Trauma — MCQs
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Immediate treatment of compound fracture of tibia includes:
Which of the following is a major risk factor for fat embolism syndrome in a patient with major trauma?
Which of the following is commonest source of Extradural haemorrhage -
A 17-year-old boy is admitted to the hospital after a road traffic accident. Per abdomen examination is normal. After adequate resuscitation, his pulse rate is 80/min and BP is 110/70 mm Hg. Abdominal CT reveals a laceration in the left lobe of the liver extending from the dome more than half way through the parenchyma. Appropriate management at this time would be:
Which of the following is a treatment option for Volkmann's ischemia?
A trauma patient was brought to emergency. On evaluation, patient was found to have metabolic acidosis and coagulopathy with liver and duodenal injury. Next step:
A comatose 28-year-old woman sustained a depressed skull fracture in an automobile collision. She has been unconscious for 6 weeks. Her vital signs are stable and she breathes room air. Following her initial decompressive craniotomy, she has returned to the operating room twice due to intracranial bleeding. Select the best method of physiologic monitoring necessary for the patient.
A 40 years old male was brought emergency with severe abdominal pain. On examination, pulse rate was 112/minute and systolic BP was 80 mmHg. Chest x-ray is given below. What is the most appropriate management?
What is the most common site of injury in an underwater blast?
Glasgow coma scale of a patient with head injury who is confused, localizes to pain on the right side but shows abnormal flexion on the left side, and opens eyes only to painful stimuli on sternum:
Trauma Indian Medical PG Practice Questions and MCQs
Question 1041: Immediate treatment of compound fracture of tibia includes:
- A. Antibiotics and debridement only
- B. Debridement and splinting only
- C. Antibiotics, debridement, and splinting (Correct Answer)
- D. Debridement, splinting, and blood transfusion
Explanation: ***Antibiotics, debridement, and splinting*** - **Antibiotics** are crucial to prevent infection in **compound (open) fractures** due to communication with the external environment. - **Debridement** removes contaminated and devitalized tissue, while **splinting** stabilizes the fracture and minimizes further soft tissue damage. *Antibiotics and debridement only* - While antibiotics and debridement are essential, **splinting** is also critical for immobilizing the fracture and preventing further injury. - Without stabilization, the fracture site can move, causing additional soft tissue damage and increasing the risk of infection and delayed healing. *Debridement and splinting only* - This option overlooks the critical need for **antibiotics** in compound fractures, which are at high risk of infection due to the exposure of bone and tissue to bacteria. - Infection can lead to serious complications such as **osteomyelitis**, significantly impacting recovery and patient outcomes. *Debridement, splinting, and blood transfusion* - While debridement and splinting are correct, a **blood transfusion** is generally not an immediate routine treatment for all compound tibial fractures unless there is significant hemorrhage leading to hypovolemic shock. - The primary immediate concerns are infection prevention and stabilization, not typically massive blood loss requiring transfusion in every case.
Question 1042: Which of the following is a major risk factor for fat embolism syndrome in a patient with major trauma?
- A. Long bone fractures (femur or tibia) (Correct Answer)
- B. Isolated soft tissue injury
- C. Hypovolemic shock
- D. Increased mobility after trauma
Explanation: ***Long bone fractures (femur or tibia)*** - **Long bone fractures**, particularly of the **femur and tibia**, are the **most common cause** of fat embolism syndrome, accounting for 90% of cases - Fat globules from the bone marrow enter the venous circulation through disrupted medullary vessels - Multiple fractures increase the risk significantly - Early fracture stabilization reduces the risk of fat embolism syndrome *Increased mobility after trauma* - Early mobilization is actually **protective** against complications like DVT and does not cause fat embolism - Fat embolism occurs due to the initial trauma itself, not subsequent mobility *Isolated soft tissue injury* - Soft tissue injuries alone rarely cause clinically significant fat embolism - Fat embolism syndrome requires release of bone marrow fat, which occurs with skeletal trauma *Hypovolemic shock* - While hypovolemic shock can occur concurrently with trauma, it is **not a causative factor** for fat embolism - Both may result from the same traumatic event but represent different pathophysiological processes
Question 1043: Which of the following is commonest source of Extradural haemorrhage -
- A. Middle meningeal artery (Correct Answer)
- B. Anterior ethmoidal artery
- C. Posterior meningeal artery
- D. Diploic veins
Explanation: ***Middle meningeal artery*** - The **middle meningeal artery** is the most common source of **extradural (epidural) hemorrhage**, typically due to a traumatic skull fracture that lacerates the vessel. - This arterial bleed leads to a rapid accumulation of blood between the dura mater and the inner table of the skull, often forming a **lenticular (lens-shaped) hematoma** on CT scans. *Anterior ethmoidal artery* - The anterior ethmoidal artery is generally associated with hemorrhage in the frontal sinuses or orbits, rather than the epidural space. - While it can be injured in facial trauma, it is not a typical source for an intradural or extradural intracranial hemorrhage. *Posterior meningeal artery* - The posterior meningeal artery is a much smaller vessel compared to the middle meningeal artery and is a less common source of extradural hemorrhage. - When involved, it typically contributes to smaller, less extensive hematomas in the posterior cranial fossa. *Diploic veins* - **Diploic veins** are located within the spongy bone of the skull and drain into dural sinuses or intracranial veins. - While they can bleed, hemorrhage from diploic veins usually results in venous bleeding, which is slower and rarely causes a large, clinically significant extradural hematoma.
Question 1044: A 17-year-old boy is admitted to the hospital after a road traffic accident. Per abdomen examination is normal. After adequate resuscitation, his pulse rate is 80/min and BP is 110/70 mm Hg. Abdominal CT reveals a laceration in the left lobe of the liver extending from the dome more than half way through the parenchyma. Appropriate management at this time would be:
- A. Conservative treatment (Correct Answer)
- B. Abdominal exploration and packing of hepatic wounds
- C. Abdominal exploration and ligation of left hepatic artery
- D. Left hepatectomy
Explanation: ***Conservative treatment*** - The patient is **hemodynamically stable** after resuscitation, with normal vital signs (pulse 80/min, BP 110/70 mm Hg), and his abdominal exam is normal despite a liver laceration. - A laceration extending more than halfway through the left hepatic lobe represents a **Grade III liver injury**. In hemodynamically stable patients, non-operative management is the preferred approach for most blunt liver injuries, including Grade III injuries, with success rates exceeding 90%. - Conservative management includes **serial clinical monitoring**, hemoglobin checks, and repeat imaging if needed, with intervention only if the patient deteriorates. *Abdominal exploration and packing of hepatic wounds* - This aggressive approach is typically reserved for patients with **hemodynamic instability** due to ongoing hemorrhage from liver trauma or those who fail non-operative management. - Perihepatic packing is a damage control technique for severe, uncontrolled bleeding, but it is not indicated for a stable patient as it comes with risks including **infection**, abdominal compartment syndrome, and the need for re-operation. *Abdominal exploration and ligation of left hepatic artery* - Hepatic artery ligation is a measure used to control **severe arterial bleeding** from hepatic injuries, usually via angioembolization (preferred) or surgical ligation in highly unstable patients after other methods have failed. - While the liver has a dual blood supply (hepatic artery and portal vein), this intervention carries risks of hepatic **necrosis** and abscess formation, which are unwarranted in a stable patient suitable for conservative management. *Left hepatectomy* - **Resective surgery** like hepatectomy is indicated for severe and complex liver injuries involving massive tissue destruction, complete devascularization, or injuries to major intrahepatic vessels causing persistent hemorrhage despite other interventions. - This patient's stable hemodynamics make major surgical resection unnecessary and inappropriate, as hepatectomy carries significant **morbidity and mortality** (10-20% mortality rate for major hepatic resections in trauma).
Question 1045: Which of the following is a treatment option for Volkmann's ischemia?
- A. Bone shortening
- B. Fasciotomy (Correct Answer)
- C. Cock up splint
- D. Turn buckle splint
Explanation: ***Fasciotomy*** - **Fasciotomy** is the **emergency surgical treatment** for **acute Volkmann's ischemia** caused by compartment syndrome. - This procedure involves making incisions through the fascia to relieve elevated compartment pressure and restore blood flow, preventing irreversible muscle and nerve damage. - Must be performed urgently to prevent progression to **Volkmann's contracture** (established muscle necrosis and fibrosis). *Bone shortening* - **Bone shortening** is a reconstructive procedure used in **late/established Volkmann's contracture**, not for acute ischemia. - It may be used to facilitate soft tissue reconstruction or correct deformities after muscle necrosis has occurred. - Does not address the acute ischemic emergency. *Cock up splint* - A **cock-up splint** maintains the wrist in extension and is used for **rehabilitation** in chronic/established Volkmann's contracture. - May help prevent further deformity or support weakened extensors after muscle damage has occurred. - Does not treat the acute compartment syndrome or restore blood flow. *Turn buckle splint* - A **turnbuckle splint** is used for **gradual correction of joint contractures** in established Volkmann's contracture. - This is a rehabilitative device for chronic cases, not for acute treatment. - Does not address the acute circulatory compromise or compartment syndrome.
Question 1046: A trauma patient was brought to emergency. On evaluation, patient was found to have metabolic acidosis and coagulopathy with liver and duodenal injury. Next step:
- A. Whipples procedure
- B. Observation and supportive care only
- C. Damage control surgery (Correct Answer)
- D. Liver repair
Explanation: ***Damage control surgery*** - A patient with significant trauma, including **liver** and **duodenal injury**, experiencing **metabolic acidosis** and **coagulopathy**, indicates profound physiological derangement, necessitating immediate **damage control surgery**. - This approach prioritizes **bleeding control** and contamination management in a rapid initial operation, followed by patient stabilization and definitive repair in a subsequent surgery once physiological parameters improve. *Whipples procedure* - A **Whipple procedure** (pancreaticoduodenectomy) is a complex and lengthy operation typically performed for pancreatic, duodenal, or distal bile duct cancers. - It is **contraindicated** in an unstable trauma patient with acute metabolic derangements due to its extensive nature and the patient's compromised physiological state. *Observation and supportive care only* - Given the severity of injuries (liver and duodenal) and the presence of **metabolic acidosis** and **coagulopathy**, **observation alone** is insufficient and would lead to rapid deterioration and death. - These injuries require **immediate surgical intervention** to control bleeding and prevent further complications like peritonitis. *Liver repair* - While **liver repair** is part of the overall surgical management for liver injury, focusing solely on this specific repair immediately, without addressing the overall patient physiology and other injuries in the context of damage control, would be inappropriate. - A **planned, definitive repair** of the liver might occur during a later stage of damage control surgery, after initial stabilization.
Question 1047: A comatose 28-year-old woman sustained a depressed skull fracture in an automobile collision. She has been unconscious for 6 weeks. Her vital signs are stable and she breathes room air. Following her initial decompressive craniotomy, she has returned to the operating room twice due to intracranial bleeding. Select the best method of physiologic monitoring necessary for the patient.
- A. Central venous catheterization
- B. Pulmonary artery catheterization
- C. Intracranial pressure monitoring (Correct Answer)
- D. Blood-gas monitoring
Explanation: ***Intracranial pressure monitoring*** - This patient has a history of **depressed skull fracture**, **decompressive craniotomy**, and **intracranial bleeding**, all of which significantly increase the risk of elevated **intracranial pressure (ICP)**. - Monitoring ICP is crucial for detecting and managing cerebral edema or hematoma expansion, preventing secondary brain injury in a comatose patient. *Central venous catheterization* - While useful for monitoring **central venous pressure (CVP)** and administering fluids/medications, it does not directly assess cerebral perfusion or intracranial dynamics. - CVP alone is a poor indicator of ICP, and changes in CVP do not reliably reflect changes in cerebral perfusion pressure (CPP). *Pulmonary artery catheterization* - This provides detailed hemodynamic information including **cardiac output**, **pulmonary artery pressure**, and **pulmonary capillary wedge pressure**, primarily for assessing cardiac function and fluid status. - It is overly invasive and unnecessary for a patient with stable vital signs whose primary concern is neurological status. *Blood-gas monitoring* - **Arterial blood gas (ABG)** analysis assesses **oxygenation**, **ventilation**, and **acid-base balance**, which are important for overall patient management. - While important, ABG monitoring does not directly provide information about ICP or cerebral perfusion, which is the most critical parameter in this specific neurological injury scenario.
Question 1048: A 40 years old male was brought emergency with severe abdominal pain. On examination, pulse rate was 112/minute and systolic BP was 80 mmHg. Chest x-ray is given below. What is the most appropriate management?
- A. Exploratory laparotomy (Correct Answer)
- B. Saline wash of stomach
- C. Intercostal tube drainage
- D. IV antibiotics
Explanation: ***Exploratory laparotomy*** - The chest x-ray shows **pneumoperitoneum (air under the diaphragm)**, which, combined with severe abdominal pain, tachycardia, and hypotension (signs of **septic shock**), is highly indicative of a **perforated viscus**. - **Emergency exploratory laparotomy** is the definitive treatment to identify and repair the perforation, control contamination, and prevent further deterioration. *Saline wash of stomach* - This procedure is typically used for gastric lavage in cases of **poisoning or drug overdose**, or to clear the stomach in preparation for endoscopy. - It does not address a viscus perforation or the widespread abdominal contamination and systemic septic response seen in this patient. *Intercostal tube drainage* - **Intercostal tube drainage** (chest tube placement) is used to drain air (pneumothorax) or fluid (pleural effusion, hemothorax, empyema) from the pleural space, not the abdominal cavity. - While there is air visible on the x-ray, it is **subdiaphragmatic (pneumoperitoneum)**, not within the pleural space, and thus a chest tube would be ineffective and inappropriate. *IV antibiotics* - **Intravenous antibiotics** are crucial for managing sepsis associated with a perforated viscus and should be administered promptly. - However, antibiotics alone are **not sufficient** to treat the underlying mechanical problem of a perforation, which requires surgical repair to prevent ongoing bacterial contamination and sepsis.
Question 1049: What is the most common site of injury in an underwater blast?
- A. Lung
- B. GIT (Correct Answer)
- C. Tympanic membrane
- D. Liver
Explanation: ***GIT (Correct Answer)*** - The **gastrointestinal tract (GIT)** is the most common site of injury in an underwater blast due to the presence of air-filled organs that are highly susceptible to pressure changes. - The **rupture of hollow viscera** such as the stomach and intestines can lead to severe abdominal pain, hemorrhage, and peritonitis. - Underwater blasts transmit pressure waves efficiently through water, causing maximum damage to air-filled hollow organs. *Lung (Incorrect)* - While **pulmonary barotrauma** can occur, the lungs are less frequently injured compared to the GIT in underwater blasts unless unprotected or subjected to severe pressure. - Lung injuries may manifest as **pneumothorax**, pulmonary contusions, or air embolism. *Tympanic membrane (Incorrect)* - The **tympanic membrane** is the most frequently ruptured structure in blast injuries and highly vulnerable to pressure changes. - However, while common, it is not the most common site of **major organ damage** or life-threatening injury in an underwater blast scenario. *Liver (Incorrect)* - The **liver**, being a solid organ, is less susceptible to direct blast injury from pressure waves compared to air-filled organs. - Liver injury is more likely to result from secondary effects such as blunt trauma from impact against objects or deceleration forces.
Question 1050: Glasgow coma scale of a patient with head injury who is confused, localizes to pain on the right side but shows abnormal flexion on the left side, and opens eyes only to painful stimuli on sternum:
- A. 11 (Correct Answer)
- B. 12
- C. 6
- D. 7
Explanation: ***11*** - The Glasgow Coma Scale (GCS) score is calculated by summing the scores for **Eye Response**, **Verbal Response**, and **Motor Response**. - In this case: **Eye Response = 2** (opens eyes to painful stimuli), **Verbal Response = 4** (confused), and **Motor Response = 5** (localizes to pain on the right side). - **Key principle**: When there is **asymmetric motor response**, the **best motor response** is used for GCS calculation, not the worse response or an average. - Right side localizes to pain (M5) and left side shows abnormal flexion (M3), so we use M5. - **Total GCS = E2 + V4 + M5 = 11** *12* - This score would require a better response in at least one GCS component than what is described. - For a GCS of 12, the patient would need either: eyes opening to voice (E3), or obeys commands for motor (M6), or no confusion (V5). - The given patient has E2 + V4 + M5, which totals to 11, not 12. *6* - A score of 6 indicates **severe neurological impairment**, much worse than the described patient. - A GCS of 6 might include: no eye opening (E1) + incomprehensible sounds (V2) + abnormal flexion (M3) = 6. - This is significantly worse than the patient's current state with localizing response and confused speech. *7* - A GCS of 7 also represents **severe neurological deficit**, though not as profound as a score of 6. - This score would typically involve lower responses such as: E1 + V2 + M4 (withdrawal to pain) = 7, or E2 + V1 + M4 = 7. - The described patient has better responses (E2 + V4 + M5 = 11) than this would indicate.
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Initial Assessment of Trauma Patient
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Advanced Trauma Life Support (ATLS) Principles
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Chest Trauma
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Abdominal Trauma
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Head Trauma
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Spinal Trauma
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Extremity Trauma
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Vascular Trauma
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Genitourinary Trauma
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Burns Management
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Mass Casualty Management
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Damage Control Surgery
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