Trauma Practice Questions

Q: In pneumothorax due to blunt injury, the treatment of choice is

Intercostal drainage. ***Intercostal drainage*** - **Intercostal drainage** (chest tube insertion) is the treatment of choice for pneumothorax caused by **blunt injury**, especially if the pneumothorax is large or causing respiratory distress. - This procedure effectively evacuates air from the **pleural space**, allowing the lung to re-expand and alleviating symptoms like shortness of breath. *Observation* - **Observation** is generally reserved for **small, asymptomatic pneumothoraces**, typically less than 20% of the hemithorax volume, particularly in spontaneous pneumothorax. - In cases of pneumothorax due to **blunt injury**, there is a higher likelihood of associated injuries and progression, making observation often insufficient or unsafe. *Pneumonectomy* - **Pneumonectomy** involves the surgical removal of an entire lung and is a drastic procedure indicated for conditions like **severe lung cancer** or extensive, irreparable lung damage. - It is not a primary treatment for pneumothorax, as the goal is to re-expand the existing lung, not remove it. *Thoracotomy* - **Thoracotomy** is a major surgical incision into the chest cavity, typically performed to access organs like the lung, heart, or esophagus for complex surgical repairs. - While it can be necessary in cases of persistent air leak or severe bleeding after chest tube insertion, it is not the **initial treatment of choice** for pneumothorax from blunt injury.

Q: All of the following are suggestive of a positive diagnostic peritoneal lavage (DPL) except.

Clear effluent with RBCs <100,000/mm3. ***Clear effluent with RBCs <100,000/mm³*** - A **clear effluent** with an **RBC count 10 mL of gross blood is aspirated directly from peritoneal cavity* - Direct aspiration of **>10 mL of gross blood** from the peritoneal cavity is a **positive DPL criterion** and indicates significant intra-abdominal hemorrhage. - This finding is a strong indicator for **immediate surgical exploration (laparotomy)** and represents one of the most definitive positive DPL findings. - When this much gross blood is aspirated initially, it confirms the need for surgery without requiring further lavage analysis. *Effluent contains RBCs >100,000/mm³* - An **RBC count >100,000/mm³** in the DPL effluent is a standard criterion for a **positive DPL**, indicating significant hemoperitoneum. - This finding typically warrants **surgical intervention** to identify and manage the source of bleeding. *Effluent contains Amylase >175 IU/dL* - An **amylase level >175 IU/dL** in the DPL effluent suggests possible **pancreatic or intestinal injury**. - This is a significant indicator of visceral injury and constitutes a **positive DPL**, often prompting surgical exploration.

Q: All of the following are true regarding renal trauma, except which of the following?

Exploration indicated in all cases. ***Exploration indicated in all cases*** - This statement is incorrect because not all renal traumas require **surgical exploration**. Many low-grade renal injuries can be managed **conservatively** with observation. - The decision for exploration depends on the **grade of injury**, hemodynamic stability, and associated injuries. **Absolute indications** for exploration include: hemodynamic instability despite resuscitation, expanding/pulsatile perirenal hematoma, and renal pedicle avulsion. - Approximately **80-90% of renal traumas** are managed non-operatively. *Observation is best* - This is true for **low-grade renal injuries (Grade I-III)**, especially in hemodynamically stable patients. - **Conservative management** with bed rest, fluid resuscitation, serial hemoglobin monitoring, and close observation is the preferred approach for most renal traumas that do not involve major vascular injury or ongoing hemorrhage. *CECT is the investigation of choice* - **Contrast-Enhanced CT (CECT)** is the **gold standard** imaging modality for evaluating renal trauma in hemodynamically stable patients. - It provides detailed information about the **grade of injury**, renal parenchymal damage, collecting system involvement, urinary extravasation, and vascular injuries. - CECT helps in **injury grading** (AAST classification) and guides management decisions regarding conservative vs. operative management. *Haematuria is a cardinal sign* - **Hematuria (blood in the urine)** is indeed a cardinal sign of renal trauma and is present in **over 90% of cases**. - The presence of gross or microscopic hematuria after blunt or penetrating abdominal trauma warrants investigation for potential renal injury. - **Important:** The degree of hematuria does NOT correlate with the severity of injury. Severe injuries like renal pedicle avulsion may present with minimal or absent hematuria.

Q: What is the percentage of total body surface area represented by the palm of an adult burn patient?

1% of total body surface area. **1% of total body surface area** ✓ - The **palm rule** is a quick method for estimating burn size, stating that an adult's palm (including fingers) represents approximately **1% of their total body surface area (TBSA)**. - This rule is particularly useful for scattered burns or when the **Rule of Nines** is difficult to apply. *18% of total body surface area* - According to the **Rule of Nines**, 18% of TBSA represents either the entire front of the trunk, the entire back of the trunk, or both entire legs. - This percentage is significantly larger than the area covered by an adult's palm. *27% of total body surface area* - This percentage does not directly correspond to a standard anatomical region in either the **Rule of Nines** or the **palm rule** for burn estimation. - It would represent a combination of multiple body parts, far exceeding the area of a single palm. *9% of total body surface area* - The **Rule of Nines** assigns 9% of TBSA to an arm, the head and neck (in adults), or half of a single leg. - While a quick estimation, this is much larger than the area of a single palm.

Q: A patient with multiple injuries exhibits paradoxical chest movements during inspiration and expiration due to?

Flail chest. **Flail chest** - **Paradoxical chest movement** is the hallmark of a flail chest, where a segment of the chest wall moves inward during inspiration and outward during expiration, opposite to the rest of the chest. - This occurs due to the **severance of multiple ribs** in at least two places, creating an unstable segment. *Pneumothorax* - A **pneumothorax** involves air accumulation in the pleural space, leading to lung collapse and **diminished breath sounds**, but not typically paradoxical motion. - While it impairs breathing, its primary mechanical effect is compression of the lung, not an unstable chest wall segment. *Cardiac tamponade* - **Cardiac tamponade** is the compression of the heart by fluid in the pericardial sac, primarily causing **hemodynamic instability** such as hypotension and muffled heart sounds. - It does not involve direct injury to the chest wall or cause paradoxical chest movements. *Hemothorax* - A **hemothorax** is the accumulation of blood in the pleural space, causing lung compression and impaired ventilation, with symptoms like **shortness of breath** and **dullness to percussion**. - Similar to pneumothorax, it compromises lung function but does not directly result in a mechanically unstable segment of the chest wall that moves paradoxically.

Q: Parkland's formula is used to calculate the fluid replacement to be given in the first 24 hours in a case of deep burns. What is the Parkland formula?

TBSA x weight in kg x 4. ***TBSA x weight in kg x 4*** - Parkland's formula calculates the **total fluid replacement during the first 24 hours** post-burn as 4 mL of Ringer's Lactate per kilogram of body weight per percentage of **total body surface area (TBSA)** burned. - Half of the calculated volume is administered within the first 8 hours, and the remaining half over the next 16 hours. *TBSA x weight in kg x 2* - This value represents half of the recommended fluid volume using the Parkland formula, and would be insufficient for total 24-hour resuscitation. - Inadequate fluid resuscitation can lead to **burn shock**, characterized by hypoperfusion and organ dysfunction. *TBSA x weight in kg x 3* - This multiplier falls short of the recommended 4 mL/kg/TBSA for comprehensive fluid resuscitation in adults. - Using this formula could result in undertreatment, potentially compromising tissue perfusion and increasing the risk of complications. *TBSA x weight in kg* - This formula represents one-fourth of the recommended fluid volume according to the Parkland formula. - This significantly inadequate fluid replacement would lead to severe **hypovolemia**, organ failure, and a very poor prognosis.

Q: True regarding management of traumatic pneumothorax is:

Immediate ICD tube insertion. ***Immediate ICD tube insertion*** - **Chest tube (ICD) insertion** is the **standard of care** for traumatic pneumothorax according to **ATLS guidelines** - Unlike spontaneous pneumothorax, traumatic cases require tube thoracostomy due to: - High risk of **tension pneumothorax** development - Need for **positive pressure ventilation** in trauma patients - Presence of **ongoing air leak** from lung injury - Frequent **associated injuries** (hemothorax, rib fractures) - Even small traumatic pneumothoraces warrant chest tube due to unpredictable progression *CT-scan should be done to confirm pulmonary leak* - **Chest X-ray** is the standard initial imaging for traumatic pneumothorax, not CT scan - CT may be used to detect **occult pneumothorax** or for surgical planning, but is not routinely required for diagnosis - The term "confirm pulmonary leak" is medically imprecise; diagnosis is typically made by chest X-ray *Intermittent needle aspiration* - **Needle aspiration** is appropriate for **primary spontaneous pneumothorax** in select cases - **Not recommended** for traumatic pneumothorax due to: - Higher recurrence rates - Need for definitive drainage - Risk of ongoing bleeding or air leak - May be used temporarily for **tension pneumothorax** as an emergency measure before chest tube insertion *Conservative management is appropriate for all cases* - The word **"all"** makes this statement incorrect - Conservative management may be considered only for **very small (<2cm), asymptomatic** occult pneumothoraces in stable patients - Most traumatic pneumothoraces require intervention due to trauma mechanism and associated risks

Q: Which agent is associated with pseudoeschar formation?

Silver sulfadiazine. ***Silver sulfadiazine*** - **Silver sulfadiazine** reacts with wound exudate to form a black precipitate, which can be mistaken for an eschar and is thus called **pseudoeschar**. - This characteristic pseudoeschar formation is an important consideration when assessing wound healing in patients treated with this agent. *Silver Nitrate* - While it has antimicrobial properties and can stain tissues, it is not primarily known for causing a widespread **pseudoeschar** formation like silver sulfadiazine. - Its mechanism often involves acting as a caustic agent, forming a crust, but not typically a pseudoeschar from its interaction with exudate. *Povidone iodine* - **Povidone iodine** is an antiseptic that can cause temporary staining of the skin to a brownish color, but it does not form a black, leathery **pseudoeschar**. - Its antiseptic action is due to the slow release of iodine, which denatures proteins and oxidizes cell components. *Mafenide acetate* - **Mafenide acetate** is a carbonic anhydrase inhibitor that can cause metabolic acidosis and pain upon application but does not typically lead to the formation of a **pseudoeschar**. - It penetrates the eschar effectively and is known for its broad-spectrum antimicrobial activity.

Q: As per the trimodal distribution, what percentage of all deaths occur immediately in major trauma?

50%. ***50%*** - The **trimodal distribution of trauma deaths** identifies three peaks in mortality following major trauma. The first peak, representing approximately **50% of all deaths**, occurs **immediately** at the scene or shortly after. - These deaths are often due to severe, unavoidable injuries such as **aortic rupture, severe brain injury, brainstem injury, or high cervical spinal cord injury**. *25%* - This percentage is too low for the immediate death peak in major trauma. The distribution indicates a significantly higher proportion of deaths occur upfront. - While a certain percentage of deaths occur later, the **initial immediate mortality** is much higher than 25%. *35%* - This value is not consistent with the established percentages of the trimodal distribution for immediate trauma deaths. - The **immediate death peak** is known to be the largest, representing a considerable proportion of overall mortality. *45%* - This is close but not the most accurate percentage for immediate trauma deaths in the trimodal distribution. - The figure of **50% is widely accepted and taught** for the initial, immediate mortality phase.

Q: A 60-kg female has a second-degree deep burn involving 40% of her total body surface area, with hoarseness of voice. What is the IMMEDIATE priority in her management?

Intubation must be done. ***Intubation must be done*** - The presence of **hoarseness of voice** in a burn patient indicates potential **airway edema** or **inhalational injury**, which can rapidly progress to complete airway obstruction. - Securing the airway via **intubation** is the immediate priority to prevent life-threatening respiratory compromise. - Early intubation is crucial because airway edema progresses over hours, and delayed intubation may become extremely difficult or impossible. *9.6 liters of Ringer's lactate should be given in the first 24 hours.* - While **fluid resuscitation** is crucial in burn management, calculating the total 24-hour fluid requirement using the **Parkland formula** (4 mL × kg × %TBSA = 4 × 60 × 40 = 9,600 mL) is secondary to **securing the airway**. - Fluid resuscitation follows the **ABC protocol** where Airway takes precedence over Circulation. *Normal saline is the fluid of choice.* - This is **incorrect**. **Ringer's lactate** is the preferred crystalloid over normal saline for burn resuscitation because it is a **balanced crystalloid** with a composition closer to plasma, reducing the risk of **hyperchloremic acidosis**. - Choice of fluid is important but is not the immediate priority over managing an impending airway emergency. *4.8 liters of Ringer's lactate should be given in the first 8 hours.* - Administering half of the total 24-hour fluid volume (9.6 L ÷ 2 = 4.8 L) in the first 8 hours is correct per the **Parkland formula** for fluid resuscitation. - This is a critical step in managing burn shock, but it follows the established **ABC (Airway, Breathing, Circulation)** protocol, placing **airway management** as the paramount immediate concern.

Question 1

In pneumothorax due to blunt injury, the treatment of choice is

Accepted Answer

Intercostal drainage

Answer

Observation

Answer

Pneumonectomy

Answer

Thoracotomy

Question 2

All of the following are suggestive of a positive diagnostic peritoneal lavage (DPL) except.

Accepted Answer

Clear effluent with RBCs <100,000/mm3

Answer

Effluent contains RBCs >100,000/mm3

Answer

Effluent contains Amylase >175 IU/dL

Answer

>10 mL of gross blood is aspirated directly from peritoneal cavity

Question 3

All of the following are true regarding renal trauma, except which of the following?

Accepted Answer

Exploration indicated in all cases

Answer

Observation is best

Answer

Haematuria is a cardinal sign

Answer

CECT is the investigation of choice

Question 4

What is the percentage of total body surface area represented by the palm of an adult burn patient?

Accepted Answer

1% of total body surface area

Answer

18% of total body surface area

Answer

27% of total body surface area

Answer

9% of total body surface area

Question 5

A patient with multiple injuries exhibits paradoxical chest movements during inspiration and expiration due to?

Accepted Answer

Flail chest

Answer

Pneumothorax

Answer

Hemothorax

Answer

Cardiac tamponade

Question 6

Parkland's formula is used to calculate the fluid replacement to be given in the first 24 hours in a case of deep burns. What is the Parkland formula?

Accepted Answer

TBSA x weight in kg x 4

Answer

TBSA x weight in kg x 2

Answer

TBSA x weight in kg x 3

Answer

TBSA x weight in kg

Question 7

True regarding management of traumatic pneumothorax is:

Accepted Answer

Immediate ICD tube insertion

Answer

CT-scan should be done to confirm pulmonary leak

Answer

Intermittent needle aspiration

Answer

Conservative management is appropriate for all cases

Question 8

Which agent is associated with pseudoeschar formation?

Accepted Answer

Silver sulfadiazine

Answer

Silver Nitrate

Answer

Mafenide acetate

Answer

Povidone iodine

Question 9

As per the trimodal distribution, what percentage of all deaths occur immediately in major trauma?

Accepted Answer

50%

Answer

25%

Answer

35%

Answer

45%

Question 10

A 60-kg female has a second-degree deep burn involving 40% of her total body surface area, with hoarseness of voice. What is the IMMEDIATE priority in her management?

Accepted Answer

Intubation must be done

Answer

9.6 liters of Ringer’s lactate should be given in the first 24 hours.

Answer

Normal saline is the fluid of choice.

Answer

4.8 liters of Ringer’s lactate should be given in the first 8 hours.

Trauma — MCQs

Trauma — MCQs

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