Trauma

Trauma Indian Medical PG Question 1: Which of the following statements are correct regarding primary survey/management of traumatic head injury patient? I. Ensure adequate oxygenation and circulation II. Exclude hypoglycaemia III. Check for mechanism of injury IV. Check pupil size and response Select the answer using the code given below :

• A. II, III and IV
• B. I, III and IV
• C. I, II and III
• D. I, II and IV (Correct Answer)

Trauma Explanation: ***I, II and IV*** - **Primary survey** in trauma management, including head injury, focuses on immediately life-threatening conditions (Airway, Breathing, Circulation, Disability, Exposure). Ensuring adequate **oxygenation and circulation** (Statement I) is paramount to prevent secondary brain injury. - Exclude **hypoglycemia** (Statement II) is critical because altered mental status due to low blood sugar can mimic head injury and delay appropriate treatment, making it an essential part of the 'D' (disability) assessment. Checking **pupil size and response** (Statement IV) is also part of the 'D' assessment, providing vital information about potential brain stem compromise or intracranial pressure changes. *II, III and IV* - While excluding hypoglycemia and checking pupil response are crucial parts of the primary survey, Statement III, "Check for mechanism of injury," is typically part of the **secondary survey** or initial assessment but not immediately life-saving like ABCD. - The primary survey prioritizes immediate threats to life, and while understanding the mechanism of injury informs subsequent care, it does not directly address a patient's immediate physiologic stability. *I, III and IV* - This option includes checking the mechanism of injury (Statement III) as part of the primary survey, which is generally conducted after the **life-threatening conditions** are addressed. - It omits the critical step of excluding **hypoglycemia** (Statement II), which is an immediate reversible cause of altered mental status that must be ruled out during the primary assessment. *I, II and III* - This option correctly includes ensuring adequate **oxygenation and circulation** (Statement I) and excluding **hypoglycemia** (Statement II) as part of the primary survey. - However, it incorrectly includes checking for the **mechanism of injury** (Statement III) as a primary survey component and omits checking **pupil size and response** (Statement IV), which is an essential part of the 'Disability' assessment in the primary survey for head injury.

Trauma Indian Medical PG Question 2: In an accident case, after the arrival of medical team, all should be done in early management except;

• A. Glasgow coma scale
• B. Check BP (Correct Answer)
• C. Stabilization of cervical vertebrae
• D. Check Respiration

Trauma Explanation: ***Check BP*** - In the **immediate/early management** of trauma (primary survey), while circulation assessment is crucial, the **initial assessment of circulation** focuses on: - **Pulse rate and quality** (radial, carotid) - **Capillary refill time** - **Skin color and temperature** - **Active hemorrhage control** - **Formal blood pressure measurement** with a cuff, while important, is typically recorded during or after these rapid initial assessments, as it takes more time to obtain an accurate reading. - In the context of this question, among the four options listed, BP measurement is relatively less immediate compared to the other life-saving priorities (airway protection, breathing assessment, C-spine stabilization, and GCS). - **Note:** This is a nuanced distinction - BP is assessed during primary survey, but the other three options have more immediate life-threatening implications if not addressed. *Glasgow coma scale* - **GCS assessment** is part of the **"D" (Disability)** step in the ATLS primary survey. - It is performed early to assess neurological status and level of consciousness. - GCS <8 indicates need for **definitive airway protection** (intubation). - This is a critical early assessment that guides immediate management decisions. *Stabilization of cervical vertebrae* - **C-spine immobilization** is part of the **"A" (Airway)** step - "Airway with cervical spine protection." - It is performed **simultaneously** with airway assessment using a **rigid cervical collar**. - This is the **first priority** in trauma management to prevent secondary spinal cord injury. - All trauma patients should be assumed to have C-spine injury until proven otherwise. *Check Respiration* - **Respiratory assessment** is part of the **"B" (Breathing)** step in the ATLS primary survey. - This involves checking: - **Respiratory rate and pattern** - **Chest wall movement** - **Air entry bilaterally** - **Signs of tension pneumothorax or flail chest** - This is an immediate life-saving priority and must be assessed early.

Trauma Indian Medical PG Question 3: Match the following weapons with their corresponding injury types: Weapons: A. Axe B. RTA (Road Traffic Accident) C. Blade D. Lathi Injury Types: 5. Incised wound 6. Tram track bruise 7. Grazed abrasion 8. Chop wound

• A. A-5, B-6, C-8, D-7
• B. A-6, B-8, C-7, D-5
• C. A-8, B-7, C-5, D-6 (Correct Answer)
• D. A-7, B-5, C-6, D-8

Trauma Explanation: ***A-8 (Axe - Chop wound), B-7 (RTA - Grazed abrasion), C-5 (Blade - Incised wound), D-6 (Lathi - Tram track bruise)*** - An **axe** is a heavy cutting tool that typically causes a **chop wound**, characterized by a combination of cutting and crushing. - A **Road Traffic Accident (RTA)** frequently results in **grazed abrasions** due to friction and shearing forces as the body slides against rough surfaces. - A **blade** (like a knife or razor) is designed to cut, producing an **incised wound** with clean, sharp edges. - A **lathi** (a heavy stick or baton) delivers blunt force trauma, often causing a **tram track bruise** due to the skin being crushed between the impactor and underlying bone, leading to parallel lines of bruising. *A-5, B-6, C-8, D-7* - This option incorrectly associates an **axe** with an **incised wound** (which is caused by a blade) and a **blade** with a **chop wound** (caused by an axe). - It also misattributes **RTA** to a **tram track bruise** and a **lathi** to a **grazed abrasion**, which are not the most typical injury patterns for these respective weapons/mechanisms. *A-6, B-8, C-7, D-5* - This pairing mistakenly links an **axe** with a **tram track bruise** and a **blade** with a **grazed abrasion**. - It also incorrectly associates an **RTA** with a **chop wound** and a **lathi** with an **incised wound**. *A-7, B-5, C-6, D-8* - This option incorrectly matches an **axe** with a **grazed abrasion** and a **lathi** with a **chop wound**. - It also inaccurately connects an **RTA** with an **incised wound** and a **blade** with a **tram track bruise**.

Trauma Indian Medical PG Question 4: What is the investigation of choice in a patient with blunt abdominal trauma with hematuria ?

• A. Ultrasonography of abdomen
• B. Intravenous urogram
• C. Contrast enhanced computed tomography (Correct Answer)
• D. Retrograde urogram

Trauma Explanation: ***Contrast enhanced computed tomography*** - **Ureteral and renal injuries** are best evaluated using **CT with intravenous contrast**, which offers detailed anatomical information. - In cases of **blunt abdominal trauma with hematuria**, **CT with contrast** is the imaging modality of choice to assess for injuries to the urinary tract. *Ultrasonography of abdomen* - While useful in some abdominal injuries, **ultrasonography** does not provide sufficient detail for precise evaluation of the **renal parenchyma, collecting system, or ureteral integrity** in trauma. - It is often used as an initial screening tool but less effective than CT for confirming and staging urinary tract injuries. *Intravenous urogram* - An **intravenous urogram (IVU)** can identify some urinary tract injuries but is **less sensitive and specific** than modern CT scans. - It also provides **less anatomical detail** of associated soft tissue and vascular injuries compared to CT. *Retrograde urogram* - A **retrograde urogram** primarily visualizes the **lower urinary tract** (ureters and bladder) by injecting contrast directly into the ureters. - It is **invasive** and not the first-line investigation for **blunt abdominal trauma with hematuria**, especially for evaluating the kidneys themselves.

Trauma Indian Medical PG Question 5: What is the primary aim of performing an abbreviated laparotomy in trauma surgery?

• A. Definitive repair of all injuries
• B. Reduction of contamination
• C. Rapid stabilization of the patient
• D. Haemostasis (Correct Answer)

Trauma Explanation: ***Haemostasis*** - The primary aim of abbreviated laparotomy (damage control surgery) is to achieve **rapid control of life-threatening hemorrhage**. - This involves temporary measures to stop bleeding from major vessels and solid organ injuries, preventing exsanguination and further physiological deterioration. - **Damage control prioritizes hemorrhage control over definitive repair**, using techniques like packing, shunts, and temporary vessel ligation. *Definitive repair of all injuries* - This is specifically **NOT** the goal of abbreviated laparotomy. - Definitive repairs are **delayed** until the patient is physiologically stable (after resuscitation in ICU). - Attempting complete repair in an unstable patient leads to the "lethal triad" (hypothermia, acidosis, coagulopathy). *Reduction of contamination* - While contamination control is an **important component** of damage control surgery, it is typically **secondary to hemorrhage control**. - The sequence prioritizes stopping bleeding first, then controlling contamination from bowel injuries. *Rapid stabilization of the patient* - This is the **overall goal** of damage control surgery but not the specific primary aim of the laparotomy itself. - Stabilization is achieved **through** specific interventions during the abbreviated laparotomy, primarily haemostasis and contamination control.

Trauma Indian Medical PG Question 6: Steps in review of patient's history during secondary survey of trauma care can be summarised as

• A. TRIAGE
• B. ABCDE
• C. AMPLE (Correct Answer)
• D. None of the options

Trauma Explanation: ***AMPLE*** - The **AMPLE history** is a mnemonic used during the **secondary survey** in trauma care to gather crucial patient information - It stands for **Allergies, Medications, Past medical history/Pregnancy, Last meal, and Events** surrounding the injury. *TRIAGE* - **Triage** is the process of prioritizing patients based on the severity of their condition and the likelihood of benefit from immediate treatment. - It is an initial assessment done to determine the urgency of care, not a detailed historical review for a single patient. *ABCDE* - The **ABCDE approach** (**Airway, Breathing, Circulation, Disability, Exposure**) is part of the **primary survey** in trauma care. - It focuses on identifying and managing immediate life-threatening conditions. *None of the options* - This option is incorrect because **AMPLE** specifically describes the historical review process during the secondary survey.

Trauma Indian Medical PG Question 7: Which among the following are complications of liver trauma? 1. Liver abscess 2. Biliary fistula 3. Portal thrombosis 4. Liver failure Select the correct answer using the code given below.

• A. 1, 2 and 4 (Correct Answer)
• B. 1, 2 and 3
• C. 2, 3 and 4
• D. 1, 3 and 4

Trauma Explanation: ***1, 2 and 4*** - **Liver abscess** is a well-recognized complication resulting from infected devitalized tissue, hematoma, or bile contamination following liver trauma. - **Biliary fistula** is a common complication occurring when bile leaks from damaged intrahepatic or extrahepatic bile ducts, potentially forming external fistulas or bilomas. - **Liver failure** may result from extensive parenchymal damage, massive blood loss causing hepatic ischemia, coagulopathy, and metabolic derangements. - These three represent the **most common and clinically significant** complications of liver trauma encountered in clinical practice. *1, 2 and 3* - While **portal thrombosis** can theoretically occur after portal vein injury in liver trauma, it is a **rare complication** compared to liver abscess, biliary fistula, and liver failure. - This option incorrectly prioritizes portal thrombosis over the more common and clinically significant complication of liver failure. *2, 3 and 4* - This option incorrectly omits **liver abscess**, which is one of the most important delayed complications of liver trauma. - Abscess formation from infected hematomas or devitalized tissue is far more commonly encountered than portal thrombosis. *1, 3 and 4* - This option incorrectly omits **biliary fistula**, which is one of the most frequent complications of liver trauma. - Bile duct injury with subsequent bile leakage occurs in a significant proportion of liver trauma cases, making biliary fistula more clinically relevant than portal thrombosis.

Trauma Indian Medical PG Question 8: In the damage control resuscitation protocol, which location is primarily focused on correcting physiological derangements after initial hemorrhage control?

• A. In OT
• B. Prehospital resuscitation
• C. In emergency
• D. In ICU (Correct Answer)

Trauma Explanation: ***In ICU*** - The **Intensive Care Unit (ICU)** is the primary location for correcting physiological derangements in the damage control resuscitation protocol after initial hemorrhage control. - This phase focuses on addressing the **"deadly triad"** of **acidosis**, **hypothermia**, and **coagulopathy** to stabilize the patient before definitive surgical repair. - The ICU provides the controlled environment and resources needed for prolonged resuscitation and physiological optimization. *In OT* - The **Operating Theater (OT)** is where initial hemorrhage control and damage control surgery are performed. - While some resuscitation occurs here, the main focus is on stopping bleeding and controlling contamination, not prolonged physiological correction. - The goal is rapid surgical intervention followed by transfer to ICU. *Prehospital resuscitation* - **Prehospital resuscitation** involves immediate life-saving interventions and rapid transport. - It prioritizes hemorrhage control, airway management, and preventing hypothermia, but lacks the resources for comprehensive physiological correction. - The focus is on rapid transport to definitive care. *In emergency* - The **Emergency Department (ED)** is crucial for initial assessment, rapid transfusion, and preparing the patient for surgery. - However, the ED phase is typically focused on rapid stabilization and transfer for definitive care rather than protracted physiological correction. - It serves as a bridge between prehospital care and the operating room.

Trauma Indian Medical PG Question 9: Which of the following statements are correct regarding ABCDE of trauma care ? I. A stands for Airway with cervical spine protection II. B stands for Breathing and ventilation III. C stands for Control of massive external haemorrhage IV. D stands for Disability (Neurological status) Select the answer using the code given below :

• A. I, II and III
• B. I, II and IV (Correct Answer)
• C. II, III and IV
• D. I, III and IV

Trauma Explanation: ***I, II and IV*** - All statements I, II, and IV accurately describe components of the **ABCDE approach in trauma care**. - **A** is for **Airway maintenance with cervical spine protection**, **B** for **Breathing and ventilation**, and **D** for **Disability (neurological status)**. - These are the core components as per **ATLS (Advanced Trauma Life Support) guidelines**. *I, II and III* - This option is incorrect because statement III is **incomplete and inaccurate**. - In the standard ATLS primary survey, **C stands for Circulation with hemorrhage control**, not just "Control of massive external haemorrhage." - While controlling hemorrhage is a critical part of 'C', the primary focus is on assessing and managing **circulation** (shock, perfusion, bleeding). - Note: ATLS 10th edition introduced **<C> for catastrophic hemorrhage** in tactical settings, but this is a separate step before A, not a replacement for C. *II, III and IV* - This option is incorrect as it omits statement I, which correctly describes **A as Airway with cervical spine protection**, the first and most critical step in trauma management. - Statement III also incorrectly describes what 'C' represents in the ABCDE approach. *I, III and IV* - This option is incorrect because it omits statement II, which correctly identifies **B as Breathing and ventilation**, an essential assessment following airway management. - Statement III is incomplete as it fails to mention that **C primarily stands for Circulation** (with hemorrhage control as one component).

Trauma Indian Medical PG Question 10: A 30-year-old young male who met with a road traffic accident was brought to trauma center. On admission his BP was 90/50 mmHg, pulse rate is 150/min, SpO₂ is 80% and GCS is 8. He has multiple injuries and FAST reveals presence of blood in all quadrants. He was operated upon and his postoperative pictures are given below. Which of the following options best describe these pictures? (AIIMS Nov 2016)

• A. Midline laparotomy and meshplasty
• B. Abdominothoracic surgery and abdominal zipping
• C. Damage control surgery and temporary mesh closure of abdomen (Correct Answer)
• D. Abdominoplasty and primary closure of abdomen

Trauma Explanation: ***Damage control surgery and temporary mesh closure of abdomen*** - The patient's critical condition with **hypotension**, **tachycardia**, **hypoxia**, **low GCS**, and **free fluid in all four quadrants on FAST** indicates severe, life-threatening trauma requiring a **damage control approach**. - The images show an **open abdomen** covered with a transparent sheet (laparostomy bag) and later a mesh with a wound VAC, characteristic of **temporary abdominal closure** following damage control surgery to manage profound shock, coagulopathy, and severe contamination. *Midline laparotomy and meshplasty* - While a midline laparotomy is the initial incision, **meshplasty** typically refers to definitive hernia repair using a mesh, not a temporary closure technique for a life-threatening trauma. - The images show a temporary closure method, not a finalized mesh repair of a hernia or a definitive abdominal wall reconstruction. *Abdominothoracic surgery and abdominal zipping* - **Abdominothoracic surgery** implies involvement of both thoracic and abdominal cavities, which is not exclusively depicted or necessarily the primary intervention described by the images. - **Abdominal zipping** (Wittmann patch) is a temporary closure method, but the images more closely resemble a combination of a wound vacuum-assisted closure (VAC) and a mesh/plastic sheet, which is a broader *temporary mesh closure* concept. *Abdominoplasty and primary closure of abdomen* - **Abdominoplasty** is an elective cosmetic procedure, completely inappropriate for a patient in severe, unstable trauma. - **Primary closure of the abdomen** would mean definitively closing the abdominal fascia and skin at the initial operation, which is contraindicated in damage control surgery when there's an anticipated need for re-exploration, edema, or ongoing resuscitation.

Trauma Flashcard 1 of 10

Question: Phase II of damage control sx consists of secondary resuscitation to correct _____, coagulopathy, and acidosis

Answer: hypothermia

Trauma Flashcard 2 of 10

Question: Aiming for permissive _____ is a part of balanced resuscitation (damage control resuscitation)

Answer: hypotension

Trauma Flashcard 3 of 10

Question: Presence of _____ red cells/L in blunt trauma indicates an intermediate diagnostic peritoneal lavage

Answer: 50,000 100,000

Trauma Flashcard 4 of 10

Question: The TRISS score takes into consideration the "_____" to calculate the severity of the patient.

Answer: injury mechanism

Trauma Flashcard 5 of 10

Question: Phase I of damage control sx consists of initial operative exploration to attain rapid control of active _____ and contamination

Answer: hemorrhage

Trauma Flashcard 6 of 10

Question: Parkland’s formula for burns: No answer _____]

Answer: :)

Trauma Flashcard 7 of 10

Question: AAST Kidney injury scale: No answer _____

Answer: :)

Trauma Flashcard 8 of 10

Question: _____ is the next best step to manage a case of intraperitoneal bladder rupture

Answer: Laparotomy

Trauma Flashcard 9 of 10

Question: Deep partial thickness burns are _____ and are painful to pressure only

Answer: not blanchable

Trauma Flashcard 10 of 10

Question: Massive transfusion (MT) is defined as the replacement by transfusion of _____ units of pRBCs in 24 hours or more than 4 units of pRBCs in one hour.

Answer: 10