Trauma — MCQs

Trauma Indian Medical PG Practice Questions and MCQs

Question 1021: Which organ is commonly involved in a stab injury to the abdomen?

A. Small intestine (Correct Answer)
B. Kidney
C. Bladder
D. Spleen

Explanation: ***Small intestine*** - The **small intestine** is the most frequently injured hollow viscus in abdominal stab wounds due to its large size and extensive intraperitoneal location. - Its vulnerability makes it a common site for trauma, leading to potential **peritonitis** if perforated. *Kidney* - The **kidneys** are retroperitoneal organs, making them less likely to be involved in a typical anterior abdominal stab wound. - Injury to the kidney often requires a stab wound to the **flank or back**. *Bladder* - The **bladder** is predominantly a pelvic organ and is only vulnerable to abdominal stab wounds when distended and rising above the pelvic brim. - Injury is less common compared to the intra-abdominal organs unless the stab wound is in the **suprapubic region**. *Spleen* - The **spleen** is a common organ involved in blunt abdominal trauma due to its friability, but it is less frequently injured by stab wounds compared to the small intestine. - Its location in the **left upper quadrant**, partially protected by the ribs, makes it less exposed to direct anterior stab injury than the more diffuse small bowel.

Question 1022: A 40 year old male driver had a car accident in which he got wedged in between. He complained of severe abdominal pain with radiation to the back. The initial CT on admission was negative except for minimal retroperitoneal hematoma. The diagnosis is

A. Liver injury
B. Bowel rupture
C. Pancreatic injury (Correct Answer)
D. Duodenal perforation

Explanation: ***Pancreatic injury*** - Severe **abdominal pain radiating to the back** after blunt trauma is a classic presentation for **pancreatic injury**, especially with a crushing mechanism as described. - Initial CT scans can be deceptively negative, as pancreatic injuries, particularly **ductal disruptions**, may not be immediately obvious, but a **minimal retroperitoneal hematoma** can be an early subtle sign. *Liver injury* - While liver injury is common in blunt abdominal trauma, it typically presents with right upper quadrant pain and is usually visible on initial CT scans, often with signs of **hemoperitoneum** or a clear parenchymal laceration. - **Pain radiation to the back** is less characteristic of an isolated liver injury compared to pancreatic pathology. *Bowel rupture* - Bowel rupture can cause significant abdominal pain, but it often leads to signs of **peritonitis** and may show **free air** on imaging or significant fluid collections not typically described as a "minimal retroperitoneal hematoma." - The mechanism of injury (wedged in between) can cause bowel injury, but the radiating back pain without peritonitis makes other diagnoses more likely. *Duodenal perforation* - **Duodenal perforation**, similar to pancreatic injury, can be subtle and cause retroperitoneal signs due to its retroperitoneal location. - However, the description of "minimal retroperitoneal hematoma" is less specific for a perforation, which often leads to **extravasation of gastric/duodenal contents** and more extensive inflammatory changes.

Question 1023: Treatment of choice in traumatic facial nerve injury with delayed onset or incomplete paralysis is -

A. Facial decompression
B. Masterly inactivity (Correct Answer)
C. Facial sling
D. Systemic corticosteroid

Explanation: ***Masterly inactivity*** - In traumatic facial nerve injuries with **delayed onset or incomplete paralysis**, the prognosis for **spontaneous recovery** is excellent (up to 90%). - This approach involves careful observation with serial clinical examinations, allowing time for nerve recovery without the risks of surgical intervention. - **Surgical exploration** is reserved for immediate complete paralysis or when electrodiagnostic tests (electromyography, electroneuronography) show >90% degeneration. *Facial decompression* - This surgical procedure is considered only in cases of **immediate complete paralysis** with temporal bone fractures and confirmed severe nerve degeneration on testing. - It is **not indicated** for delayed-onset or incomplete injuries, as these have excellent spontaneous recovery rates. - Carries risks of further nerve damage, CSF leak, and hearing loss. *Facial sling* - A facial sling is a **late reconstructive procedure** used for permanent facial paralysis when nerve recovery has failed after 1-2 years. - It is a palliative measure to improve facial symmetry and eye protection, not a treatment for acute nerve injury. *Systemic corticosteroid* - While corticosteroids have a role in **Bell's palsy** (idiopathic facial paralysis), their benefit in **traumatic facial nerve injury is unproven**. - The primary pathology in trauma is mechanical disruption, not inflammatory edema that would respond to steroids. - Some clinicians use steroids empirically, but evidence does not support this as standard treatment.

Question 1024: To calculate the initial fluid requirement in a burn patient, the best approach is:

A. CVP
B. Urine output
C. Estimate body surface area (burn) (Correct Answer)
D. Blood volume measurement

Explanation: ***Estimate body surface area (burn)*** - The primary determinant for initial fluid resuscitation in burn patients is the **total body surface area (TBSA)** affected by the burn. Formulas like the **Parkland formula** use TBSA to calculate initial fluid requirements. - Accurate estimation of TBSA is crucial for preventing both under-resuscitation (leading to shock) and over-resuscitation (leading to complications like compartment syndrome or ARDS). *CVP* - **Central venous pressure (CVP)** is generally not a reliable indicator for guiding fluid resuscitation in burn patients due to its poor correlation with cardiac output and tissue perfusion in this specific patient population. - Changes in CVP can be influenced by many factors, including intrathoracic pressure and right ventricular function, making it an insensitive marker for systemic fluid status in significant burns. *Urine output* - While **urine output** is an essential parameter for monitoring the adequacy of fluid resuscitation in burn patients *after* initial fluid administration, it is not used to *investigate* or *calculate* the initial fluid requirement. - It serves as a real-time indicator of organ perfusion and helps in titrating fluid rates but does not determine the initial bolus or 24-hour fluid volume. *Blood volume measurement* - **Direct measurement of blood volume** is a complex and often invasive procedure that is not practical or readily available for emergency assessment and initial fluid calculation in burn patients. - It is not a standard method for calculating initial fluid requirements in acute burn care.

Question 1025: A 19 year old girl sustained blunt abdominal trauma. She was diagnosed of having splenic rupture. Her pulse is 110/min and BP is normal. She is tachypneic with respiratory rate of 22/min and she is anxious. Her approximate blood loss is -

A. 1500 - 2000ml
B. < 750 ml
C. 750 - 1500ml (Correct Answer)
D. > 2000ml

Explanation: ***750 - 1500ml*** - The patient's **pulse of 110/min**, **normal blood pressure**, tachypnea (22/min), and anxiety are indicative of **Class II hemorrhage**, which typically involves a blood loss of 750-1500 ml. - In Class II hemorrhage, the body's compensatory mechanisms maintain blood pressure, but **tachycardia** (pulse >100 bpm) is a primary sign, often accompanied by **anxiety** and increased respiratory rate. *1500 - 2000ml* - A blood loss of 1500-2000 ml (Class III hemorrhage) would typically present with **significant hypotension** (systolic BP <90 mmHg), marked tachycardia (>120 bpm), and altered mental status. - The patient's **normal blood pressure** rules out this extent of blood loss. *< 750 ml* - A blood loss of less than 750 ml (Class I hemorrhage) would typically present with **minimal or no changes** in vital signs, and the patient would likely not exhibit significant anxiety or a pulse of 110/min. - The patient's **tachycardia** (110/min) indicates more significant blood loss than Class I. *> 2000ml* - A blood loss of more than 2000 ml (Class IV hemorrhage) is a life-threatening condition presenting with **profound hypovolemic shock**, including severe hypotension, marked tachycardia (>140 bpm), and usually unresponsiveness. - The patient's **normal blood pressure** and only moderate tachycardia do not align with this massive blood loss.

Question 1026: Which of the following burn cases requires IMMEDIATE referral to a specialized burn center?

A. 25% superficial burn in adult
B. Burn in palm
C. 10% superficial burn in child
D. 25% deep burn in adult (Correct Answer)
E. 5% superficial scald in adult

Explanation: ***25% deep burn in adult*** - A **deep burn** (full thickness or deep partial thickness) covering **greater than 10% TBSA** is an **absolute criterion** for immediate referral to a specialized burn center per ABA guidelines. - This is due to the high risk of **complications**, need for specialized **wound care**, and potential for **surgical intervention** like skin grafting. - The **combination of depth and extent** makes this the most urgent scenario requiring immediate specialized care. *25% superficial burn in adult* - **Superficial burns** (first-degree) involve only the epidermis and typically heal within days without scarring. - While 25% TBSA is extensive, **superficial burns** can often be managed with supportive care and do not meet the depth criterion for mandatory burn center referral. *Burn in palm* - **Burns involving hands** are considered **special areas** and typically require burn center evaluation for optimal functional outcomes. - However, without specification of **depth and extent**, a small superficial palm burn may be managed locally initially, whereas the question asks for IMMEDIATE referral. - The **25% deep burn** takes precedence due to its life-threatening nature and clear-cut indication. *10% superficial burn in child* - For children, burns greater than **10% TBSA** warrant consideration for burn center referral due to higher morbidity risk. - However, **superficial burns** (first-degree) in children, while concerning, are less urgent than deep burns of significant extent. - The depth of injury is a critical factor; superficial burns may be managed with close monitoring if appropriate expertise is available locally. *5% superficial scald in adult* - A **5% TBSA superficial burn** in an adult does not meet the threshold for mandatory burn center referral (typically >10% for partial thickness burns). - **Superficial scalds** can usually be managed with outpatient care, wound dressing, and pain control. - This would only require referral if other complicating factors were present (e.g., involvement of special areas, inhalation injury).

Question 1027: In an unconscious patient, spinal injury is assessed by:

A. Absence of response to painful stimulus
B. Abdominal respiration
C. Absence of deep tendon reflexes
D. All of the options (Correct Answer)

Explanation: ***All of the options*** In an unconscious patient, spinal cord injury assessment relies on a **comprehensive clinical examination** using multiple findings, as the patient cannot provide history or cooperate with neurological examination. All three assessment methods are used: - **Absence of response to painful stimulus below a certain level** indicates sensory pathway disruption and helps localize the level of spinal injury - **Abdominal (diaphragmatic) respiration** occurs when intercostal muscles are paralyzed due to high cervical/thoracic spinal cord injury (typically C3-C5), forcing the diaphragm to compensate - this is a key clinical sign - **Absence of deep tendon reflexes** below the injury level indicates spinal shock or complete spinal cord lesion, as neural pathways for reflexes are interrupted Since the patient is unconscious and cannot communicate, clinicians must use **objective physical findings** - all three signs together help assess for potential spinal injury and guide urgent management including spinal immobilization and imaging. *Why individual findings alone would be insufficient:* Each sign can have other causes, so comprehensive assessment using all findings together increases diagnostic accuracy and prevents missed injuries in this high-risk scenario.

Question 1028: What is the fluid of choice in burns?

A. Fresh frozen plasma
B. Ringer lactate (Correct Answer)
C. Dextrose 5% in water (D5W)
D. Normal saline

Explanation: ***Ringer lactate*** - **Ringer lactate** is the fluid of choice in burn resuscitation because its electrolyte composition is similar to that of extracellular fluid, helping to maintain **fluid and electrolyte balance**. - It also contains **lactate**, which is metabolized in the liver to bicarbonate, helping to correct the **metabolic acidosis** often seen in burn patients. *Fresh frozen plasma* - **Fresh frozen plasma (FFP)** is a blood product that contains clotting factors and plasma proteins, primarily used for patients with significant **coagulopathy** or **massive transfusions**. - It is not the initial fluid of choice for routine burn resuscitation, as its primary role is not volume expansion. *Dextrose 5% in water (D5W)* - **D5W** is primarily a source of free water and provides minimal electrolytes or volume expansion compared to crystalloids. - Administering large volumes of D5W in burn patients can lead to **hyponatremia** and exacerbate cerebral edema. *Normal saline* - While **normal saline** is a crystalloid and can be used for volume expansion, high volumes can cause **hyperchloremic metabolic acidosis** due to its high chloride content. - Ringer lactate is preferred due to its balanced electrolyte profile and ability to buffer acidosis.

Question 1029: You evaluate an 18 yrs old male who sustained a right sided cervical laceration during a gang fight. Which of the following is a relative rather than an absolute indication for neck exploration?

A. Dysphonia
B. Expanding hematoma
C. Pneumothorax (Correct Answer)
D. Dysphagia

Explanation: ***Pneumothorax*** - A pneumothorax, while concerning, can often be managed with a **chest tube** insertion without immediate surgical exploration, making it a relative indication. - Its presence suggests potential compromise to structures in the neck/chest but doesn't always mandate direct surgical wound exploration as a first step. *Dysphonia* - **Hoarseness or difficulty speaking** after a neck injury suggests potential direct laryngeal, tracheal, or recurrent laryngeal nerve injury, warranting exploration to assess and repair. - This symptom implies a direct compromise of the **airway or critical nerves**, making exploration more immediate. *Expanding hematoma* - An **expanding hematoma** indicates active, potentially life-threatening bleeding and/or mass effect, which can compromise the airway or blood supply to the brain. - This is an **absolute indication for immediate surgical exploration** to control hemorrhage and prevent airway obstruction. *Dysphagia* - **Difficulty swallowing** post-neck trauma suggests injury to the pharynx or esophagus. - Such injuries carry a significant risk of **mediastinitis** or sepsis if not promptly identified and repaired via surgical exploration.

Question 1030: In a patient with head injury, eye opening is seen with painful stimulus, localizes the pain and there is inappropriate verbal response. What would be the score on Glasgow coma scale:

A. 9
B. 8
C. 11
D. 10 (Correct Answer)

Explanation: ***10*** - **Eye Opening (E)**: **2** (due to painful stimulus) - **Verbal Response (V)**: **3** (due to inappropriate verbal response) - **Motor Response (M)**: **5** (due to localizing pain) - The total GCS score is calculated by summing these individual scores: 2 + 3 + 5 = **10**. *9* - This score might arise from different combinations, for instance, if the motor response was only withdrawal from pain instead of localization. - Withdrawal from pain for motor response is rated as **4**, making total score 2+3+4 = 9 *8* - This score could result from even lower responses, such as eye opening to pain (2), incomprehensible sounds (2), and withdrawal from pain (4). - This might reflect more severe neurological impairment. *11* - A score of 11 would imply better responses in one or more categories. For example in eye opening, verbal or motor response respectively. - Example: Eye opening to pain (2) + Confused conversation (4) + Localizing pain (5) = 11.

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