WBR0193

Author	Mahmoud Sakr M.D.
Exam Type	USMLE Step 3
Main Category	Emergency Room
Sub Category	Cardiovascular, Surgery
Prompt	[[Prompt::. A 25-year-old male who was involved in a high speed motor vehicle accident is brought to the emergency room in a critical condition. Blood pressure is 60/30, pulse is 142 bpm, RR is 22. Physical exam is unremarkable.Labs were ordered and the patient was started on IV vigorous hydration and IV norepinephrine. A Chest X-ray is shown. Which of the following is the most appropriate next step in management?]]
Answer A	An urgent high resolution CT scan of the chest without IV contrast
Answer A Explanation	Aortic rupture carries a high mortality and if the diagnosis is suspected based on history, physical or initial chest radiograph, consultation with a thoracic surgeon is warranted for immediate life-saving surgery to stop the bleeding.
Answer B	An urgent high resolution CT scan of the chest with contrast
Answer B Explanation	Aortic rupture carries a high mortality and if the diagnosis is suspected based on history, physical or initial chest radiograph, consultation with a thoracic surgeon is warranted for immediate life-saving surgery to stop the bleeding.
Answer C	Open Thoracotomy
Answer C Explanation	This is the correct answer as the emergency surgery will entail an open thoracotomy and aortic repair.
Answer D	Switch to IV dopamine
Answer D Explanation	The patient is on Iv pressors already and switching to another pressor will be of little benefit. The mainstay of treatment is stop the blood loss as early as possible.
Answer E	Chest tube placement
Answer E Explanation	The patient may need a chest tube if there's an associated large hemothorax, However that can be done after repair of the aorta. The chest Xray here does not reveal a hemothorax.
Right Answer	C
Explanation	Aortic injuries carry a high mortality rate and are immediately fatal in an estimated 80%–90% of all cases. Evaluation for mediastinal hematoma, and by inference a major vascular injury, is the main goal of the initial chest radiograph as shown above. Acute traumatic aortic injuries are considered to be surgical emergencies, and patients should undergo repair immediately especially if they are hemodynamically unstable as is the case here. Educational Objective: References:
Approved	Yes
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