WBR290
WBRQuestion |QuestionAuthor=Gonzalo A. Romero, M.D. [1] |ExamType=USMLE Step 2 CK |MainCategory=Surgery |SubCategory=Cardiovascular, Surgery |MainCategory=Surgery |SubCategory=Cardiovascular, Surgery |MainCategory=Surgery |SubCategory=Cardiovascular, Surgery |MainCategory=Surgery |MainCategory=Surgery |SubCategory=Cardiovascular, Surgery |MainCategory=Surgery |SubCategory=Cardiovascular, Surgery |MainCategory=Surgery |SubCategory=Cardiovascular, Surgery |MainCategory=Surgery |SubCategory=Cardiovascular, Surgery |MainCategory=Surgery |MainCategory=Surgery |SubCategory=Cardiovascular, Surgery |Prompt=A 62-year-old-female is brought to the ER after getting involved in a high-speed motor vehicle accident. Her vitals upon admission to the hospital are T 36C, 82bpm, BP=100/60 mmHg, 20 respirations/min. She has multiple bruises on her anterior chest. Her sternum is tender to palpation. A CXR reveals a widened mediastinum. What is the next best step in management? |Explanation=The widened mediastinum following a trauma to the chest could be due to an aortic dissection or thoracic vertebral fractures. The best next step in management is performing a spiral CT scan to rule out these conditions. A sternal fracture can also cause a myocardial contusion, therfore an EKG, and troponins should be ordered in order to rule out arrythmias and myocardial damage. The real important test is the spiral CT to rule out aortic dissection, which could rupture if left untreated. The surrogate markers of aortic rupture are fractures of the following bones: sternum, scapula and of the first rib. A flail chest is also a surrogate marker of an aortic injury. A contained rupture hematoma due to an aortic dissection is different from an aortic rupture, which has inmediate mortality. Patients with aortic rupture, do not arrive to the hospital alive.
Educational Objective:
References: Master the Boards for Step 2CK, surgery chapter
|AnswerA=EKG |AnswerAExp=Incorrect.This is an important step to rule out arrhythmias in case of a myocardial contusion. |AnswerB=Thoracic ultrasound |AnswerBExp=Incorrect. |AnswerC=Repeat CXR |AnswerCExp=Incorrect. |AnswerD=Troponins |AnswerDExp=Incorrect. |AnswerE=Spiral CT |AnswerEExp=Correct. See overall explanation |RightAnswer=E |WBRKeyword=Aortic rupture, aortic dissection, thoracic trauma |Approved=No }}