Damage Control Surgery — MCQs

10 questions

Which of the following is not a component of damage control surgery?

In the initial management of a hemodynamically unstable polytrauma patient, what is the recommended initial crystalloid bolus dose of Ringer's lactate for assessment and stabilization?

Which of the following is the correct management of abdominal compartment syndrome?

Triad following massive blood transfusion includes:

A patient who presented with blunt abdominal injury underwent complete repair of liver and was given transfusion of 12 units of whole blood. Thereafter, it is found that the wound is bleeding. It is treated by

Abbreviated laparotomy done for:

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)

True about chest trauma:

A 25-year-old patient presents in coma with GCS of 5 and extensor posturing after a bike accident. Which of the following will be the best management of the patient?

Q10

Which intervention is best in patients operated for bilateral acoustic neuroma for hearing rehabilitation?

Damage Control Surgery 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: In the initial management of a hemodynamically unstable polytrauma patient, what is the recommended initial crystalloid bolus dose of Ringer's lactate for assessment and stabilization?

A. 2000 ml Ringer's lactate bolus
B. 1000 ml Ringer's lactate bolus, then regulated by clinical indicators (Correct Answer)
C. 250 ml Ringer's lactate bolus
D. 500 ml Ringer's lactate bolus, then regulated by clinical indicators

Explanation: ***1000 ml Ringer's lactate bolus, then regulated by clinical indicators*** - For **hemodynamically unstable** polytrauma patients, the initial recommended crystalloid bolus is typically **1 liter (1000 mL)** of Ringer's lactate. - This initial bolus allows for rapid assessment of the patient's response and guides subsequent fluid management based on **clinical indicators** such as blood pressure, heart rate, and urine output, avoiding over-resuscitation. *2000 ml Ringer's lactate bolus* - A **2000 ml bolus** is generally considered too large for an initial dose in trauma, as it can lead to **dilutional coagulopathy**, worsening hemorrhage, and **abnormal fluid shifts**, especially in cases where definitive hemorrhage control is not yet achieved. - Excessive fluid administration can lead to complications such as **abdominal compartment syndrome** and **acute respiratory distress syndrome (ARDS)**. *250 ml Ringer's lactate bolus* - A **250 ml bolus** is generally too small to effectively address **hemodynamic instability** in a polytrauma patient, offering insufficient volume to significantly improve circulation or organ perfusion. - While small boluses might be used in specific situations (e.g., small children or patients with cardiac comorbidities), this dose is not adequate for initial resuscitation in a severely unstable adult trauma patient. *500 ml Ringer's lactate bolus, then regulated by clinical indicators* - While **500 mL** is a common bolus size in other medical settings, it may be insufficient for the initial resuscitation of a **hemodynamically unstable adult polytrauma patient**. - Current trauma guidelines often recommend a larger initial bolus (e.g., 1000 mL) to gain a more immediate and measurable hemodynamic response for assessment.

Question 3: Which of the following is the correct management of abdominal compartment syndrome?

A. Antihypertensives
B. Urgent Fasciotomy
C. Wait and monitor for 24 hours
D. Urgent decompressive laparotomy (Correct Answer)

Explanation: ***Urgent decompressive laparotomy*** - The definitive treatment for abdominal compartment syndrome (ACS) is **urgent surgical decompression** via **decompressive laparotomy**. - This involves opening the abdominal fascia to immediately **reduce intra-abdominal pressure (IAP)**, typically indicated when IAP >20 mmHg with new organ dysfunction. - Decompression is crucial to prevent irreversible organ damage, restore perfusion to compressed organs, and improve ventilation. - The abdomen is often left open temporarily with negative pressure wound therapy until the patient stabilizes. *Antihypertensives* - Antihypertensives may manage systemic hypertension but do not address the **elevated intra-abdominal pressure** that is the primary pathology in ACS. - This approach is insufficient and could worsen **organ perfusion** by reducing the perfusion pressure gradient (MAP - IAP) to already compressed abdominal organs. - ACS requires mechanical decompression, not pharmacological blood pressure management. *Urgent Fasciotomy* - Fasciotomy is the correct treatment for **extremity compartment syndrome** (e.g., leg, forearm), where it relieves pressure within muscle compartments. - It is anatomically inappropriate for **abdominal compartment syndrome**, which requires opening the abdominal cavity, not limb fascial compartments. - This represents a fundamental misunderstanding of the anatomical site requiring decompression. *Wait and monitor for 24 hours* - ACS is a **surgical emergency** that can rapidly progress to multiorgan failure, acute kidney injury, respiratory failure, and cardiovascular collapse. - Delaying intervention by 24 hours would likely result in **irreversible organ damage** and significantly increased mortality. - Once diagnosed (IAP >20 mmHg with organ dysfunction), urgent decompression is mandatory.

Question 4: Triad following massive blood transfusion includes:

A. Acidosis, hypothermia, coagulopathy (Correct Answer)
B. Acidosis, hyperthermia, hypokalemia
C. Alkalosis, hyperthermia, hyperkalemia
D. Alkalosis, hypothermia, hyperkalemia

Explanation: ***Acidosis, hypothermia, coagulopathy*** - This is the classic **"lethal triad" or "trauma triad of death"** in massive transfusion and severe trauma. - **Acidosis** develops from hypoperfusion, shock, and the acidic pH of stored blood products (citrate metabolism). - **Hypothermia** occurs from rapid infusion of cold blood products and decreased metabolic heat production in shock. - **Coagulopathy** results from dilution of clotting factors and platelets, consumption of factors, platelet dysfunction from hypothermia, and acidosis-induced impairment of the coagulation cascade. - These three conditions create a **vicious cycle**: each worsens the others and significantly increases mortality if not corrected. *Acidosis, hyperthermia, hypokalemia* - While **acidosis** occurs, **hyperthermia** is incorrect—cold blood products cause hypothermia, not hyperthermia. - **Hypokalemia** is incorrect for the triad; the third component is coagulopathy, not a potassium disturbance. *Alkalosis, hyperthermia, hyperkalemia* - **Alkalosis** is incorrect; the immediate effect is acidosis (late citrate metabolism may cause alkalosis after resuscitation). - **Hyperthermia** is incorrect—patients become hypothermic from cold blood. - **Hyperkalemia** is not part of the classic triad, though it can occur as a separate complication. *Alkalosis, hypothermia, hyperkalemia* - **Alkalosis** is incorrect as the immediate effect is acidosis. - While **hypothermia** is correct, **hyperkalemia** is not part of the lethal triad—the third component is coagulopathy. - Hyperkalemia can occur from potassium leakage from stored RBCs but is a separate complication, not part of the triad.

Question 5: A patient who presented with blunt abdominal injury underwent complete repair of liver and was given transfusion of 12 units of whole blood. Thereafter, it is found that the wound is bleeding. It is treated by

A. Vitamin-K
B. Platelet concentrates (Correct Answer)
C. Calcium gluconate/calcium chloride
D. Fresh Frozen Plasma

Explanation: ***Platelet concentrates*** - Transfusion of **large volumes of whole blood** can lead to **dilutional coagulopathy**, primarily affecting platelet count and function. - The most effective immediate treatment for bleeding due to dilutional coagulopathy after massive transfusion is the administration of **platelet concentrates** to replenish platelet levels. *Vitamin-K* - **Vitamin-K** is essential for the synthesis of **coagulation factors II, VII, IX, and X** in the liver. - Its administration is typically indicated for patients with **warfarin overdose** or **liver dysfunction**, neither of which is the primary cause of bleeding in this scenario. *Calcium gluconate/calcium chloride* - **Calcium** is an important cofactor in several steps of the coagulation cascade. - While citrate in transfused blood can chelate calcium, significant **symptomatic hypocalcemia** affecting coagulation is less common and usually does not manifest as persistent surgical site bleeding. *Fresh Frozen Plasma* - **Fresh Frozen Plasma (FFP)** provides a broad spectrum of **coagulation factors**, addressing deficiencies in clotting factors. - While FFP can be helpful in massive transfusion protocols, the primary issue after 12 units of whole blood is often **dilutional thrombocytopenia**, making platelet concentrates a more direct and effective initial treatment for sustained bleeding.

Question 6: Abbreviated laparotomy done for:

A. Hemodynamically stable patients with minor trauma
B. Damage control in hemodynamically unstable trauma patients (Correct Answer)
C. Elective abdominal surgeries
D. Early wound healing promotion

Explanation: ***Damage control in hemodynamically unstable trauma patients*** - **Abbreviated laparotomy** is a key component of **damage control surgery**, primarily indicated for hemodynamically unstable trauma patients. - The goal is to rapidly control life-threatening issues like hemorrhage and contamination, then temporarily close the abdomen for physiologic stabilization before definitive repair. *Hemodynamically stable patients with minor trauma* - These patients typically do not require prompt surgical intervention; their injuries can often be managed non-operatively or with standard surgical techniques. - An abbreviated laparotomy is an aggressive approach reserved for severe, life-threatening scenarios, not minor trauma in stable patients. *Elective abdominal surgeries* - Elective surgeries are planned procedures performed on stable patients with no immediate life-threatening conditions. - They allow for complete surgical repair in a single setting, which is the opposite of the staged approach of an abbreviated laparotomy. *Early wound healing promotion* - The focus of an abbreviated laparotomy is on resuscitation and source control, not primarily on wound healing. - The initial closure is temporary, often leaving the wound open, which is not conducive to early, primary wound healing.

Question 7: 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

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.

Question 8: True about chest trauma:

A. All of the options
B. ECG done in all cases associated with sternal fracture (Correct Answer)
C. Urgent surgery needed in all cases
D. Under water seal drainage if associated with pneumothorax. X-ray chest investigation of choice

Explanation: ***ECG done in all cases associated with sternal fracture*** - A **sternal fracture** is a significant injury often caused by high-impact trauma, which can lead to **myocardial contusion** or other cardiac injuries. - An **ECG** is **mandatory** in all cases of sternal fracture for detecting potential cardiac involvement, such as **arrhythmias** or **ischemic changes**, indicating underlying myocardial damage. - This is a clear, unequivocal true statement about chest trauma management and the **best answer**. *All of the options* - This option is incorrect because not all statements provided are true or represent best practices in chest trauma management. - Specifically, "urgent surgery needed in all cases" is clearly false, making this option incorrect. *Urgent surgery needed in all cases* - This statement is **false**. Approximately **80-85% of chest trauma** cases are managed **non-operatively** with supportive care. - Urgent surgery is required only in specific situations: **massive hemothorax**, **cardiac tamponade**, **major airway injury**, **esophageal perforation**, or ongoing bleeding. - Simple rib fractures, minor pneumothorax, and pulmonary contusions rarely require surgery. *Under water seal drainage if associated with pneumothorax. X-ray chest investigation of choice* - While both components of this statement are individually true, the option combines two separate management concepts without clear connection. - **Underwater seal drainage (chest tube)** is indeed appropriate for significant pneumothorax, and **chest X-ray** is the initial investigation of choice for chest trauma. - However, this option is less precise than Option B, which states an absolute management protocol, making Option B the superior choice.

Question 9: A 25-year-old patient presents in coma with GCS of 5 and extensor posturing after a bike accident. Which of the following will be the best management of the patient?

A. Hemi-craniectomy (Correct Answer)
B. Burr hole surgery
C. Hypertonic saline
D. Thrombolysis

Explanation: ***Correct: Hemi-craniectomy (Decompressive Craniectomy)*** - **GCS of 5** with **extensor posturing** indicates **severe traumatic brain injury (TBI)** with critically elevated **intracranial pressure (ICP)** and impending herniation - This clinical picture suggests **diffuse cerebral edema** or **massive intracranial pathology** requiring **urgent surgical decompression** - **Decompressive hemicraniectomy** removes a large skull bone flap to allow brain swelling, reducing life-threatening ICP and preventing herniation - This procedure is indicated for **refractory elevated ICP** despite maximal medical management, particularly in severe TBI with clinical deterioration - In the context of such severe presentation (GCS 5 with decerebrate posturing), surgical decompression is the definitive life-saving intervention *Incorrect: Burr hole surgery* - **Burr hole evacuation** is appropriate for **chronic subdural hematomas** or small, accessible lesions - It provides **inadequate decompression** for the diffuse cerebral swelling and massive pressure causing decerebrate posturing - Cannot address the extensive brain swelling and mass effect causing such severe neurological deterioration *Incorrect: Hypertonic saline* - **Hypertonic saline** is an important **medical adjunct** for temporizing elevated ICP by creating osmotic gradient - Used as part of **initial resuscitation** and bridging therapy to surgery - However, it is **not definitive management** for this severity of injury - with GCS 5 and extensor posturing, medical management alone has failed or is insufficient - Surgical decompression is required for survival in this critical presentation *Incorrect: Thrombolysis* - **Thrombolysis** is used for **acute ischemic stroke** to dissolve arterial clots - It is **absolutely contraindicated** in **traumatic brain injury** due to high risk of intracranial hemorrhage - Would cause catastrophic bleeding and certain death in this trauma patient

Question 10: Which intervention is best in patients operated for bilateral acoustic neuroma for hearing rehabilitation?

A. Bilateral cochlear implant
B. Auditory brainstem implant (ABI) (Correct Answer)
C. Unilateral cochlear implant
D. High power hearing aid

Explanation: ***Auditory brainstem implant (ABI)*** - Patients with bilateral acoustic neuromas often suffer damage to both **auditory nerves** during surgery, rendering cochlear implants ineffective. - The **ABI** bypasses the damaged auditory nerves and directly stimulates the **cochlear nucleus** in the brainstem, allowing for sound perception. *Bilateral cochlear implant* - This intervention is suitable when the **auditory nerve** remains intact and functional, which is typically not the case after bilateral acoustic neuroma surgery. - Cochlear implants depend on the integrity of the auditory nerve to transmit electrical signals to the brain. *Unilateral cochlear implant* - Similar to bilateral cochlear implants, a unilateral implant relies on a functional **auditory nerve** on the implanted side. - In bilateral acoustic neuroma, both auditory nerves are usually compromised or sacrificed, making a unilateral implant unsuitable for binaural hearing rehabilitation. *High power hearing aid* - Hearing aids only amplify sound and are effective for **sensorineural hearing loss** where the cochlea and auditory nerve are still functional. - They would not be beneficial in cases where the auditory nerve is damaged or absent, as occurs after bilateral acoustic neuroma removal.

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