Abdominal Trauma Management — MCQs
Which of the following is not a component of damage control surgery?
What is the investigation of choice for blunt abdominal trauma in an unstable patient?
Which of the following statements is NOT true regarding rapid induction of anesthesia?
In trauma transfusion, what is the ratio of RBCs, FFP, and platelets?
Which of the following is a contraindication to nonoperative management of splenic injury?
A 25-year-old patient presents in emergency with abdominal trauma. Why is FAST done?
A patient with abdominal injury presents to the emergency department with signs of peritonitis and shock. Airway and breathing were secured and IV fluids were started with 2 large bore cannulas. The next line of management should be
What is the first-line fluid to be administered in a patient presenting with acute hemorrhagic shock?
What is the correct sequence of management in a patient who presents to the casualty with an RTA? 1. Cervical spine stabilization 2. Intubation 3. IV cannulation 4. CECT
Haemodynamically unstable patient with blunt trauma to abdomen and suspected liver injury; which of the following is the first investigation performed in the emergency room?
Abdominal Trauma Management Indian Medical PG Practice Questions and MCQs
Question 1: Which of the following is not a component of damage control surgery?
- A. Control of contamination
- B. Control of hemorrhage
- C. Definitive repair (Correct Answer)
- D. Temporary closure
Explanation: ***Definitive repair*** - **Damage control surgery** is a staged approach for severely injured patients, prioritizing stabilization over complete repair. - **Definitive repair** is the goal of the final stage, after the patient's physiological status has improved, not an initial component. *Control of contamination* - This is a crucial early step in damage control surgery to prevent **sepsis** and further physiological deterioration. - It involves measures like **bowel repair** or diversion, and thorough abdominal lavage. *Control of hemorrhage* - This is the **primary immediate goal** of damage control surgery, often achieved through packing or temporary shunts. - Uncontrolled bleeding leads to the **lethal triad** of coagulopathy, hypothermia, and acidosis. *Temporary closure* - After addressing immediate life-threatening issues, the abdomen or other body cavity is temporarily closed to prevent **abdominal compartment syndrome**. - This allows time for patient resuscitation and correction of physiological derangements before definitive repair.
Question 2: What is the investigation of choice for blunt abdominal trauma in an unstable patient?
- A. X-ray abdomen
- B. MRI
- C. USG (Correct Answer)
- D. Diagnostic Peritoneal Lavage (DPL)
Explanation: ***USG (FAST Exam)*** - In an **unstable patient** with blunt abdominal trauma, **Focused Assessment with Sonography for Trauma (FAST) exam** is the investigation of choice. - It is **rapid, non-invasive, and bedside**, allowing immediate detection of **free fluid** (blood) in the peritoneal cavity, pericardium, and pleural spaces without transporting the patient. - Guides immediate decision for **laparotomy** in hemodynamically unstable patients. - **Note:** In **stable patients**, **CT abdomen** is the gold standard as it provides detailed anatomical information, but it requires patient transport and time. *X-ray abdomen* - Provides limited information in blunt trauma, primarily showing **free air** (bowel perforation) or **bony fractures**. - **Not sensitive** for detecting intraperitoneal bleeding, which is the primary concern in unstable patients. *MRI* - Offers excellent soft tissue detail but is **time-consuming** and requires the patient to be **hemodynamically stable**. - **Impractical** for unstable trauma patients requiring rapid assessment and intervention. *Diagnostic Peritoneal Lavage (DPL)* - An **invasive procedure** that is sensitive for detecting intra-abdominal hemorrhage. - Has largely been **replaced by FAST exam** in most trauma centers due to FAST being non-invasive, rapid, and repeatable. - DPL has a **higher false-positive rate** and cannot identify the source of bleeding.
Question 3: Which of the following statements is NOT true regarding rapid induction of anesthesia?
- A. Suxamethonium is often used.
- B. Mechanical ventilation is typically avoided before intubation.
- C. Pre-oxygenation is mandatory
- D. Sellick's maneuver is always required. (Correct Answer)
Explanation: ***Sellick's maneuver is always required.*** - **Sellick's maneuver**, or cricoid pressure, is applied to compress the esophagus against the vertebrae, aiming to prevent **gastric regurgitation** and aspiration during rapid sequence intubation (RSI). - While historically considered a standard component of RSI, its routine use has been increasingly questioned due to a lack of strong evidence supporting its efficacy and potential to impede glottic visualization and intubation. It is not "always" required; its application is often at the discretion of the anesthetist based on patient factors and risk assessment. *Pre-oxygenation is mandatory* - **Pre-oxygenation** is a critical step in rapid sequence induction, involving administering 100% oxygen for several minutes prior to induction. - This denitrogenates the functional residual capacity (FRC), creating an oxygen reservoir that extends the safe apnea time, thus preventing **hypoxemia** during the intubation attempt. *Suxamethonium is often used.* - **Suxamethonium** (succinylcholine) is a depolarizing neuromuscular blocker primarily used in rapid sequence intubation due to its **ultra-rapid onset** (30-60 seconds) and short duration of action (5-10 minutes). - Its rapid action facilitates quick muscle relaxation for tracheal intubation, which is crucial for minimizing the risk of aspiration in patients with a full stomach or other risk factors. *Mechanical ventilation is typically avoided before intubation.* - During rapid sequence induction, **positive pressure ventilation** with a bag-valve mask is typically avoided before intubation to prevent gastric insufflation. - Gastric insufflation can increase the risk of **regurgitation** and pulmonary aspiration of gastric contents, which is a major concern in patients undergoing RSI.
Question 4: In trauma transfusion, what is the ratio of RBCs, FFP, and platelets?
- A. 1:1:3
- B. 1:1:4
- C. 1:1:1 (Correct Answer)
- D. 1:1:2
Explanation: ***1:1:1*** - A **1:1:1 ratio** of **Red Blood Cells (RBCs), Fresh Frozen Plasma (FFP), and platelets** is the current recommendation for massive transfusion protocols in trauma. - This ratio aims to mimic whole blood and address the "lethal triad" of acute traumatic coagulopathy: **acidosis, hypothermia, and coagulopathy**. *1:1:3* - This ratio provides proportionally more **platelets** than typically recommended in massive transfusion protocols as compared to FFP and RBCs. - While platelets are crucial for hemostasis, a 1:1:3 ratio might not optimally balance all components for initial trauma resuscitation. *1:1:4* - This ratio implies an even higher proportion of **platelets** relative to RBCs and FFP. - Such a high platelet ratio is generally not the initial target for massive transfusion protocols in trauma, which prioritize balanced component replacement. *1:1:2* - This ratio suggests a slightly higher proportion of **platelets** compared to the standard 1:1:1, but still less than 1:1:3 or 1:1:4. - While closer to the recommended range than other incorrect options, the 1:1:1 ratio is currently considered the ideal balance for comprehensive trauma resuscitation.
Question 5: Which of the following is a contraindication to nonoperative management of splenic injury?
- A. Hemodynamic instability (Correct Answer)
- B. History of hematologic disorder
- C. HIV infection
- D. Presence of multiple solid-organ injuries
Explanation: ***Hemodynamic instability*** - **Hemodynamic instability** in a patient with splenic injury indicates ongoing hemorrhage, which requires immediate surgical intervention to control bleeding and prevent hypovolemic shock. - This is a critical contraindication to non-operative management, as delaying surgery significantly increases morbidity and mortality. *History of hematologic disorder* - While certain **hematologic disorders** like coagulopathies can increase the risk of bleeding after splenic injury, they are not an absolute contraindication to non-operative management if the patient is hemodynamically stable and bleeding is contained. - Close monitoring and correction of coagulopathy might be necessary, but it does not automatically preclude conservative treatment. *HIV infection* - **HIV infection** itself is not a contraindication to non-operative management of splenic injury. The decision for operative versus non-operative management is based on the patient's hemodynamic status and the grade of splenic injury, not their HIV status. - While immune compromise can affect recovery, it does not directly impact the initial management decision for splenic trauma. *Presence of multiple solid-organ injuries* - The presence of **multiple solid-organ injuries** does not automatically contraindicate non-operative management for the splenic injury itself, provided the patient remains hemodynamically stable. - Each organ injury is assessed individually, and the decision for surgery is usually driven by ongoing hemorrhage or other complications from one or more of the injured organs that cannot be managed conservatively.
Question 6: A 25-year-old patient presents in emergency with abdominal trauma. Why is FAST done?
- A. Detection of aortic injury
- B. Detection of mesenteric injury
- C. Detection of bowel perforation
- D. Detection of free fluid in the abdomen (hemoperitoneum) (Correct Answer)
Explanation: ***Detection of free fluid in the abdomen (hemoperitoneum)*** - **FAST (Focused Assessment with Sonography for Trauma)** is primarily used to rapidly identify the presence of **free fluid**, typically blood, within the peritoneal, pericardial, or pleural spaces. - In abdominal trauma, the detection of **hemoperitoneum** guides immediate management decisions, such as the need for surgical intervention. *Detection of aortic injury* - While FAST can sometimes identify large pericardial effusions or mediastinal hematomas which might suggest aortic injury, it is **not sensitive or specific enough** to definitively diagnose an aortic injury. - **CT angiography** is the gold standard for diagnosing aortic injuries. *Detection of mesenteric injury* - **Mesenteric injuries** involve damage to the blood supply of the intestines and are difficult to detect with FAST. - These injuries might cause **intraperitoneal bleeding** detectable by FAST, but FAST cannot directly visualize the mesenteric damage itself. *Detection of bowel perforation* - **Bowel perforations** release air and contents into the peritoneal cavity, but FAST is generally **poor at detecting free air**. - While it might indirectly show some free fluid as a result of inflammation, it is not the primary diagnostic tool for perforation; **plain radiographs** or **CT scans** are more effective.
Question 7: A patient with abdominal injury presents to the emergency department with signs of peritonitis and shock. Airway and breathing were secured and IV fluids were started with 2 large bore cannulas. The next line of management should be
- A. Laparoscopy
- B. Insertion of abdominal drain followed by laparotomy
- C. Exploratory Laparotomy under general anesthesia (Correct Answer)
- D. FAST
Explanation: ***Exploratory Laparotomy under general anesthesia*** - The presence of **peritonitis** and **shock** following abdominal injury indicates a **life-threatening intra-abdominal injury** requiring immediate surgical intervention. - An **exploratory laparotomy** allows for direct visualization, control of hemorrhage, repair of organ damage, and addressing the source of peritonitis. *Laparoscopy* - While minimally invasive, laparoscopy is often **contraindicated in hemodynamically unstable patients** or those with diffuse peritonitis due to the risk of exacerbating shock and limited access. - It is also generally **more time-consuming** than a laparotomy in acute trauma settings, delaying definitive treatment. *Insertion of abdominal drain followed by laparotomy* - **Insertion of an abdominal drain** in the context of peritonitis and shock is insufficient and inappropriate as a primary measure. - A drain cannot address active bleeding, repair visceral perforation, or adequately decontaminate the peritoneal cavity, thus **delaying definitive surgical treatment**. *FAST* - **Focused Assessment with Sonography for Trauma (FAST)** is a diagnostic tool used to detect free fluid (blood) in the abdomen or pericardium. - While useful for initial assessment, a **positive FAST scan in an unstable patient** with peritonitis necessitates immediate surgical intervention, not further diagnostic delay.
Question 8: What is the first-line fluid to be administered in a patient presenting with acute hemorrhagic shock?
- A. PRBC
- B. Crystalloid (Correct Answer)
- C. Colloid
- D. Whole blood
Explanation: ***Crystalloid*** - Initial fluid resuscitation in **hemorrhagic shock** prioritizes **crystalloids** (e.g., normal saline or lactated Ringer's) to restore intravascular volume rapidly and maintain perfusion. - This approach is based on their immediate availability, cost-effectiveness, and ability to expand the extracellular fluid compartment. *PRBC* - While **packed red blood cells (PRBCs)** are crucial for replacing oxygen-carrying capacity in significant hemorrhage, they are typically administered *after* or *concurrently* with initial crystalloid resuscitation once the need for blood products is established. - Administering PRBCs as the *first-line* fluid might delay volume expansion and could be less effective for initial circulatory support. *Colloid* - **Colloid solutions** (e.g., albumin, dextran) remain controversial in initial hemorrhagic shock resuscitation due to concerns about their cost, potential side effects, and lack of clear superiority over crystalloids in improving patient outcomes. - They are also not as readily available as crystalloids in all emergency settings. *Whole blood* - **Whole blood** is the ideal resuscitation fluid as it contains all components of blood but is generally not readily available for initial emergency resuscitation in most civilian settings. - Its use is often limited to specific trauma centers or military combat scenarios due to logistical challenges.
Question 9: What is the correct sequence of management in a patient who presents to the casualty with an RTA? 1. Cervical spine stabilization 2. Intubation 3. IV cannulation 4. CECT
- A. 2,1,4,3
- B. 1,3,2,4
- C. 2,1,3,4
- D. 1,2,3,4 (Correct Answer)
Explanation: ***1,2,3,4*** - This sequence follows the **ATLS (Advanced Trauma Life Support)** protocol, prioritizing immediate life threats in order. - **Cervical spine stabilization** is the **first action upon patient contact** to prevent secondary neurological injury in any trauma patient. - **Airway management (intubation)** is then performed **with maintained in-line c-spine stabilization** - these occur nearly simultaneously but c-spine protection is instituted first. - **IV cannulation (circulation)** follows to establish vascular access for resuscitation and medications. - **CECT (imaging)** is performed last, once the patient is stabilized after addressing immediate life threats. - This follows the **ATLS Primary Survey: Airway (with c-spine protection) → Breathing → Circulation → Disability → Exposure**. *2,1,4,3* - This incorrectly places intubation **before** cervical spine stabilization is initiated. - In ATLS, **c-spine protection must be applied immediately upon patient contact** before any airway manipulation. - Delaying IV cannulation until after CECT is inappropriate as circulatory access is critical for early resuscitation. *1,3,2,4* - While this correctly starts with cervical spine stabilization, it incorrectly places **IV cannulation before intubation**. - In the ATLS primary survey, **Airway comes before Circulation** - securing the airway takes priority over establishing IV access. - This sequence could delay critical airway management in a patient with respiratory compromise. *2,1,3,4* - This sequence places **intubation before cervical spine stabilization**, which violates ATLS principles. - **C-spine stabilization must be the first action** upon approaching any trauma patient to prevent secondary spinal cord injury. - While intubation with in-line stabilization is possible, the c-spine protection must be instituted first, not after beginning airway manipulation.
Question 10: Haemodynamically unstable patient with blunt trauma to abdomen and suspected liver injury; which of the following is the first investigation performed in the emergency room?
- A. CT Scan
- B. Diagnostic peritoneal lavage
- C. FAST (Correct Answer)
- D. Standing X ray Abdomen
Explanation: ***FAST*** - For a **hemodynamically unstable** patient with blunt abdominal trauma, **Focused Assessment with Sonography for Trauma (FAST)** is the quickest and most appropriate initial investigation to detect **free fluid** (indicating hemorrhage) in the abdomen or pericardium. - Its **rapidity and non-invasiveness** make it ideal for immediate decision-making regarding surgical intervention. *CT Scan* - **CT scans** provide detailed anatomical information but require the patient to be **hemodynamically stable** and are time-consuming for an emergency assessment. - Moving an unstable patient to radiology for a CT scan can significantly **delay definitive treatment**. *Diagnostic peritoneal lavage* - While historically used, **diagnostic peritoneal lavage (DPL)** is an **invasive procedure** that is less commonly performed now due to the availability of FAST. - It has a high rate of **false positives** and potential complications, making it less favorable as a first-line investigation. *Standing X ray Abdomen* - A **standing X-ray of the abdomen** is primarily useful for detecting **free air under the diaphragm** (indicating bowel perforation) or major bony injuries. - It is **poor at detecting free fluid** or organ injury, which is the primary concern in suspected liver trauma in an unstable patient.
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