Abdominal Trauma — MCQs
What is the investigation of choice in a patient with blunt abdominal trauma with hematuria?
A 30-year-old woman involved in a car crash is brought into the emergency department. Her blood pressure is 90/60 mm Hg, pulse rate is 120 bpm, and respiration rate is 18 breaths per minute. On peritoneal lavage, she is noted to have free blood in the peritoneal cavity. At the time of exploratory laparotomy, a liver laceration is noted, and there is a 2.5-cm-diameter contusion to an area of small bowel. How should the small-bowel contusion be treated?
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?
In the damage control resuscitation protocol, which location is primarily focused on correcting physiological derangements after initial hemorrhage control?
A 19-year-old man is brought into the emergency department with a gunshot wound that occurred 4 hours before admission. At exploratory laparotomy, an injury is noted in the transverse colon with extensive tissue destruction. There is a large amount of fecal contamination. Management of this injury should include which of the following?
Mr. Ramu, a 35-year-old male, sustained a straddle injury in a motor vehicle accident and presents to the emergency department with blood at the urethral meatus. What is the next appropriate step in his management?
A 26 year old male patient was brought to the emergency department with abdominal pain and obstipation for 3 days. He gives a history of bull gore to the abdomen 3 days back. His chest X-ray is given below. What is the probable diagnosis?
A driver wearing seat belt applied brake suddenly to avoid a collision. Which of the following body parts is most likely to be injured?
What is the investigation of choice in a patient with blunt abdominal trauma with hematuria ?
Abdominal Trauma Indian Medical PG Practice Questions and MCQs
Question 1: What is the investigation of choice in a patient with blunt abdominal trauma with hematuria?
- A. USG of the abdomen
- B. Retrograde urogram
- C. IVP
- D. CECT (Correct Answer)
Explanation: ***Correct Answer: CECT*** - **Contrast-enhanced computed tomography (CECT)** is the investigation of choice for evaluating blunt abdominal trauma with hematuria as it accurately assesses the extent of injury to the **kidneys, ureters, bladder**, and surrounding structures. - It provides detailed images for detecting **renal lacerations, hematomas, urine extravasation**, and other abdominal organ injuries. - **Gold standard** in trauma protocols for comprehensive evaluation of renal and abdominal injuries. *Incorrect: USG of the abdomen* - **Ultrasound** can identify gross abnormalities like large hematomas or free fluid but is less sensitive than CECT for subtle renal injuries or collecting system disruptions. - It is often used as an initial screening tool (FAST exam) but not the definitive investigation of choice in this context. *Incorrect: Retrograde urogram* - A **retrograde urogram** primarily evaluates the **lower urinary tract** (ureters and bladder) by injecting contrast directly into the urethra. - It is not suitable for assessing the extent of renal parenchymal injury or other abdominal organ damage in blunt trauma. *Incorrect: IVP* - **Intravenous pyelogram (IVP)** uses intravenous contrast to visualize the kidneys, ureters, and bladder, but it has largely been replaced by CECT due to its lower sensitivity and specificity for traumatic injuries. - It provides less detailed anatomical information about surrounding soft tissues and can miss subtle parenchymal or vascular injuries.
Question 2: A 30-year-old woman involved in a car crash is brought into the emergency department. Her blood pressure is 90/60 mm Hg, pulse rate is 120 bpm, and respiration rate is 18 breaths per minute. On peritoneal lavage, she is noted to have free blood in the peritoneal cavity. At the time of exploratory laparotomy, a liver laceration is noted, and there is a 2.5-cm-diameter contusion to an area of small bowel. How should the small-bowel contusion be treated?
- A. Resection of the bowel and ileostomy
- B. Inversion of the area of contusion with a row of fine nonabsorbable mattress sutures
- C. Transillumination evaluation of hematoma with meticulous hemostasis
- D. Resection of the bowel with single-layer anastomosis (Correct Answer)
Explanation: ***Resection of the bowel with single-layer anastomosis*** - A **2.5-cm contusion** of small bowel represents significant trauma with risk of **transmural injury and delayed perforation** - The standard approach is **resection of the involved segment** with **primary anastomosis** - Small bowel has **excellent blood supply** and heals well even in trauma settings - **Primary anastomosis** is safe in small bowel injuries unless there is massive peritoneal contamination, multiple injuries requiring damage control, or the patient is in extremis requiring abbreviated laparotomy - This patient, though hypotensive, is stable enough for formal laparotomy and definitive repair *Resection of the bowel and ileostomy* - **Ileostomy** is reserved for more severe scenarios: extensive bowel destruction, massive contamination, colon injuries in unstable patients, or damage control situations - For a **localized small bowel contusion**, creating an ileostomy is unnecessarily morbid - Small bowel anastomoses have high success rates even in emergency settings *Transillumination evaluation of hematoma with meticulous hemostasis* - This conservative approach might be considered for **very minor serosal contusions** (<1 cm) in stable patients - A **2.5-cm contusion** is too large to observe safely due to high risk of **delayed perforation** (can occur 24-72 hours post-injury) - Transillumination helps assess bowel viability but doesn't eliminate perforation risk from significant contusions *Inversion of the area of contusion with a row of fine nonabsorbable mattress sutures* - **Inverting sutures** are an outdated technique that can cause **stricture formation** and don't address potential transmural injury - This approach doesn't remove potentially devitalized tissue and creates a weak point prone to perforation - Modern trauma surgery principles favor resection over repair attempts for significant contusions
Question 3: 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 4: 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.
Question 5: 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)
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.
Question 6: A 19-year-old man is brought into the emergency department with a gunshot wound that occurred 4 hours before admission. At exploratory laparotomy, an injury is noted in the transverse colon with extensive tissue destruction. There is a large amount of fecal contamination. Management of this injury should include which of the following?
- A. Resection of the wound with primary anastomosis and proximal cecostomy
- B. Debridement and closure of wound with a proximal colostomy
- C. Resection of the injured colon with primary anastomosis and proximal colostomy
- D. Resection with proximal colostomy and distal mucous fistula (Correct Answer)
Explanation: ***Resection with proximal colostomy and distal mucous fistula*** - Extensive **tissue destruction** and significant **fecal contamination** in a gunshot wound to the colon necessitate diversion to prevent peritonitis and sepsis. - A **proximal colostomy** diverts the fecal stream, and a **distal mucous fistula** allows drainage of the distal segment, preventing a closed-loop obstruction and reducing the risk of anastomotic leak if a primary repair were attempted under septic conditions. *Resection of the wound with primary anastomosis and proximal cecostomy* - **Primary anastomosis** in the setting of extensive tissue destruction and heavy fecal contamination carries a high risk of **anastomotic leak** and peritonitis. - A **cecostomy** is generally insufficient for complete diversion of the fecal stream when dealing with injuries to the transverse colon or beyond. *Debridement and closure of wound with a proximal colostomy* - **Debridement and primary closure** are inadequate for extensive tissue destruction caused by a gunshot wound, as devitalized tissue will likely lead to breakdown and leak. - While a **proximal colostomy** provides diversion, inadequate management of the injury itself is prone to failure and complications. *Resection of the injured colon with primary anastomosis and proximal colostomy* - Although **resection** addresses the damaged tissue, performing a **primary anastomosis** in the presence of extensive **fecal contamination** significantly increases the risk of **anastomotic leak**. - A **proximal colostomy** would provide diversion, but the retained anastomosis remains a high-risk factor in this contaminated field.
Question 7: Mr. Ramu, a 35-year-old male, sustained a straddle injury in a motor vehicle accident and presents to the emergency department with blood at the urethral meatus. What is the next appropriate step in his management?
- A. CECT Abdomen
- B. FAST
- C. Abdomen X-ray
- D. Retrograde urethrogram (Correct Answer)
Explanation: ***Retrograde urethrogram*** - **Blood at the urethral meatus** after a straddle injury is highly suggestive of **urethral injury**, and a retrograde urethrogram is the diagnostic test of choice to assess the integrity of the urethra. - This procedure involves injecting contrast into the urethra to visualize any extravasation, strictures, or complete disruptions before attempting catheterization. *CECT Abdomen* - A CECT abdomen is primarily used to assess **solid organ injuries** or **intra-abdominal bleeding**, which is not the primary concern suggested by blood at the urethral meatus. - While broad abdominal trauma may warrant a CECT, it does not directly evaluate urethral integrity. *FAST* - **FAST (Focused Assessment with Sonography for Trauma)** is a rapid ultrasound examination to detect **free fluid (blood)** in the peritoneal or pericardial cavities. - It is used to identify **intra-abdominal or pericardial hemorrhage** and guide resuscitation, but it does not visualize the urethra. *Abdomen X-ray* - An abdomen X-ray can detect **fractures of the pelvis** or foreign bodies, but it does not provide detailed imaging of soft tissues like the urethra. - It would not show urethral extravasation or disruption, making it insufficient for diagnosing urethral injury.
Question 8: A 26 year old male patient was brought to the emergency department with abdominal pain and obstipation for 3 days. He gives a history of bull gore to the abdomen 3 days back. His chest X-ray is given below. What is the probable diagnosis?
- A. Hemothorax
- B. Hollow viscus perforation (Correct Answer)
- C. Pneumothorax
- D. Intestinal obstruction
Explanation: ***Hollow viscus perforation*** - The chest X-ray clearly shows **free air under the diaphragm** (pneumoperitoneum), which is a hallmark sign of a perforated hollow viscus in the abdomen. - The history of **bull gore to the abdomen** and subsequent abdominal pain and obstipation further supports a traumatic perforation of a stomach or intestinal segment. *Hemothorax* - Hemothorax would present as **fluid in the pleural space**, typically seen as blunting of the costophrenic angles or an effusion on X-ray, which is not evident here. - While trauma can cause hemothorax, the prominent finding on this X-ray is intra-abdominal air, not intrathoracic fluid. *Pneumothorax* - Pneumothorax is characterized by the presence of **air in the pleural space**, leading to lung collapse and absence of lung markings in the affected area, which is not observed on this X-ray. - The air seen is clearly **below the diaphragm**, indicating intra-abdominal free air, not air in the chest cavity surrounding the lung. *Intestinal obstruction* - Intestinal obstruction typically presents with **dilated bowel loops** and **air-fluid levels** on an abdominal X-ray, along with abdominal pain and obstipation. - While the patient has obstipation, the primary X-ray finding is free air under the diaphragm, which is not characteristic of an uncomplicated intestinal obstruction.
Question 9: A driver wearing seat belt applied brake suddenly to avoid a collision. Which of the following body parts is most likely to be injured?
- A. Mesentery (Correct Answer)
- B. Spleen
- C. Liver
- D. Abdominal aorta
Explanation: ***Mesentery*** - The **mesentery** is the most characteristic injury in **seatbelt syndrome** during rapid deceleration with restraint. - The seatbelt creates a **fulcrum effect** across the abdomen, causing compression and shearing forces on the mobile small bowel and its mesentery against the fixed retroperitoneum. - Mesenteric injuries include **tears, hematomas, and vascular disruption** leading to bowel ischemia or hemorrhage. - This is part of the classic **"seatbelt syndrome"** triad: abdominal wall contusion (seatbelt sign), hollow viscus injury (especially small bowel), and Chance fracture of lumbar spine. *Spleen* - While splenic injury is common in general blunt abdominal trauma, it is **not the most characteristic injury** specifically associated with seatbelt mechanism. - Splenic rupture occurs more with direct lateral impact or compression, rather than the anterior compression and shearing forces of a seatbelt. - The left upper quadrant position makes it vulnerable, but the mechanism of injury differs from typical seatbelt trauma. *Liver* - Liver injuries can occur in blunt trauma but are less common than mesenteric injuries in seatbelt-specific mechanisms. - The liver is more prone to injury from **direct right-sided impact** rather than the anterior abdominal compression from a seatbelt. *Abdominal aorta* - Aortic injuries require **extreme deceleration forces** and typically involve transection at points of fixation (e.g., ligamentum arteriosum). - These are rare and not the most likely injury in seatbelt trauma scenarios. - Solid organ injuries (spleen, liver) and hollow viscus injuries (bowel, mesentery) are far more common.
Question 10: 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
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.
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