Surgery Question

[PrussianBlue1]

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Person with gunshot wound above the pubis (presumably injuring the bladder), what is the next step?

1) Diagnostic Study?

2) or Surgery?


The Pestana Review doesn't seems to clear this up. Since it is technically a gunshot wound to the abdomen I tend to think surgery. But at the same time since with urethral injury we do urethrogram, and we also have the equivalent cystogram, then what is the correct way to go in a case like this?

 

[Instatewaiter]

Now I could be wrong on this but:

Penetrating wounds get an ex-lap. So GSW--> surgery if between nipples and pubis.

The urethral injuries c blood in the meatus are often blunt trauma so the indication for emergency surgery isnt there and you need to figure out where the blood is coming from.

 

[Winged Scapula]

Person with gunshot wound above the pubis (presumably injuring the bladder), what is the next step?

1) Diagnostic Study?

2) or Surgery?


The Pestana Review doesn't seems to clear this up. Since it is technically a gunshot wound to the abdomen I tend to think surgery. But at the same time since with urethral injury we do urethrogram, and we also have the equivalent cystogram, then what is the correct way to go in a case like this?

You haven't given us enough data.

To make it simple, simply ask, :"stable or unstable?"

An unstable patient belongs in the OR. Patients tend to die on the CT scanner. You can take the unstable patient with penetrating abdominal trauma to the OR, and if you suspect ureteral injury (which is more important and harder to see than a bladder injury), perform a 1 shot IVP either on the table or while in the trauma bay while getting ready to go to the OR.

The stable patient has time for imaging, if you feel you need it. A CT scan would not be inappropriate in the setting of a stable patient with a GSW to the abdomen. Since a GSW to the belly has lots of potential complications (ie, is unlikely to only injure the bladder) a CT scan can give you lots of info about the bullet path through the viscera.

The most common bladder injury question on any surgery board exam is for blunt injury with either intraperitoneal vs extraperitoneal rupture.

 

[SLUser11]

You haven't given us enough data.

To make it simple, simply ask, :"stable or unstable?"

An unstable patient belongs in the OR. Patients tend to die on the CT scanner. You can take the unstable patient with penetrating abdominal trauma to the OR, and if you suspect ureteral injury (which is more important and harder to see than a bladder injury), perform a 1 shot IVP either on the table or while in the trauma bay while getting ready to go to the OR.

The stable patient has time for imaging, if you feel you need it. A CT scan would not be inappropriate in the setting of a stable patient with a GSW to the abdomen. Since a GSW to the belly has lots of potential complications (ie, is unlikely to only injure the bladder) a CT scan can give you lots of info about the bullet path through the viscera.

The most common bladder injury question on any surgery board exam is for blunt injury with either intraperitoneal vs extraperitoneal rupture.

Still....for the purpose of this NBME shelf exam.....the answer is emergent laparotomy.

Obviously, from our perspective there are a few variables that need to be considered.



To MS3s: For the Surgery shelf, anytime you have an abdominal trauma patient that is unstable (regardless of blunt vs. penetrating), the answer is go to the OR. Anytime you have a GSW to the abdomen, the answer is go to the OR. When a patient has blunt abdominal trauma and is stable, you go to the CT scanner.


Now, Stab wounds are a whole different beast, and many people (including big names in the field) advocate serial exams for stable patients. I'm not sure where the NBME shelf exam is on this issue, so I have no advice.

 

[smq123]

Now, Stab wounds are a whole different beast, and many people (including big names in the field) advocate serial exams for stable patients. I'm not sure where the NBME shelf exam is on this issue, so I have no advice.

From what I remember, there wasn't much about stab wounds on either the shelf or Step 2. If you get a patient with a stab wound on the exam, it's likely to be something REALLY obvious - i.e. multiple abdominal stab wounds with a pulse of 140 and a bp of 60/20, or a chest stab wound with increasingly noisy respiratory difficulty, etc.

 

[Winged Scapula]

Still....for the purpose of this NBME shelf exam.....the answer is emergent laparotomy.

Obviously, from our perspective there are a few variables that need to be considered.



To MS3s: For the Surgery shelf, anytime you have an abdominal trauma patient that is unstable (regardless of blunt vs. penetrating), the answer is go to the OR. Anytime you have a GSW to the abdomen, the answer is go to the OR. When a patient has blunt abdominal trauma and is stable, you go to the CT scanner.


Now, Stab wounds are a whole different beast, and many people (including big names in the field) advocate serial exams for stable patients. I'm not sure where the NBME shelf exam is on this issue, so I have no advice.

You're right...I was thinking "real world" rather than the Surgery Shelf exam. As smq notes, it will be really obvious on the Shelf and they are likely (if presenting any stab wound) to have the patient be unstable with a penetrating injury.

Given the proclivity of the boards to be several years behind current management (for example, they asked, for the FIRST TIME EVER, about laparoscopic hernia repair on the September 2008 oral boards, even though its been common practice for years), I cannot imagine serial examination being an option (even though I haved personally done it in a stable patient).

 

[PeepshowJohnny]

The stable patient has time for imaging, if you feel you need it. A CT scan would not be inappropriate in the setting of a stable patient with a GSW to the abdomen. Since a GSW to the belly has lots of potential complications (ie, is unlikely to only injure the bladder) a CT scan can give you lots of info about the bullet path through the viscera.

Very good point here. As an MS3 on trauma I was a bit dissapointed when our first GSW to the belly wasn't an immediate "Get this man to the OR!" situation. The residents on were kind enough to explain the difference between "real world" management vs. "shelf exam" management of this situation.