General Surgery Sample Questions - Book 1 2006
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QUESTION

19.        A 55-year-old HIV+ male presents to the Emergency Department complaining of dysphagia, fever, and increasing left side neck swelling for 5 days.

Upon examination you notice the patient has swelling, cellulitis, tenderness of left side of neck and trismus. CT scan reveals an abscess in the deep neck space.

What is your preferred approach?

A. Broad spectrum antibiotics ( non operative treatment)
B. Incision and drainage under local anesthesia and sending the specimen for culture and     sensitivity to start appropriate antibiotic
C. Oro-tracheal intubation and incision and drainage in OR
D. Tracheostomy under local anesthesia and  wide surgical drainage in OR
E. Rapid sequence intubation in ER and transfer the patient to OR for surgical drainage

ANSWER

19.                   D          Tracheostomy under local anesthesia and wide surgical drainage in OR

The advent of antibiotics has significantly decreased the incidence and mortality rate of deep neck infections. Despite this progress, deep neck infections remain life-threatening conditions and demand prompt diagnosis and treatment. In the years before antibiotics, 70% of deep neck infections resulted from direct spread of localized abscesses from the pharyngeal-tonsillar areas. Consequently, the Para pharyngeal space was the most frequently involved space in deep neck infections. An increasing percentage of currently treated infections, however, are of dental and salivary gland origin, which results in sub maxillary space abscesses. Any patient with a recent history of tonsillitis, pharyngitis, an odontogenic infection, or recent dental work with onset of neck swelling and pain must be assumed to have a deep neck infection until proven otherwise. Other common findings include odynophagia, trismus, and respiratory compromise. If the diagnosis is suspected, a high-resolution CT scan must be obtained to confirm the diagnosis.

The first step in caring for these patients is securing and maintaining an adequate airway. If intubation is not possible because of airway edema or trismus, a tracheotomy under local anesthesia must be performed, remembering that the trachea may be deviated because of the inflammation. Wide surgical drainage of the entire involved space is the required treatment for the abscess itself. After surgery, the patient is treated with intravenous ampicillin/sulbactam therapy or clindamycin with a third-generation cephalosporin.

1. Surgery: Scientific Principles and Practice, 3rd Edition. Edited by Greenfield LJ, Mulholland MW, Oldham KT, Zelenock GB, Lillemoe KD. Philadelphia, Lippincott Williams & Wilkins, 2001:648.

QUESTION

125.      A 27-year-old male presents to the Emergency Department after a single stab wound to the midline of the anterior neck in zone 2. 

The patient’s vital signs are stable and on physical examination, cervical crepitus is palpated and oozing of blood is noted from the 1 cm laceration.  Auscultation of the chest reveals a mediastinal crunching sound.  A portable chest x-ray is obtained. 

Which of the following is CORRECT concerning this injury?

A. The injury most likely only involves the trachea as the esophagus is well protected by      the trachea
B. Primary repair is contraindicated due to risk of mediastinitis
C. Although penetrating injuries to the esophagus are more common, blunt injury can result     from increased intraluminal pressure against a closed glottis
D. Contrast esophagraphy is absolutely contraindicated prior to a complete evaluation of      the esophagus with esophagoscopy
E. Clinical signs or symptoms are present in 25% of cases with cervical esophageal injuries

ANSWER

125.                 C         Although penetrating injuries to the esophagus are more common, blunt injury can result from increased intraluminal pressure against a closed glottis.

Perforation of the esophagus can be one of the most lethal injuries of any site in the gastrointestinal tract.  Several factors account for the complexity of diagnosis and the challenge of therapy.  These include a segmental blood supply with little collateralization, lack of a serosal covering, surrounding loose areolar tissue and the prevertebral and paraesophageal planes communicating freely with the mediastinum.  Other important factors include relative lack of protection of the esophagus and trachea as well as the intimate contact between the membranous portions of the trachea with the esophagus.  The majority of injuries result from penetrating trauma to the cervical area.  Blunt trauma is uncommon but may result from increased intraluminal pressures against a closed glottis.  Clinical signs or symptoms are present in 60-80% of cases and include odynophagia, dysphagia, hematemesis, oropharyngeal blood, cervical crepitus, dyspnea, pain in the neck or chest, hoarseness, cough, stridor, and mediastinal crunching sounds (Hamman’s sign).  Evaluation begins in the stable patient with radiographs of the neck and chest and will be abnormal in 82% of cases.  X-ray may demonstrate pneumothorax, hydrothorax, pneumomediastinum, widened mediastinum and retropharyngeal or subcutaneous cervical air.  Further evaluation of the esophagus requires contrast esophagraphy.  This is performed in two steps, first with a water soluble agent, followed with barium.  Esophagoscopy may be employed but is very user dependant and may actually result in further esophageal injury.  Many injuries to the cervical esophagus can be directly repaired with sutures, preferably 2 layer sutures.  More complex injury may require resection and/or debridement and concominent repair of the trachea.  Prophylactic antibiotic therapy against skin flora is initiated at the time of diagnosis. 

A closed drain is placed and it is advised to cover the repair with vascularized tissue (sternohyoid, sternothyroid, sternocleidomastoid muscle).  Injury to the thoracic esophagus is frequently associated with injury to the surrounding structures which take priority in repair.  Surgical repair of the esophagus entails local debridement, wide drainage, primary repair of the perforation and buttressing with a tissue flap.  Primary repair can usually be performed within 24 hours of injury.  As time progresses, mediastinal and pleural inflammation increase making primary repair dangerous.  If primary repair is not feasible, several techniques exist and include esophageal diversion, total esophageal exclusion, esophagectomy, and t-tube drainage.  The majority of experience with delayed repair exists secondary to non-traumatic injury and because there is no underlying esophageal or gastric pathology or forceful distribution of mediastinal sepsis, delayed presentation following trauma is much more likely to respond to wide local drainage and creation of a controlled fistula without resection, diversion or replacement of the esophagus.
 
1. Moore EE, Mattox K, Feliciano D. Trauma Manual, Edited by Noujaim SR, Strauss M, Brown RY. New York, McGraw-Hill Professional, 2003:178-181.

QUESTION

56.        A 15-year-old male presents to the Emergency Department after sustaining blunt trauma to the chest as well as a single stab wound 1 cm left of the sternum in the 6th intercostal space. As per EMS, the patient’s vital signs were stable in the field and on transport. 

On presentation, the patient’s vital signs reveal a blood pressure of 80/40 and a heart rate of 120. The patient is anxious and physical exam reveals distended jugular veins and muffled heart sounds. 

Which of the following is CORRECT in the management of this patient?

A. Obtains a chest x-ray and intubate the patient with an endotracheal tube if a      pneumothorax is noted
B. Perform an Emergency Department ultrasound examination (FAST) and take the patient to the OR if the FAST is (+)
C. Insert a left sided chest tube and perform a CT scan of the chest
D. Intubate the patient with an endotracheal tube and insert a left sided chest tube
E. Needle decompress the left hemithorax and then place a chest tube

ANSWER

56.                   B          Perform an Emergency Department ultrasound examination (FAST) and take the patient to the OR if the FAST is (+)

Penetrating cardiac injuries can be caused by knifes, guns, fractured ribs or sternum as well as by iatrogenic means such as central line placement, intracardiac injections or cardiac catheterizations.  The right ventricle is at the greatest risk of involvement.  80-90% of stab wounds present with cardiac tamponade.  Gun shot wounds often result in extensive hemorrhage.  Chest radiographs may be misleading in the evaluation of suspected penetrating cardiac injury.  The most helpful finding in a patient with a penetrating wound to the precordium, superior mediastinum or epigastric area is hemodynamic instability.  Pericardiocentesis has no role in the evaluation of a suspected penetrating cardiac injury.  FAST (focused abdominal sonography for trauma) is currently the most widely used study to evaluate the pericardium which has a sensitivity of 100% and a specificity of 97.3%.  A patient with a positive FAST (pericardial fluid) should be taken emergently to the OR for sternotomy or thoracotomy.  Hemodynamic instability is an indication for Emergency Department thoracotomy.  Stab wounds are associated with 97% survival while gun shot wounds are associated with 71% survival with patients that present with vital signs.  Patients who present without vital signs had only a 2% survival.  Blunt trauma to the heart ranges from minimal injury (cardiac contusion) to frank rupture.  Blunt trauma may result in valve injury; aortic, mitral and tricuspid in decreasing order of prevalence, as well as septal injury/rupture, papillary muscle, chordae tendinae and coronary vessels.

1. Moore EE, Mattox K, Feliciano D. Trauma Manual, Edited by Noujaim SR, Strauss M, Brown RY. New York, McGraw-Hill Professional, 2003:195-200.

QUESTION

205.      All of the following are TRUE of wound dressings in burn patients EXCEPT:

A. Sulfamyolon is a potent inhibitor of Carbonic Anhydrase and therefore may induce
    acid- base derangements
B. Application of Silvadene may cause severe pain
C. Povidone-Iodine (Betadine) can cause excessive drying of the Eschar
D. Bacitracin has no anti-fungal properties
E. Sulfamyolon actively penetrates through the Eschar

ANSWER

205.                 B          Application of Silvadene may cause severe pain

Sodium mafenide (Sulfamyolon) is a topically applied cream that is very effective in penetrating eschars, has a broad spectrum coverage of Gram-positive, Gram-negatives, anaerobes and has some anti-fungal properties as well. It is a potent inhibitor of Carbonic Anhydrase and can lead to acid-base derangements. Acidosis may rapidly develop in a patient with pulmonary dysfunction. Other disadvantages include pain on application.

Silver sulfadiazine (Silvadene) is associated with fewer disadvantages. It has essentially the same bacterial spectrum as Sulfamyolon, but does not cause pain.

Bacitracin and gentamicin do not have anti-fungal properties and long term usage on open wounds can result in fungal growth.

Povidone-iodine is effective against wide range of Gram-positives, Gram-negatives and fungi. It results in desiccation of the eschar resulting in difficulty with mobility. It can also cause pain on application. These agents do not sterilize the wound, but only suppress the bacterial population. The agents are effective in preventing bacterial conversion of second degree burns to full thickness burns, thus reducing the amount of skin grafting.

1. Demling RH. Burn Care in the Immediate Resuscitation Period, ACS Surgery, Principles and Practice. New York, WebMD Professional Publishing.2004:1000.

QUESTION

172.      The distraught mother of a 3-week-old male born at 30 weeks gestation presents to the Emergency Department stating that she noticed the baby’s abdomen becoming larger and that the baby has begun vomiting his formula. She also states that this morning she noted blood in the baby’s diaper.

Patient’s exam shows a lethargic, 1500 gm baby with HR 80, BP 80/30, markedly distended abdomen with hypoactive bowel sounds, and (+) gross blood on rectal exam. AXR is done and shows several air fluid levels with distended large bowel that has air within the walls in all four quadrants. 

Proper management of this patient should be to:

A. Recommend changing baby’s formula and discharge patient home
B. Insert a nasogastric tube for decompression, IV fluids initiation of broad-spectrum      antibiotics, serial abdominal x-rays and observe
C. Insert a nasogastric tube, IV fluids resuscitation, initiation of broad-spectrum      antibiotics, serial abdominal x-rays, placement of a peritoneal drain and observe
D. Insert a nasogastric tube, IV Fluid resuscitation, initiation of broad-spectrum antibiotics      and emergent laparotomy
E. None of the above

 ANSWER

172.                 D         
Insert a nasogastric tube, IV Fluid resuscitation, initiation of broad-spectrum antibiotics and emergent laparotomy

The patient described above has necrotizing entercolitis (NEC).  NEC is the most common gastrointestinal emergency in the neonatal population. NEC is a disease that primarily affects premature neonates in the 2-3 week of life.  Though no clear etiology is known, there has been a linkage to premature neonates with premature bowel that are more susceptible to bacterial translocation. In fact, positive blood cultures are found in 30% of patients with NEC with the most commonly identified organisms being Escherichia coli and Klebsiella pneumoniae.

The clinical presentation of NEC includes a history of vomiting, diarrhea, feeding intolerance and high gastric residuals following feedings. The Bell staging system is used to determine the management of patients with NEC. In Bell I, there is one or more historical factor(s) related to perinatal stress; there are systemic manifestations, including temperature instability, lethargy, apnea, and bradycardia; the GI symptoms include poor feeding, increasing prelavage residuals, emesis (may be bilious or test positive for occult blood), mild abdominal distension, and occult blood in stool; and the abdominal radiographs demonstrating distension with mild ileus. In Bell II, there are signs and symptoms of stage I plus persistent occult or gross GI bleeding; marked abdominal distension; and an abdominal radiograph showing intestinal distension with ileus, small-bowel separation (edema in bowel wall or peritoneal fluid), unchanging or persistent rigid fixed bowel loops, pneumatosis intestinalis, or portal-vein gas. In Bell III, one sees signs and symptoms of stage II plus deterioration of vital signs with hypotension, bradycardia, and apnea with evidence of septic shock or marked GI hemorrhage; or radiographic findings of stage II plus pneumoperitoneum. In Bell I or II, supportive care with no food or water by mouth (NPO), nasogastric tube decompression, adequate intravenous hydration, antibiotics for 7 to 14 days, serial abdominal radiographs and observation are sufficient. Patients with Bell III disease require an emergent laparotomy because there is evidence of necrotic intestine. While the most compelling predictor of intestinal necrosis indicating a need for operative intervention is pneumoperitoneum, unstable vital signs, distended abdomen with palpable mass, and abdominal radiograph with portal vein gas or pneumatosis intestinalis in four quadrants are sufficient evidence to warrant laparotomy. It is important to note that severe pneumatosis in all 4 quadrants is a fair indicator for lapartomy, but pneumatosis alone is not because more than 50% of infants with NEC and pneumatosis can be successfully treated with nonoperative treatment. Many consider a formal laparotomy a relative contraindication in critically ill newborns. Although a temporizing measure, these extremely ill infants occasionally recover with a peritoneal drain placement alone and do not require exploratory laparotomy. Nonetheless, peritoneal drain placement may be the treatment of choice for extremely small (<600 g) premature newborns.

1. Surgery: Scientific Principles and Practice, 4th Edition. Edited by Mulholland MW, Lillemore KD, Doherty GM, Maier RV, Upchurch GR. Philadelphia, Lippincott Williams & Wilkins, 2005:1895-1898.

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