Trauma — MCQs

Trauma Indian Medical PG Practice Questions and MCQs

Question 161: Which of the following is NOT a sign of cerebral compression?

A. Bradycardia
B. Hypotension (Correct Answer)
C. Papilloedema
D. Vomiting

Explanation: The correct answer is **Hypotension**. ### **Explanation** Cerebral compression occurs when intracranial pressure (ICP) rises due to space-occupying lesions (like hematomas or edema). The physiological response to increased ICP is governed by the **Cushing’s Reflex**, which consists of a classic triad: 1. **Hypertension** (Widening pulse pressure): The body raises systemic blood pressure to maintain Cerebral Perfusion Pressure (CPP). 2. **Bradycardia**: A reflex response to the sudden rise in systemic blood pressure. 3. **Irregular Respiration**: Due to brainstem compression. Therefore, **Hypertension**, not hypotension, is a sign of cerebral compression. Hypotension in a head injury patient usually suggests internal hemorrhage elsewhere (e.g., abdomen or thorax) rather than the brain injury itself. ### **Analysis of Other Options** * **Bradycardia:** Part of the Cushing’s triad; it occurs as a compensatory baroreceptor response to systemic hypertension. * **Papilloedema:** A classic sign of chronic or subacute increased ICP caused by the mechanical compression of the optic nerve sheath. * **Vomiting:** Specifically "projectile vomiting" without preceding nausea, caused by direct pressure on the postrema area in the medulla. ### **High-Yield Clinical Pearls for NEET-PG** * **Cerebral Perfusion Pressure (CPP) Formula:** $CPP = MAP - ICP$. To keep CPP constant when ICP rises, the Mean Arterial Pressure (MAP) must increase. * **Earliest Sign of Compression:** Altered level of consciousness (GCS) or an ipsilateral dilated pupil (due to 3rd nerve compression). * **Late Sign:** Cushing’s Triad is often a late/pre-terminal sign indicating impending transtentorial herniation. * **Management:** Mannitol (20%), hypertonic saline, and head elevation (30°) are used to reduce ICP.

Question 162: Tension pneumothorax results in all of the following except?

A. Respiratory alkalosis (Correct Answer)
B. Decreased cardiac output
C. Decreased venous return
D. Absent breath sounds

Explanation: ### Explanation **Tension Pneumothorax** is a life-threatening clinical diagnosis where a "one-way valve" mechanism allows air to enter the pleural space during inspiration but prevents it from escaping during expiration. This leads to a progressive buildup of intrapleural pressure. **1. Why "Respiratory Alkalosis" is the correct answer (the "Except"):** In tension pneumothorax, the primary physiological derangement is **Respiratory Acidosis**, not alkalosis. The massive accumulation of air causes complete collapse of the ipsilateral lung and compression of the contralateral lung. This severely impairs gas exchange and leads to CO₂ retention (hypercapnia), resulting in respiratory acidosis. Furthermore, as cardiac output drops, tissue perfusion decreases, which can lead to a concomitant **metabolic acidosis** due to lactic acid buildup. **2. Analysis of Incorrect Options:** * **Decreased Venous Return:** The high intrapleural pressure shifts the mediastinum to the opposite side, causing kinking and compression of the superior and inferior vena cava. This mechanical obstruction directly reduces venous return to the heart. * **Decreased Cardiac Output:** As a direct consequence of reduced venous return (decreased preload), the stroke volume and overall cardiac output fall, leading to obstructive shock and hypotension. * **Absent Breath Sounds:** Lung collapse on the affected side prevents air entry, leading to the classic clinical finding of absent or significantly diminished breath sounds on auscultation. **3. NEET-PG High-Yield Pearls:** * **Clinical Triad:** Hypotension (shock), jugular venous distension (JVD), and absent breath sounds. * **Tracheal Deviation:** A late sign; the trachea shifts toward the **contralateral** (healthy) side. * **Percussion:** Hyper-resonant note on the affected side. * **Management:** It is a **clinical diagnosis**. Do NOT wait for an X-ray. Immediate management is **Needle Decompression** (5th intercostal space, mid-axillary line in adults) followed by Tube Thoracostomy (Chest tube).

Question 163: Which of the following is NOT a concept of Damage Control Surgery (DCS) operative principles?

A. Arrest hemorrhage
B. Control sepsis
C. Protect from further injury
D. Definitive repair of injury (Correct Answer)

Explanation: **Explanation:** Damage Control Surgery (DCS) is a life-saving strategy used in hemodynamically unstable trauma patients. It prioritizes the reversal of the **"Lethal Triad"** (Acidosis, Hypothermia, and Coagulopathy) over the anatomical restoration of injuries. **Why "Definitive repair of injury" is the correct answer:** The primary goal of DCS is physiological restoration, not anatomical perfection. Definitive repairs (such as complex vascular grafting or biliary reconstruction) are time-consuming and exacerbate the lethal triad. In DCS, these are intentionally **deferred** to a later stage (usually 24–48 hours later) once the patient’s physiology has stabilized in the ICU. **Analysis of incorrect options:** * **Arrest hemorrhage (A):** This is the most critical step of DCS. Rapid control of bleeding (via packing, shunting, or simple ligation) is essential to stop the depletion of clotting factors and prevent further shock. * **Control sepsis (B):** Also known as "contamination control," this involves rapid measures like stapling off perforated bowel or simple diversion to prevent further peritoneal soilage. * **Protect from further injury (C):** This involves temporary measures like abdominal packing and temporary abdominal closure (e.g., Bogota bag or VAC) to prevent abdominal compartment syndrome and protect viscera until the return to the OR. **NEET-PG High-Yield Pearls:** 1. **Stages of DCS:** * **Stage I:** Immediate laparotomy (Hemorrhage & Contamination control). * **Stage II:** ICU resuscitation (Rewarming, correcting coagulopathy). * **Stage III:** Planned re-operation for definitive repair. 2. **The "Lethal Triad":** Hypothermia, Coagulopathy, and Metabolic Acidosis. 3. **Indications:** pH < 7.2, Temperature < 34°C, or massive transfusion requirement (>10 units).

Question 164: Which of the following statements are true regarding pancreatic trauma?

A. Solitary involvement is common
B. Blunt injury is the usual cause
C. Surgery is always needed
D. Amylase is elevated in 90% of cases (Correct Answer)

Explanation: **Explanation:** Pancreatic trauma is relatively rare due to the organ's retroperitoneal location, but it carries high morbidity and mortality. **1. Why Option D is Correct:** Serum amylase levels are elevated in approximately **90% of pancreatic trauma cases**. However, it is a high-yield point to remember that amylase is **not specific** (can rise in bowel injury) and its initial level does not correlate with the severity of the injury. A persistently rising amylase level is more clinically significant than a single baseline value. **2. Why the Other Options are Incorrect:** * **Option A:** Solitary involvement is **uncommon**. Due to the proximity of the liver, spleen, and major vessels (aorta, IVC), pancreatic injury is associated with other intra-abdominal organ injuries in about 90% of cases. * **Option B:** While blunt trauma (e.g., steering wheel injury) is a classic mechanism, **penetrating trauma** (gunshot or stab wounds) is actually the more common cause of pancreatic injury in many clinical series. * **Option C:** Surgery is **not always needed**. Grade I and II injuries (minor contusions or lacerations without ductal involvement) are often managed conservatively. Surgery is primarily indicated for ductal disruption (Grade III+) or hemodynamic instability. **Clinical Pearls for NEET-PG:** * **Mechanism:** The pancreas is often crushed against the vertebral column (L1-L2) in blunt trauma. * **Investigation of Choice:** **CECT abdomen** is the gold standard for stable patients. * **Management Hallmark:** The integrity of the **Main Pancreatic Duct** is the single most important factor determining management and prognosis. * **ERCP:** Useful if CT is equivocal regarding ductal injury. * **Complications:** Pancreatic fistula is the most common complication; pseudocyst and abscess may also occur.

Question 165: A 14-year-old child presents to the emergency department with a history of blunt abdominal trauma. On examination, Ballance's sign is found to be positive. Which of the following statements is not true?

A. A palpable tender mass can be felt in the left upper quadrant with persistent dullness.
B. It is due to an extracapsular or subcapsular hematoma of the spleen.
C. It is managed with conservative treatment.
D. Splenectomy is required. (Correct Answer)

Explanation: **Explanation:** **Ballance’s Sign** is a classic clinical finding associated with **splenic injury** following blunt abdominal trauma. It is characterized by fixed dullness to percussion in the left flank and shifting dullness in the right flank. 1. **Why Option D is the Correct Answer (The "Not True" Statement):** In modern trauma management, especially in the pediatric population (14-year-old in this case), a positive Ballance’s sign does not automatically mandate a **splenectomy**. Most blunt splenic injuries in children are managed via **Non-Operative Management (NOM)** or conservative treatment, provided the patient is hemodynamically stable. Surgery is reserved for hemodynamic instability or failed conservative management. 2. **Analysis of Other Options:** * **Option A:** True. The fixed dullness in the left upper quadrant is due to the presence of a large, clotted **subcapsular or extracapsular hematoma** which does not move with change in position. * **Option B:** True. The sign is specifically caused by the accumulation of blood (hematoma) around the spleen. * **Option C:** True. As mentioned, conservative management (ICU monitoring, serial hemoglobin checks, and bed rest) is the gold standard for stable pediatric splenic trauma to preserve immunological function. **High-Yield Clinical Pearls for NEET-PG:** * **Kehr’s Sign:** Referred pain to the left shoulder due to diaphragmatic irritation by splenic blood (Phrenic nerve, C3-C5). * **Saegesser’s Sign:** Tenderness upon pressure over the left phrenic nerve in the neck. * **Investigation of Choice:** **CECT Abdomen** is the gold standard for grading splenic injury in stable patients. * **Oversedation Risk:** Post-splenectomy patients are at risk for **OPSI** (Overwhelming Post-Splenectomy Infection), primarily by encapsulated organisms (*S. pneumoniae, H. influenzae, N. meningitidis*).

Question 166: A severely injured patient with multiple injuries is brought to the casualty. After primary survey and stabilization, what is the preferred investigation?

A. Whole body CT with IV contrast (Correct Answer)
B. CT head, abdomen, and X-ray of suspected limb fractures
C. CT head, FAST scan, with X-ray of C-spine and pelvis
D. CT head and neck, FAST scan of chest, and pelvis X-ray

Explanation: ### Explanation **Correct Option: A (Whole body CT with IV contrast)** In a hemodynamically stable patient with multiple injuries (polytrauma), **Whole Body CT (WBCT)**—often referred to as "Pan-scan"—is now the gold standard. The underlying concept is the **"Golden Hour"** management, where rapid, definitive diagnosis of all life-threatening injuries is crucial. WBCT with IV contrast (covering head, neck, chest, abdomen, and pelvis) is faster and more sensitive than a piecemeal approach. It significantly reduces the time to definitive treatment and has been shown to improve survival rates in severely injured patients compared to selective imaging. **Why other options are incorrect:** * **Option B:** This represents a selective imaging approach. It may miss occult injuries in the thorax or pelvis, which are common in high-energy trauma. * **Option C & D:** These options rely on **FAST (Focused Assessment with Sonography for Trauma)** and X-rays. While FAST is excellent for unstable patients in the primary survey, it is less sensitive than CT for detecting retroperitoneal injuries, solid organ lacerations, or hollow viscus injuries in a stable patient. X-rays of the C-spine have largely been replaced by CT due to the latter’s superior sensitivity for fractures. **Clinical Pearls for NEET-PG:** * **Prerequisite for CT:** The patient **must be hemodynamically stable**. If the patient is unstable, the priority is resuscitation and immediate surgical intervention (e.g., Laparotomy) or bedside FAST/X-ray. * **Contrast:** IV contrast is essential for WBCT to evaluate vascular injuries and solid organ (liver/spleen) grading. * **Sequence:** A typical WBCT protocol includes a non-contrast CT head followed by contrast-enhanced CT from the neck to the pubic symphysis.

Question 167: Which of the following is the best parameter to assess fluid intake in a polytrauma patient?

A. Urine output (Correct Answer)
B. Blood pressure
C. Pulse
D. Pulse oximetry

Explanation: In the management of a polytrauma patient, **Urine Output (UOP)** is considered the most reliable and sensitive non-invasive indicator of end-organ perfusion and the adequacy of fluid resuscitation. ### Why Urine Output is the Best Parameter The kidneys are highly sensitive to changes in blood volume. When a patient is in shock, the body prioritizes blood flow to the brain and heart by vasoconstricting peripheral and renal vessels. A steady urine output (target: **0.5 ml/kg/hr in adults** and **1 ml/kg/hr in children**) indicates that the "core" circulation is stable and the kidneys are being adequately perfused. It reflects the actual physiological response to fluid intake rather than just a static pressure measurement. ### Why Other Options are Less Reliable * **Blood Pressure:** This is a late sign of shock. Due to compensatory mechanisms (catecholamine release), blood pressure may remain normal even after a 15–30% loss of blood volume (Class I and II shock). * **Pulse:** While tachycardia is an early sign of volume depletion, it is non-specific. It can be elevated due to pain, anxiety, or medications, making it an unreliable sole indicator of fluid status. * **Pulse Oximetry:** This measures arterial oxygen saturation, not volume status or tissue perfusion. In severe shock with peripheral vasoconstriction, pulse oximetry may even fail to provide a reading. ### High-Yield Clinical Pearls for NEET-PG * **Target UOP:** 0.5 ml/kg/hr (Adults); 1 ml/kg/hr (Children); 2 ml/kg/hr (Infants). * **Best Indicator of Tissue Perfusion (Invasive):** Serum Lactate or Base Deficit. * **Earliest Sign of Hemorrhagic Shock:** Tachycardia (except in patients on beta-blockers or those with pacemakers). * **Golden Hour:** The first 60 minutes post-trauma where prompt resuscitation significantly improves survival.

Question 168: Following trauma, which hormone is not released?

A. Thyroxine (Correct Answer)
B. Glucagon
C. ADH
D. GH

Explanation: **Explanation:** The metabolic response to trauma is characterized by a complex neuroendocrine activation aimed at maintaining hemodynamic stability and mobilizing energy substrates. This response is divided into the **Ebb phase** (initial shock) and the **Flow phase** (catabolism and hypermetabolism). **Why Thyroxine is the Correct Answer:** Unlike most hormones, **Thyroxine (T4) and Triiodothyronine (T3) levels typically decrease** or remain unchanged following major trauma. This phenomenon is known as "Sick Euthyroid Syndrome." The body downregulates the conversion of T4 to T3 to lower the basal metabolic rate and conserve energy during the acute stress phase. Therefore, it is not "released" in response to trauma. **Analysis of Incorrect Options:** * **Glucagon:** Released by the pancreas in response to catecholamines. It promotes glycogenolysis and gluconeogenesis, contributing to post-traumatic hyperglycemia. * **ADH (Vasopressin):** Released from the posterior pituitary due to hypovolemia and pain. It acts on the kidneys to conserve water and maintain blood pressure. * **GH (Growth Hormone):** Released from the anterior pituitary. While traditionally anabolic, in trauma, it acts synergistically with cortisol to promote lipolysis and insulin resistance. **NEET-PG High-Yield Pearls:** * **Hormones that Increase:** Cortisol (the primary stress hormone), Catecholamines (Adrenaline/Noradrenaline), Glucagon, ADH, GH, and Renin-Angiotensin-Aldosterone. * **Hormones that Decrease:** Insulin (relative deficiency/resistance), T3/T4, and Gonadotropins (Testosterone/Estrogen). * **The "Ebb" Phase:** Characterized by decreased CO, decreased O2 consumption, and decreased body temperature. * **The "Flow" Phase:** Characterized by increased CO, increased O2 consumption, and hypermetabolism.

Question 169: What is the most common carcinoma that arises after burn injuries?

A. Squamous cell carcinoma (Correct Answer)
B. Adenocarcinoma
C. Melanoma
D. Mucoid carcinoma

Explanation: The correct answer is **Squamous cell carcinoma (SCC)**. ### **Explanation** The development of a malignancy in a chronic non-healing wound, scar tissue, or chronic inflammatory site is known as a **Marjolin’s ulcer**. While this can occur in various chronic conditions (like osteomyelitis or venous ulcers), it is most classically associated with **post-burn scars**. The underlying pathophysiology involves chronic irritation and repeated trauma to the unstable scar tissue, leading to malignant transformation. In approximately **95% of cases**, the histological type is **Squamous cell carcinoma**. These tumors are typically more aggressive than UV-induced SCC and have a higher rate of regional lymph node metastasis. ### **Why other options are incorrect:** * **B. Adenocarcinoma:** This arises from glandular epithelium. While it can occur in the gastrointestinal tract or breast, it is not associated with cutaneous burn scars. * **C. Melanoma:** Although malignant melanoma can rarely arise in a Marjolin’s ulcer, it is far less common than SCC. * **D. Mucoid carcinoma:** This is a variant of adenocarcinoma (often seen in the breast or GI tract) and has no clinical association with burn injuries. ### **High-Yield Clinical Pearls for NEET-PG:** * **Marjolin’s Ulcer:** The classic triad is a chronic scar, a non-healing ulcer, and everted edges. * **Latent Period:** The average time from the initial burn to the development of SCC is **25–30 years**. * **Diagnosis:** Gold standard is a **wedge biopsy** from the edge of the ulcer. * **Management:** Wide local excision (usually with a 2 cm margin) is the treatment of choice; lymph node dissection is indicated if nodes are palpable.

Question 170: Which of the following statements is true regarding fat embolism?

A. Most patients with major trauma involving long bones have urinary fat globules (Correct Answer)
B. All patients with urinary fat globules develop fat embolism
C. Peak incidence of respiratory insufficiency for pulmonary fat embolism is around day 7 after injury
D. Heparin as an anticoagulant decreases mortality and morbidity in fat embolism syndrome

Explanation: **Explanation:** **Fat Embolism Syndrome (FES)** is a clinical diagnosis following orthopedic trauma, most commonly involving long bone fractures (e.g., femur). **1. Why Option A is correct:** Following major trauma to long bones, fat globules are released from the bone marrow into the systemic circulation. Studies show that **over 50% (and up to 90%)** of patients with such fractures will have detectable fat globules in their urine (lipiduria). However, the presence of these globules is a marker of trauma and does not necessarily imply the clinical syndrome. **2. Why the other options are incorrect:** * **Option B:** While lipiduria is common after trauma, only a small fraction (approx. 1–5%) of these patients progress to develop the clinical **Fat Embolism Syndrome**. Therefore, urinary fat globules are sensitive but not specific for FES. * **Option C:** The peak incidence of respiratory insufficiency in FES typically occurs **24 to 72 hours** after the initial injury, not at day 7. It presents as a classic triad of respiratory distress, neurological changes, and a petechial rash. * **Option D:** Heparin was historically used to clear lipemia, but it is **no longer recommended**. It can increase the levels of toxic free fatty acids and increases the risk of bleeding in trauma patients. Management is primarily **supportive** (oxygenation and early fracture stabilization). **High-Yield Clinical Pearls for NEET-PG:** * **Gurd’s Criteria:** Used for diagnosis (Major: Petechial rash, Respiratory insufficiency, CNS depression). * **Petechial Rash:** Found in the conjunctiva, neck, and axilla; it is the most specific sign but occurs in only 20-50% of cases. * **Snowstorm Appearance:** Classic finding on Chest X-ray (diffuse bilateral pulmonary infiltrates). * **Prevention:** The most effective way to prevent FES is **early operative fixation** of the fracture.

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Trauma — MCQs

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