #29

what if A is changed to U/S, should we go for U/S to see if there is intra-abd bleeding first?


  #30

Interesting case;
In fact the main two things that should be done in this case are both clinical. In the instance of trauma and cardiovascular collapse, 3 main bleeding reservoirs should be suspected: 1-Thorax, 2-Abdomen, 3-Pelvis. The question stem rules out thorax since the JVD is 0 (rules out cardiac tamponade, tension pneumothorax, fat/thrombus emboli) and the CXR is normal (rules out hemothorax, pneumothorax, wide mediastinium due to aortic rupture). Abdominal examination reveals distension but not tenderness. This is a big suspect, the patient is collapsing.

To rule out pelvis hemorrhage a single manuever must me done as described in (J Am Coll Surg. 2002 Feb;194(2):121-5; The utility of clinical examination in screening for pelvic fractures in blunt trauma. by Gonzalez RP, Fried PQ, Bukhalo M. - a bit more information in my journal. And it involves exercising some pressure on the pelvis to elicit pain, just like you would do to your car before a long trip to test the tires. Additionally from the stem we learn that the pelvis and limb X-rays are normal.

Since there was positive findings in the abdomen and thorax & pelvis have been ruled out, no further testing is necessary and since the patient is in hypovolemic shock hemorrhage has to be stopped.

Possibly if U/S is available would be the first thing to be done before X-rays and get a quick view of everything. I kind of remember hearing about using it on the chest too. Don't recall the source though.


  #31

Definetely C


  #32

Indications for diagnostic peritoneal lavage include:
• Unexplained abdominal pain
• Trauma of the lower part of the chest
• Hypotension, systolic 90 mmHg, haematocrit fall with no obvious explanation
• Any patient suffering abdominal trauma and who has an altered mental state (drugs, alcohol, brain injury)
• Patient with abdominal trauma and spinal cord injuries
• Pelvic fractures.

We have 3 choices in determining the presence of intraperitoneal hemorrhage whether from a blunt trauma or penetrating injuries, the DPL, FAST, and helical CT scan.. BEcause our patient is hemodynamically unstable, CT scan is not possible. DPL is less frequently use now because of the availability of FAST, but in this case FAST is not among the choices, so i think the best next step is to do DPL.


  #33

Here is the link for the algorithm for blunt trauma

www.ncbi.nlm.nih.gov/pmc/ar...cles/PMC2663535/figure/F6/




  #34

abdominal trauma & hemodynamically unstable... go to OR and do exploratory lap.





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