Question about trauma from USMLEW

[shwtime11]

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I had two questions today from USMLE World with trauma patients and they had two different answers so I want to see the consensus.

1) MVA pt with BP of 70/0, Pulse is 150, JVP is 0. Mild Distended abdomen. CXR, Pelvic X-ray, and X-ray of extremeties are clear. Rapid IV bolus is given with no response and pt is still hypotensive. What is the next step?
Answer--> DPL because she has intra abdominal bleed

2) MVA pt with BP of 80/0, Pulse is 140, and low JVP. Abd is distended with a bruise. She is intubated and given 2L of lactated Ringer's and her pressure is 72/0. What is the next step?
Answer--> Ex-Lap because of suspected Intra-abdominal bleed

I'm sorry, but in my mind both patients are unstable with intra-abdominal bleeds and they both would go right to the Operating Room with those signs. Can't figure out why they wanted to DPL the first patient. Is anyone else frustrated by how inconsistent the answers are in USMLE World?

 

[ozzie20]

I had two questions today from USMLE World with trauma patients and they had two different answers so I want to see the consensus.

1) MVA pt with BP of 70/0, Pulse is 150, JVP is 0. Mild Distended abdomen. CXR, Pelvic X-ray, and X-ray of extremeties are clear. Rapid IV bolus is given with no response and pt is still hypotensive. What is the next step?
Answer--> DPL because she has intra abdominal bleed

2) MVA pt with BP of 80/0, Pulse is 140, and low JVP. Abd is distended with a bruise. She is intubated and given 2L of lactated Ringer's and her pressure is 72/0. What is the next step?
Answer--> Ex-Lap because of suspected Intra-abdominal bleed

I'm sorry, but in my mind both patients are unstable with intra-abdominal bleeds and they both would go right to the Operating Room with those signs. Can't figure out why they wanted to DPL the first patient. Is anyone else frustrated by how inconsistent the answers are in USMLE World?

In both cases, the next best step is always to stop the bleeding, and to stop it you must do surgery, I would agree with you on this one. The only thing i can think of is that they might have misprinted the vitals on the first one and want you to realize that before going into surgery on a stable patient you have to do a DPL to rule in abdominal origin of the bleed, but other than that i don't know.

edit- i just happened to come across the first vignette, i still have to agree this is an emergency, and i'd probably go to laparotomy, but there was also no signs of peritoneal irritation, which makes it difficult to assume for certain that the blood loss is from the abdomen (could still be from the pelvis, or legs). Hence why DPL is the best bet. But i still have to say that the severity of the vital signs make this a poor test question.

 

[persia]

Sometimes I have read their answers and felt like they must be wrong. Then I look it up in my big clinical reference book, and sure enough there it is. Something that is not necessarily done in everyday clinical medicine but according to the book, is first line recommendation. I keep wanting the get the definitive answer for everything and sometimes it seems more gestalt. As for the DPL, I have read and been told that it is pretty much a non-used test because it is not diagnostic and it could easily miss the real problem. It might once have been the gold standard but now it is seen as a less reliable test.

I have had some trouble with level of pickiness of UW, and I am trying to just accept what they say, confirm it and move on.

 

[Jatpot]

I had the exact same problem with the mva BP 70/0 question. So much so that I asked my surgical mentor (head of trauma for my area health service) and she said absolutly you would go to the OR in that scenario. I want to be a trauma surgeon, so I found I was overthinking a lot of the surgery/trauma questions, but I thought that question was obvious...why would you do a DPL...if it's negative you'll do an exp. lap. and if it's positive...you'll do an exp lap to find the source. So a DPL doesn't change your management, but certainly wastes time. That was my logic anyway.


I told myself that for the purpose of Step 2, I guess I'll put DPL (kind of like putting dark field microscopy although I dont know if anyone actually does it in practice). However, if it makes you feel better, I just took the exam last week and I found the trauma questions (and most questions in general) far more straightforward and I didn't have to guess which of two answers was what they wanted me to say vs what was correct in practice. Good luck.

 

[cbdoctor]

I took the test yesterday, and I also did NOT have a trauma question with vague answers.

When I was doing UW, I also struggled with these questions--DPL vs exp lap.

I will post a more thorough exam experience when I have the chance.

 

[tedstriker]

Hey cbdoctah, any news? We'd be grateful for your words of guidance and wisdom 😉

 

[BklynWill]

We did a DPL just two days ago, so yes it is still done in practice. Our reasoning was that the pt was unresponsive to our fluid challenge and could not respond to an abdominal exam, in addition to the complete lack of objective signs indicating blood in the abdomen. DPL is used to search for a bleeding site, although some would argue that a FAST scan should be used on the abdomen.

The questions you present are definitely ambiguous, but if I were forced to identify a defining difference, it's that the second pt shows objective evidence of blunt abdominal trauma. The first pt may have a partially transected aorta and ascites, therefore requiring further work-up before laparotomy.