Trauma Practice Questions

Q: The ideal treatment for hemothorax with drainage greater than 200 ml/hr for 2-4 hours is:

Open thoracotomy with ligation of vessels. **Open thoracotomy with ligation of vessels** - A **hemothorax** with continued blood loss exceeding **200 ml/hr for 2-4 hours** (or initial drainage >1500 ml) indicates significant ongoing bleeding that necessitates immediate surgical intervention per **ATLS guidelines**. - **Open thoracotomy** allows direct visualization of the bleeding source, enabling **ligation of vessels** to achieve definitive hemostasis. - This is a critical indication for emergency thoracotomy to prevent exsanguination and cardiovascular collapse. *Intercostal tube* - While an intercostal tube (chest tube) is the **initial management** for hemothorax and essential for diagnosis, persistent large-volume bleeding (>200 ml/hr for 2-4 hours) indicates the drain alone is insufficient to control hemorrhage. - It serves as both a diagnostic and therapeutic tool for initial drainage but does not address significant arterial or venous bleeding requiring operative control. *Wait and watch* - **Waiting and watching** in the presence of persistent significant blood loss (>200 ml/hr for 2-4 hours) is dangerous and can lead to **hypovolemic shock**, coagulopathy, or death. - This approach is inappropriate for active, ongoing bleeding and is reserved only for stable, small hemothoraces with minimal or resolved bleeding. *Needle aspiration* - **Needle aspiration** is used for diagnostic purposes in pleural effusions or small pneumothoraces, not for significant hemothorax management. - It is completely ineffective for draining large-volume **hemothoraces** and cannot control active bleeding from damaged vessels.

Q: Early cause of death due to burns is :

Shock. ***Shock*** - **Hypovolemic shock** due to massive fluid shifting from the intravascular space to the interstitial space (capillary leak) is the most immediate and life-threatening complication of severe burns. - This **fluid loss** leads to decreased cardiac output and inadequate tissue perfusion, which can be fatal if not promptly treated with aggressive fluid resuscitation. *Infection* - While a major cause of death in burn patients, **infection** typically occurs days to weeks after the initial injury, as the compromised skin barrier and immune suppression create a fertile ground for pathogens. - It is considered a **late complication**, not an early one, compared to the acute physiological changes leading to shock. *Haemorrhage* - **Haemorrhage** is not a primary early cause of death in burn patients unless there is an associated traumatic injury causing significant bleeding. - Burns themselves do not typically lead to acute major blood loss, as the initial injury often causes **coagulation** of vessels. *Diabetes* - **Diabetes** is a chronic metabolic condition and is not directly caused by acute burn trauma. - While stress hyperglycemia can occur in burn patients, it is a **secondary metabolic response** and not an immediate cause of death from the burn injury itself.

Q: Burns with vesiculation of the epidermis and upper dermis are

2nd degree. ***2nd degree*** - **Second-degree burns** involve the epidermis and a portion of the dermis, characterized by **blistering** (vesiculation), pain, and redness. - They often appear moist as the dermal layer is exposed and can cause significant pain due to nerve endings being intact. *1st degree* - **First-degree burns** only affect the **epidermis**, presenting as redness and pain without blistering. - They typically heal within a few days and do not involve damage to the dermal layer. *4th degree* - **Fourth-degree burns** are full-thickness burns that extend through the skin and involve underlying fat, muscle, and even bone. - These burns are often **painless** due to complete destruction of nerve endings, and the tissue may appear charred or mummified. *3rd degree* - **Third-degree burns** are full-thickness burns that destroy both the epidermis and the entire dermis, leading to a **dry, leathery appearance**. - These burns are typically **painless** in the center due to nerve damage but may have painful edges, and they do not blister.

Q: Burns involving the skin and the superficial part of the dermis are categorized as

Superficial 2nd degree burn. ***Superficial 2nd degree burn*** - This classification describes burns that involve the **epidermis** and the **superficial part of the dermis**, characterized by **blistering**, redness, and pain. - Damaged **nerve endings** in the superficial dermis result in significant pain perception. *First degree burns* - These burns only affect the **epidermis**, causing redness and pain but **no blistering**. - They typically heal within a few days without scarring. *Third degree burns* - These burns extend through the **entire dermis** and into the **subcutaneous tissue**, damaging nerves and often appearing leathery or charred. - They are typically **painless** due to nerve destruction and require grafting for healing. *Deep 2nd degree burn* - These burns involve the **epidermis** and **deep dermis**, often presenting with **wet or waxy appearance** and less blistering than superficial 2nd degree burns. - While they involve the dermis, the question specifically asks for burns involving the **superficial part of the dermis**, making superficial 2nd degree the more precise answer.

Q: Which is an ominous sign in case of severe head injury?

Anisocoria. ***Anisocoria*** - **Anisocoria** (unequal pupil size) in the setting of severe head injury indicates uncal herniation, a life-threatening condition where the temporal lobe compresses the **oculomotor nerve (CN III)**. - This compression leads to ipsilateral pupillary dilation that is **non-reactive to light**, signifying severe brainstem compromise and poor prognosis. *Depressed skull fracture* - A **depressed skull fracture** is a significant injury but does not inherently indicate immediate life-threatening brainstem compression or herniation. - While it can lead to neurological deficits or infection, it is usually amenable to surgical intervention and does not carry the same immediate ominous prognosis as anisocoria. *Development of diabetes insipidus* - **Diabetes insipidus** can occur due to damage to the posterior pituitary or hypothalamus affecting **ADH secretion**, but it typically develops days after the injury. - While a serious complication indicating **hypothalamic-pituitary axis damage**, it is not an immediate sign of impending brain herniation or brainstem failure like anisocoria. *New focal deficit* - A **new focal deficit** (e.g., hemiparesis) signifies localized brain injury or worsening intracranial pathology (like hematoma expansion). - While concerning and requiring urgent evaluation, it is generally less immediately ominous than anisocoria, which specifically points to **brainstem compression and herniation**, often indicating an irreversible process if not promptly treated.

Q: At what percentage of total body surface area (TBSA) burns does shock set in an adult, if untreated?

15%. ***15%*** - A **total body surface area (TBSA)** burn of **15% or more** in adults is the threshold at which **burn shock** can develop due to massive fluid shifting from the intravascular to the extravascular space. - This is the standard cutoff for initiating aggressive IV fluid resuscitation protocols (such as the Parkland formula) to prevent systemic hypoperfusion and organ dysfunction. - If untreated, burns at or above this threshold lead to hypovolemic shock that can be fatal. *25%* - While a 25% TBSA burn would certainly cause severe burn shock, it is not the *minimum* threshold in adults. - The critical point for initiating fluid resuscitation begins at a lower percentage. *10%* - A 10% TBSA burn in adults usually does not lead to significant systemic shock with appropriate management. - This percentage is the threshold for **children and elderly patients**, not healthy adults. - Adult compensatory mechanisms can generally handle this degree of fluid loss. *30%* - A 30% TBSA burn represents a severe, life-threatening injury where burn shock is definitively present. - However, this is well above the initial percentage where shock begins to manifest and resuscitation must be started.

Q: A 56-year-old male is burned while sleeping in his home. His right upper and lower extremity and the anterior chest have extensive second-degree burns. What is the total percentage of body surface area affected? Reference: Rule of Nines for Adults - Each arm: 9% - Head: 9% - Anterior trunk: 18% - Posterior trunk: 18% - Each leg: 18% - Total: 99%

40%. ***40%*** - The **Rule of Nines** is used to estimate the percentage of total body surface area (TBSA) affected by burns in adults. - **Right upper extremity** (entire arm): 9% - **Right lower extremity** (entire leg): 18% - **Anterior chest**: The burn involves a significant portion of the anterior trunk, accounting for approximately 13% (more than half of the 18% anterior trunk) - **Total**: 9% + 18% + 13% = **40%** - This patient has a major burn requiring fluid resuscitation and likely transfer to a burn center. *10%* - This percentage is far too low for the described burn distribution, which includes an entire arm and an entire leg alone (27% combined). - A 10% burn would typically involve only one arm or the head. *20%* - This percentage significantly underestimates the extent of injury. - This would represent approximately one arm (9%) plus one leg (18%), but fails to account for the anterior chest burns. *30%* - While closer, 30% still underestimates the total body surface area affected. - This would account for the arm (9%) and leg (18%) but significantly underestimates the extent of anterior chest involvement described in the scenario.

Q: Indication for thoracotomy in a patient with traumatic hemothorax -

Open thoracotomy with ligation of vessel. ***Open thoracotomy with ligation of vessel*** - Indications for **thoracotomy in hemothorax** include: - Initial chest tube drainage **>1500 ml** - Ongoing bleeding **>200 ml/hour for 2-4 consecutive hours** - Persistent hemodynamic instability despite resuscitation - **Open thoracotomy** allows direct visualization and **ligation of the bleeding vessel** to control hemorrhage definitively. *Wait and watch* - This approach is appropriate only for **small, stable hemothoraces** (<300 ml) with minimal bleeding. - Active bleeding requiring thoracotomy cannot be managed conservatively. *Needle aspiration* - **Needle aspiration** is generally reserved for **diagnostic purposes** or small effusions. - It is insufficient to evacuate large volumes of blood and cannot control active hemorrhage. *Intercostal tube* - An **intercostal tube (chest drain)** is the **initial management** for hemothorax to evacuate blood and monitor output. - However, if drainage criteria for thoracotomy are met (>1500 ml initially or >200 ml/hour for 2-4 hours), **surgical intervention** is required as the tube alone cannot stop major vessel bleeding.

Q: True about chest trauma:

ECG done in all cases associated with sternal fracture. ***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.

Q: Formula for calculating initial fluid resuscitation volume in burns for the first 24 hours:

% body surface area X weight in Kgs X 4 = Volume in ml. ***% body surface area X weight in Kgs X 4 = Volume in ml*** - This formula represents the **Parkland formula (or Baxter formula)**, which is the most widely accepted method for calculating fluid resuscitation in burn patients. - The formula specifies giving 4 mL of lactated Ringer's solution per kilogram of body weight per percent of total body surface area (%TBSA) burned. *% body surface area X weight in pounds X 4 = Volume in ml* - This formula incorrectly uses **weight in pounds** instead of kilograms, which would lead to an overestimation of fluid requirements. - The standard Parkland formula uses kilograms for body weight to maintain consistency with medical calculations. *% body surface area X weight in Kgs X 5 = Volume in ml* - This formula uses a multiplier of **5 mL/kg/%TBSA**, which would result in an excessive amount of fluid administration. - Over-resuscitation can lead to complications such as **pulmonary edema** and **abdominal compartment syndrome**. *% body surface area X weight in Kgs X 3 = Volume in ml* - This formula uses a multiplier of **3 mL/kg/%TBSA**, which would likely result in an inadequate amount of fluid administration. - Under-resuscitation can lead to **hypovolemic shock** and **renal failure**.

Question 1

The ideal treatment for hemothorax with drainage greater than 200 ml/hr for 2-4 hours is:

Accepted Answer

Open thoracotomy with ligation of vessels

Answer

Intercostal tube

Answer

Wait and watch

Answer

Needle aspiration

Question 2

Early cause of death due to burns is :

Accepted Answer

Shock

Answer

Infection

Answer

Haemorrhage

Answer

Diabetes

Question 3

Burns with vesiculation of the epidermis and upper dermis are

Accepted Answer

2nd degree

Answer

1st degree

Answer

4th degree

Answer

3rd degree

Question 4

Burns involving the skin and the superficial part of the dermis are categorized as

Accepted Answer

Superficial 2nd degree burn

Answer

First degree burns

Answer

Third degree burns

Answer

Deep 2nd degree burn

Question 5

Which is an ominous sign in case of severe head injury?

Accepted Answer

Anisocoria

Answer

Depressed skull fracture

Answer

Development of diabetes insipidus

Answer

New focal deficit

Question 6

At what percentage of total body surface area (TBSA) burns does shock set in an adult, if untreated?

Accepted Answer

15%

Answer

25%

Answer

10%

Answer

30%

Question 7

A 56-year-old male is burned while sleeping in his home. His right upper and lower extremity and the anterior chest have extensive second-degree burns. What is the total percentage of body surface area affected?

Reference: Rule of Nines for Adults
- Each arm: 9%
- Head: 9%
- Anterior trunk: 18%
- Posterior trunk: 18%
- Each leg: 18%
- Total: 99%

Accepted Answer

40%

Answer

10%

Answer

20%

Answer

30%

Question 8

Indication for thoracotomy in a patient with traumatic hemothorax -

Accepted Answer

Open thoracotomy with ligation of vessel

Answer

Wait and watch

Answer

Needle aspiration

Answer

Intercostal tube

Question 9

True about chest trauma:

Accepted Answer

ECG done in all cases associated with sternal fracture

Answer

All of the options

Answer

Urgent surgery needed in all cases

Answer

Under water seal drainage if associated with pneumothorax. X-ray chest investigation of choice

Question 10

Formula for calculating initial fluid resuscitation volume in burns for the first 24 hours:

Accepted Answer

% body surface area X weight in Kgs X 4 = Volume in ml

Answer

% body surface area X weight in pounds X 4 = Volume in ml

Answer

% body surface area X weight in Kgs X 5 = Volume in ml

Answer

% body surface area X weight in Kgs X 3 = Volume in ml

Trauma — MCQs

Trauma — MCQs

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