Trauma — MCQs

Trauma Indian Medical PG Practice Questions and MCQs

Question 1221: What is the fluid of choice for resuscitation in a child with thermal burns within the first 24 hours?

A. Fresh frozen plasma
B. Isolye-P
C. Ringer lactate (Correct Answer)
D. Platelet transfusion

Explanation: ***Ringer lactate*** - **Ringer lactate** is the preferred fluid for burn resuscitation in children due to its **isotonic nature** and buffering capacity which helps to correct acidosis. - It closely mimics the body's plasma electrolyte composition, effectively restoring circulating volume and addressing the **capillary leak** experienced in burn injuries. *Fresh frozen plasma* - **Fresh frozen plasma** is primarily used to replace **clotting factors** and **plasma proteins** in cases of severe bleeding or coagulopathy, not for initial fluid resuscitation. - Its high cost and potential for allergic reactions or **transfusion-related acute lung injury (TRALI)** make it unsuitable as a primary resuscitation fluid. *Isolye-P* - **Isolye-P** is a proprietary solution, and while some balanced electrolyte solutions may be used, it is not universally recognized as the **fluid of choice** for burn resuscitation over Ringer lactate. - Ringer lactate has a long-standing evidence base and widespread acceptance for managing burn shock. *Platelet transfusion* - **Platelet transfusions** are indicated for patients with **thrombocytopenia** or **platelet dysfunction** causing bleeding, which is not the primary concern in the initial phase of burn resuscitation. - Administering platelets without a specific indication is inappropriate and carries risks.

Question 1222: In which of the following locations should the incision be made for the saphenous cutdown procedure in an obese patient with no visible or palpable superficial veins, requiring intravenous fluids in shock?

A. Anterior to the medial malleolus (Correct Answer)
B. Posterior to the lateral malleolus
C. Anterior to the lateral malleolus
D. On the dorsum of the foot

Explanation: ***Anterior to the medial malleolus*** - The **greater saphenous vein** consistently runs anterior, one finger breadth to the medial malleolus, making this a reliable site for incision even when veins are not visible or palpable, particularly in **obese patients** or those in shock. - This location allows for direct access to a relatively large vein, crucial for rapid **intravenous fluid administration** in an emergency. *Posterior to the lateral malleolus* - This location is typically associated with the **small saphenous vein**, which is generally smaller and more variable in its superficial course, making it less dependable for cutdown in an emergent situation. - Incision here carries a higher risk of damaging the **sural nerve**, leading to sensory deficits. *Anterior to the lateral malleolus* - The veins in this region are usually smaller and less surgically significant for a **saphenous cutdown** required for rapid fluid infusion. - Accessing a suitable vein here is often more challenging and time-consuming, especially in an obese patient. *On the dorsum of the foot* - While veins on the **dorsum of the foot** are commonly used for routine IV access, they are smaller and more prone to collapse during shock, making them inadequate for rapid, high-volume fluid resuscitation. - The superficial location also makes them more susceptible to accidental dislodgement during patient movement.

Question 1223: What is the most common fracture pattern of petrous bone fractures?

A. Longitudinal (Correct Answer)
B. Transverse
C. Mixed
D. Comminuted

Explanation: ***Longitudinal*** - **Longitudinal fractures** account for the majority of petrous bone fractures, occurring in about 70-90% of cases. - They typically result from **lateral impact** to the head, running parallel to the long axis of the petrous pyramid and often sparing the otic capsule. - Commonly cause **conductive hearing loss** due to ossicular chain disruption or hemotympanum, and may result in tympanic membrane perforation. *Transverse* - **Transverse fractures** are less common, making up 10-20% of petrous bone fractures. - They are usually caused by **frontal or occipital impact** and run perpendicular to the long axis of the petrous pyramid. - Frequently involve the **otic capsule**, leading to **sensorineural hearing loss**, vestibular dysfunction, and higher incidence of facial nerve palsy. *Mixed* - **Mixed (oblique) fractures** represent a combination of longitudinal and transverse patterns and account for a small percentage of cases. - This pattern implies a more complex injury mechanism, often associated with a higher incidence of complications affecting both **conductive and sensorineural hearing**. *Comminuted* - **Comminuted fractures** involve multiple fracture lines with fragmentation of the petrous bone. - They result from high-energy trauma and are associated with severe complications. - While recognized in the classification, they are much less common than longitudinal fractures.

Question 1224: A patient presents with engorged neck veins, a blood pressure of 80/50 mmHg, and a pulse rate of 100 beats per minute following blunt trauma to the chest. The diagnosis is:

A. Pneumothorax
B. Right ventricular failure
C. Cardiac tamponade (Correct Answer)
D. Hemothorax

Explanation: ***Cardiac tamponade*** - The clinical presentation shows **two components of Beck's triad**: **engorged neck veins (elevated JVP)** and **hypotension** (80/50 mmHg). While muffled heart sounds (the third component) are not mentioned, this is not required for diagnosis. - The combination of **blunt chest trauma** and these symptoms strongly suggests fluid accumulation in the pericardial sac, compressing the heart and impairing its filling. - **Tachycardia** (100 bpm) represents a compensatory response to reduced cardiac output. *Pneumothorax* - While pneumothorax can cause respiratory distress and hypotension, it typically presents with **absent breath sounds** on the affected side and **hyperresonance to percussion**, which are not described. - Engorged neck veins are not characteristic of simple pneumothorax. **Tension pneumothorax** can cause distended neck veins and severe hypotension, but would also present with severe respiratory distress and tracheal deviation away from the affected side. *Right ventricular failure* - Right ventricular failure can cause **engorged neck veins** but usually presents with signs of systemic congestion like **peripheral edema** and hepatomegaly, developing over time. - This is not typically an acute, immediate consequence of blunt chest trauma. The **acute hypotension** and **tachycardia** are more indicative of obstructive shock (cardiac tamponade) rather than pump failure. *Hemothorax* - Hemothorax involves blood accumulation in the pleural space, leading to **absent breath sounds** and **dullness to percussion** on the affected side. - While it can cause hypotension and tachycardia due to **hypovolemic shock** from blood loss, **engorged neck veins** are not a feature. In fact, significant blood loss typically causes **flat or collapsed neck veins** due to reduced venous return.

Question 1225: Which of the following statements about burns is NOT true?

A. Pseudomonas is a common infection in burn wounds.
B. Cephalosporins are not the drug of choice for burn management.
C. Moist dressings are beneficial for burn care. (Correct Answer)
D. Toxic shock syndrome is uncommon in burn patients.

Explanation: ***Moist dressings are beneficial for burn care.*** - This statement is **NOT true** in the traditional sense being implied here. - While **modern wound care** does favor maintaining a moist wound environment for many wound types, **burn management** specifically uses **topical antimicrobial agents** (like silver sulfadiazine, mafenide acetate) rather than simple "moist dressings." - Traditional moist dressings without antimicrobial properties can actually **increase infection risk** in burns. - The key principle is **antimicrobial coverage**, not just maintaining moisture. *Pseudomonas is a common infection in burn wounds.* - **Pseudomonas aeruginosa** is indeed one of the most common and serious pathogens in burn wounds. - It thrives in the moist, protein-rich environment of burn injuries and is notoriously difficult to treat due to antibiotic resistance. - Pseudomonas infection significantly increases morbidity and mortality in burn patients. *Cephalosporins are not the drug of choice for burn management.* - This statement is **TRUE**. - **Topical antimicrobials** (silver sulfadiazine, mafenide acetate, silver-impregnated dressings) are the primary agents for burn wound management. - Systemic antibiotics, including cephalosporins, are **not used prophylactically** and are reserved for documented infections. - When systemic treatment is needed, it is **culture-guided**, and for Pseudomonas coverage, anti-pseudomonal agents are preferred. *Toxic shock syndrome is uncommon in burn patients.* - **Toxic Shock Syndrome (TSS)** from *Staphylococcus aureus* or *Streptococcus pyogenes* is indeed a **rare but serious complication** in burn patients. - While burns create a susceptible environment for bacterial colonization, TSS remains uncommon compared to other infectious complications.

Question 1226: Indications for emergency thoracotomy are all of the following except:

A. Cardiac tamponade
B. Tension pneumothorax (Correct Answer)
C. Major tracheobronchial injuries
D. Penetrating injuries to anterior chest

Explanation: ***Tension pneumothorax*** - While a life-threatening condition, a **tension pneumothorax** is initially managed with **needle decompression** or **chest tube insertion**, not an immediate emergency thoracotomy. - Emergency thoracotomy is reserved for situations requiring direct repair or control of massive bleeding that cannot be addressed by less invasive means. *Major tracheobronchial injuries* - These injuries can lead to severe **airway obstruction**, **massive air leak**, and **hemorrhage**, necessitating direct surgical repair via emergency thoracotomy. - Prompt surgical intervention is crucial to restore airway integrity and prevent life-threatening respiratory collapse. *Cardiac tamponade* - **Cardiac tamponade** can be caused by penetrating or blunt trauma, leading to circulatory collapse due to compression of the heart. - While initial management may involve pericardiocentesis, persistent or rapidly recurring tamponade, especially after trauma, often requires an **emergency thoracotomy** for direct repair of cardiac injury and evacuation of blood. *Penetrating injuries to anterior chest* - **Penetrating anterior chest injuries** carry a high risk of damage to vital structures such as the heart, great vessels, and major airways. - These injuries often result in rapid **hemodynamic instability**, severe hemorrhage, or cardiac arrest, making emergency thoracotomy essential for direct exploration and definitive repair.

Question 1227: In case of polytrauma with multiple injuries to the chest, neck, and abdomen, what is the highest priority intervention?

A. Stabilization of the airway (Correct Answer)
B. Vasopressors
C. Assessing disability
D. Stabilization of the cervical spine

Explanation: ***Stabilization of the airway*** - Maintaining a **patent airway** is the absolute first priority in any trauma patient (following the **ABCDE approach**), as inadequate oxygenation and ventilation can rapidly lead to irreversible brain damage and death. - In a patient with injuries to the chest, neck, and abdomen, the airway is particularly vulnerable to compromise from direct trauma, swelling, or aspiration. *Vasopressors* - Vasopressors are used to support blood pressure in cases of **hypotensive shock**, but establishing adequate ventilation and oxygenation (airway, breathing) must precede circulatory support. - Administering vasopressors without a patent airway and efficient breathing will not be effective and can be detrimental. *Assessing disability* - Assessing disability (neurological status) is part of the **D** in the **ABCDE approach**, which comes after addressing airway, breathing, and circulation. - While important, it is not the highest priority intervention as an immediate threat to life takes precedence. *Stabilization of the cervical spine* - While crucial in trauma (especially with neck injuries) to prevent further neurological damage, **cervical spine stabilization** is often performed concurrently or immediately after airway assessment and control, under the **"A" for Airway with cervical spine protection** principle. - However, establishing a patent airway without moving the neck (if possible) still takes absolute priority over full stabilization, as a blocked airway is an immediate life threat.

Question 1228: When a seat belt is worn, if an accident occurs, sudden deceleration can result in:

A. Rupture of mesentery (Correct Answer)
B. Liver injury
C. Spleen injury
D. Vertebral injury

Explanation: ***Rupture of mesentery*** - The **lap belt** component of a seatbelt causes compression and shear forces across the abdomen during sudden deceleration, leading to the classic **"seatbelt sign"** (abdominal wall ecchymosis). - This mechanism commonly causes **mesenteric tears** and bowel injuries, which represent the **most frequent intra-abdominal injuries** in the seatbelt syndrome. - Mesenteric avulsion can lead to bowel ischemia and perforation, making it a critical injury to identify in restrained trauma patients. *Liver injury* - While liver injury can occur in motor vehicle accidents, it is **less specifically associated** with the seatbelt mechanism. - Liver lacerations typically result from **direct impact** or compression against the rib cage, and are actually **reduced in incidence** with proper seatbelt use compared to unrestrained occupants. - Not a characteristic finding of the seatbelt injury complex. *Spleen injury* - Splenic trauma is similarly more common with **direct lateral impact** to the left upper quadrant rather than the anterior compression from a lap belt. - Proper seatbelt restraint generally **protects** against severe splenic injury compared to unrestrained passengers. - Not part of the classic seatbelt syndrome. *Vertebral injury* - The **Chance fracture** (horizontal fracture-dislocation of the lumbar spine) is indeed a **recognized component of seatbelt syndrome**, caused by flexion-distraction forces over the fulcrum of the lap belt. - However, in the context of seatbelt injuries, **soft tissue injuries** (mesentery, bowel) are **more common** than bony Chance fractures. - When evaluating the "seatbelt complex," mesenteric injury is the **primary visceral injury** to suspect, while Chance fracture represents the associated skeletal injury pattern. - This question focuses on the most characteristic and frequent injury pattern.

Question 1229: An elderly man gets a burn injury to his hands. Over several weeks, the burned skin heals without the need for skin grafting. The most critical factor responsible for the rapid healing in this case is:

A. Remnant skin appendages (Correct Answer)
B. Underlying connective tissues
C. Minimal edema and erythema
D. Granulation tissue

Explanation: ***Remnant skin appendages*** - The presence of **hair follicles** and **sweat glands** contributes to the healing process by providing a source of epithelial cells for regeneration [1]. - These **skin appendages** facilitate quicker re-epithelialization compared to areas without appendages [1]. *Underlying connective tissues* - While connective tissues support healing, they are not the primary factor in **rapid re-epithelialization** in this scenario. - Their role is more about structural integrity rather than direct promotion of skin regeneration. *Minimal edema and erythema* - These conditions indicate less inflammation, but they do not directly enhance the healing rate of the skin. - The absence of these symptoms is beneficial, yet healing still relies on **active cellular processes** rather than just inflammation levels. *Granulation tissue* - Granulation tissue is primarily involved in the healing of deeper wounds and is more critical during the **initial phases** of healing [2]. - Its presence is generally more associated with greater **tissue damage**, rather than contributing to quick healing when skin appendages are intact. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. (Basic Pathology) introduces the student to key general principles of pathology, both as a medical science and as a clinical activity with a vital role in patient care. Part 2 (Disease Mechanisms) provides fundamental knowledge about the cellular and molecular processes involved in diseases, providing the rationale for their treatment. Part 3 (Systematic Pathology) deals in detail with specific diseases, with emphasis on the clinically important aspects., pp. 104-105. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. (Basic Pathology) introduces the student to key general principles of pathology, both as a medical science and as a clinical activity with a vital role in patient care. Part 2 (Disease Mechanisms) provides fundamental knowledge about the cellular and molecular processes involved in diseases, providing the rationale for their treatment. Part 3 (Systematic Pathology) deals in detail with specific diseases, with emphasis on the clinically important aspects., pp. 105-106.

Question 1230: Which of the following is a contraindication to nonoperative management of splenic injury?

A. Hemodynamic instability (Correct Answer)
B. History of hematologic disorder
C. HIV infection
D. Presence of multiple solid-organ injuries

Explanation: ***Hemodynamic instability*** - **Hemodynamic instability** in a patient with splenic injury indicates ongoing hemorrhage, which requires immediate surgical intervention to control bleeding and prevent hypovolemic shock. - This is a critical contraindication to non-operative management, as delaying surgery significantly increases morbidity and mortality. *History of hematologic disorder* - While certain **hematologic disorders** like coagulopathies can increase the risk of bleeding after splenic injury, they are not an absolute contraindication to non-operative management if the patient is hemodynamically stable and bleeding is contained. - Close monitoring and correction of coagulopathy might be necessary, but it does not automatically preclude conservative treatment. *HIV infection* - **HIV infection** itself is not a contraindication to non-operative management of splenic injury. The decision for operative versus non-operative management is based on the patient's hemodynamic status and the grade of splenic injury, not their HIV status. - While immune compromise can affect recovery, it does not directly impact the initial management decision for splenic trauma. *Presence of multiple solid-organ injuries* - The presence of **multiple solid-organ injuries** does not automatically contraindicate non-operative management for the splenic injury itself, provided the patient remains hemodynamically stable. - Each organ injury is assessed individually, and the decision for surgery is usually driven by ongoing hemorrhage or other complications from one or more of the injured organs that cannot be managed conservatively.

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