Trauma Practice Questions

Q: In frostbite, the skin becomes hard and black in about:

2 weeks. ***2 weeks*** - In cases of severe frostbite, the affected **skin and underlying tissue** typically become **hard, black, and mummified** within approximately 2 weeks after the injury. - This progression indicates **full-thickness tissue necrosis** and often leads to the need for **amputation or debridement**. *3 days* - While initial signs of **tissue damage**, such as blistering and swelling, may appear within 24-48 hours, the full extent of **mummification or eschar formation** usually takes longer. - **Hardening and blackening** within 3 days would be an unusually rapid progression, typically associated with very severe and immediate tissue death, which is not the common timeline for such extensive changes. *7 days* - By 7 days, there can be significant **blistering and tissue discoloration**, but the complete **mummification and blackening** characteristic of full-thickness necrosis generally takes longer to develop. - Necrotic tissue may start to become firm and discolored, but may not fully achieve the typical **hard, black appearance** indicative of complete demarcation. *4-6 weeks* - By 4-6 weeks, the **demarcation line** between viable and non-viable tissue is usually well-established, and spontaneous **auto-amputation** or surgical intervention may have already occurred. - The initial **hardening and blackening** of the skin would have developed much earlier, typically by 2 weeks.

Q: Most common cause of acquired atrioventricular fistula is -

Penetrating trauma. ***Penetrating trauma*** - **Penetrating injuries**, such as stab wounds or gunshot wounds to the chest, are the most frequent cause of **acquired atrioventricular fistulas**. - These injuries can directly transect or damage the walls of adjacent cardiac chambers and great vessels, creating an abnormal communication. *Bacterial infection* - While bacterial infections can lead to conditions like **endocarditis** or abscess formation, they are not the most common direct cause of an **acquired atrioventricular fistula**. - Endocarditis primarily involves valve damage and can rarely extend to form fistulas, but this is less frequent than trauma. *Fungal infection* - Fungal infections, especially in immunocompromised individuals, can cause **mycotic aneurysms** or severe endocarditis. - However, they are a rare cause of direct **atrioventricular fistula formation** compared to traumatic injuries. *Blunt trauma* - **Blunt chest trauma** can cause myocardial contusion, rupture of cardiac chambers, or vessel dissection. - While severe blunt trauma can lead to cardiac injury, it is less likely to create a discrete **atrioventricular fistula** than a sharp penetrating injury that punctures both structures.

Q: What is the primary purpose of triage in emergency medicine?

Patient prioritization based on severity. ***Patient prioritization based on severity*** - Triage is fundamentally about **sorting patients** according to the **urgency of their conditions** and the resources required. - The goal is to allocate limited resources effectively to **maximize the number of survivors** and optimize outcomes in mass casualty incidents or busy emergency departments. *Preventing future casualties* - While related to overall emergency management, triage itself does not directly prevent future casualties; it focuses on managing **existing casualties**. - **Prevention** is a broader public health and safety initiative, distinct from the immediate management phase of triage. *Providing immediate treatment to all patients* - In situations with limited resources or a high patient volume, providing immediate, comprehensive treatment to *all* patients simultaneously is often **impossible** or **impractical**. - Triage helps decide *who* gets immediate treatment based on need, rather than treating everyone at once. *Assessing potential outcomes of injuries* - While an assessment of injury impact is part of the triage process, the primary purpose is not just to assess outcomes, but to use that assessment for **prioritization of care**. - Predicting potential outcomes contributes to the decision-making but is not the overarching goal of triage.

Q: A 40-year-old woman was brought to the casualty 8 hours after sustaining burns on the abdomen, both limbs, and back. What is the best formula to calculate the amount of fluid to be replenished?

4 mL/kg x %TBSA. ***4 mL/kg x %TBSA*** - This is the **Parkland formula** (also known as Baxter formula), which is the most widely accepted method for calculating fluid resuscitation in burn patients. - The formula calculates a **total 24-hour fluid requirement** of **4 mL of Ringer's lactate per kilogram of body weight per percentage of total body surface area (%TBSA)** burned. - **Timing protocol:** Half of the calculated total volume (2 mL/kg x %TBSA) is given in the **first 8 hours post-burn**, and the remaining half over the **next 16 hours**. - This is the **gold standard** for initial burn fluid resuscitation. *2 mL/kg x %TBSA* - This represents **only half the total 24-hour fluid volume** recommended by the Parkland formula. - Using only 2 mL/kg x %TBSA as the total would lead to **severe under-resuscitation**, increasing the risk of burn shock, acute kidney injury, and other complications. - This volume is correct only for the **first 8 hours**, not the total calculation. *8 mL/kg x %TBSA* - This suggests **twice the fluid volume** recommended by the Parkland formula. - Administering 8 mL/kg x %TBSA would result in **over-resuscitation**, leading to complications such as pulmonary edema, abdominal compartment syndrome, acute respiratory distress syndrome (ARDS), and extremity compartment syndrome. *4 mL/kg x %TBSA in first 8 hours followed by 2 mL/kg/hour x %TBSA* - This option incorrectly suggests giving the **entire 24-hour calculated volume** in the first 8 hours, then continuing with an additional **hourly rate**. - This would result in **massive over-resuscitation** and life-threatening complications. - The correct Parkland protocol gives **half the total** (2 mL/kg x %TBSA) in the first 8 hours, then the **remaining half over 16 hours** (not an additional continuous rate).

Q: Treatment of choice for a stab injury to the caecum is

Primary repair. ***Primary repair*** - For most stab injuries to the caecum, **primary repair** is the treatment of choice, especially when the injury is small and there is no significant tissue loss or contamination. - The caecum has a relatively **large diameter** and **rich blood supply**, which facilitates successful primary closure. - Primary repair is simple, effective, and avoids the morbidity associated with ostomy creation. *Caecostomy* - A **caecostomy** involves bringing a portion of the caecum to the surface as a temporary fecal diversion. - It is generally reserved for more complex injuries with significant tissue loss, severe contamination, or hemodynamic instability requiring damage control surgery. - This procedure carries risks of **infection** and **fistula formation**, and is more invasive than primary repair for isolated stab injuries. *Transverse colostomy* - A **transverse colostomy** is a diverting ostomy created in the transverse colon. - It is typically used for injuries to the distal colon or rectum, or in cases of severe abdominal contamination requiring fecal diversion from a more compromised section of the bowel. - This is a more extensive procedure than necessary for an isolated low-grade caecal injury and would involve unnecessary diversion of a longer segment of colon. *Sigmoid colostomy* - A **sigmoid colostomy** is a diverting ostomy created in the sigmoid colon. - It is primarily indicated for injuries or diseases affecting the distal colon or rectum, providing fecal diversion to allow healing of those structures. - This option is inappropriate for a caecal injury as it is too distal and would not directly protect the site of injury or provide adequate proximal diversion.

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: 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: 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.

Question 1

In frostbite, the skin becomes hard and black in about:

Accepted Answer

2 weeks

Answer

3 days

Answer

7 days

Answer

4-6 weeks

Question 2

Most common cause of acquired atrioventricular fistula is -

Accepted Answer

Penetrating trauma

Answer

Bacterial infection

Answer

Fungal infection

Answer

Blunt trauma

Question 3

What is the primary purpose of triage in emergency medicine?

Accepted Answer

Patient prioritization based on severity

Answer

Preventing future casualties

Answer

Providing immediate treatment to all patients

Answer

Assessing potential outcomes of injuries

Question 4

A 40-year-old woman was brought to the casualty 8 hours after sustaining burns on the abdomen, both limbs, and back. What is the best formula to calculate the amount of fluid to be replenished?

Accepted Answer

4 mL/kg x %TBSA

Answer

2 mL/kg x %TBSA

Answer

8 mL/kg x %TBSA

Answer

4 mL/kg x %TBSA in first 8 hours followed by 2 mL/ kg/hour x %TBSA

Question 5

Treatment of choice for a stab injury to the caecum is

Accepted Answer

Primary repair

Answer

Transverse colostomy

Answer

Sigmoid colostomy

Answer

Caecostomy

Question 6

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

Accepted Answer

Intercostal drainage

Answer

Observation

Answer

Pneumonectomy

Answer

Thoracotomy

Question 7

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 8

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 9

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 10

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

Trauma — MCQs

Trauma — MCQs

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