Help with a USMLE world Q...

[RussianJoo]

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I keep getting this wrong.... so what am i thinking wrong here..

abdominal trauma post MVA the dude is unstable bp 80/50, HR 120, resps 16..

His neck veins are flat, lungs are clear with positive breath sounds. he has bruises over his abdomen an positive peritoneal signs. ABCs are done, IVF are started. What do you do next?

A) Diagnostic Peritoneal Lavage
B) Ex-Lap
C)Chest X-Ray
D) Abdominal CT

I answered Diagnostic Peritoneal Lavage. and it was wrong.. UW says the dude is not stable, and obviously bleeding into the abdomen so go in there and fix it. the DPL is not needed...

So then I do another set of Q's the same type of Q comes up and I answer Ex-Lap.. Bam wrong again.. now they say you need to check for abdominal bleeding before cutting him open.. what the f uck... i am so frustrated i want to throw my computer against the wall... and my exam is in a little over a week.

I tried following this dudes algorithm and it makes sense, and I know it so why do I keep getting these q's wrong?
[YOUTUBE]http://www.youtube.com/watch?v=-LEjdH9-9WY&feature=channel_page[/YOUTUBE]

 

[bbpiano1]

In the first example, I would agree. Ex-lap because you already know something has gone awry in the abdomen. Maybe in the second question the patient didn't have peritoneal signs???

 

[jtre506]

Exploratory Lap is indicated in
-Gunshot wounds to the abdomen
-Stab Wounds the penetrate the abdomen
-Any truama where the patient develpoes an acute abdomen
-Also in signs of internal bleeding. which include fast thready pulse low CVP ect...

If the patient does not present with any of these DPL is indicated
Hope this helps.
Good luck

 

[RussianJoo]

thanks for the help.

 

[medInUSA]

Just had this exam same question on Uworld and also got it wrong.


So jtre506 are you saying that if the patient is hemodynamicaly unstable after a blunt ab trauma we would go to Exp lap and not do DPL?

in that case the youtube video that RussianJoo linked to is wrong since it says to do DPL in cases of hemodynamic instability after blunt ab trauma.

 

[RussianJoo]

I think if it's obvious the dude is bleeding into the abdoman and no other place like the chest or pelvis and is unstable you do ex-lap. if it's not obvious and the dude is unstable you do a FAST U/S or DPL. if they're stable you do a CT-scan.

 

[docmd2010]

i think the key here is that he has positive peritoneal signs. regardless of the fact that the IV fluid challenge may/may not stabilize this patient, positive peritoneal signs indicates hollow viscous perforation and/or a ruptured vessel, an absolute indication to go to the OR right away. in a similar case however, when peritoneal signs would not be present, if the iv fluids stabilize the vitals, then do you do you CT? or dpl? or fast?, what if the iv fluids do not stabilize the vitals? ex lap?

 

[RussianJoo]

i think the key here is that he has positive peritoneal signs. regardless of the fact that the IV fluid challenge may/may not stabilize this patient, positive peritoneal signs indicates hollow viscous perforation and/or a ruptured vessel, an absolute indication to go to the OR right away. in a similar case however, when peritoneal signs would not be present, if the iv fluids stabilize the vitals, then do you do you CT? or dpl? or fast?, what if the iv fluids do not stabilize the vitals? ex lap?

if iv fluids stabalize the vitals then the pt is stable so you do a CT, if they don't you do a FAST U/S or DPL.