Trauma Practice Questions

Q: In traumatic brain injury, what is the target cerebral perfusion pressure that should be maintained?

70 - 90 mm Hg. **Explanation:** The management of Traumatic Brain Injury (TBI) focuses on preventing secondary brain injury by ensuring adequate oxygenation and perfusion. **Cerebral Perfusion Pressure (CPP)** is defined as the difference between the Mean Arterial Pressure (MAP) and the Intracranial Pressure (ICP) $[CPP = MAP - ICP]$. **Why 70 – 90 mm Hg is Correct:** According to standard surgical guidelines (including ATLS and Bailey & Love), the goal in TBI is to maintain a CPP between **70 and 90 mm Hg**. This range ensures sufficient blood flow to overcome increased intracranial pressure, preventing cerebral ischemia while avoiding the risks of hyperperfusion. **Analysis of Incorrect Options:** * **A (35 – 50 mm Hg):** This range is critically low. A CPP below 50 mm Hg is associated with significant cerebral ischemia and poor neurological outcomes. * **B (50 – 70 mm Hg):** While some neurosurgical protocols accept 60 mm Hg as a minimum, 50–70 mm Hg is generally considered suboptimal in the acute phase of severe TBI where higher pressures are needed to salvage the penumbra. * **D (> 90 mm Hg):** Excessively high CPP (above 90-100 mm Hg) increases the risk of **Acute Respiratory Distress Syndrome (ARDS)** and cerebral edema due to hydrostatic pressure, without providing additional neurological benefit. **High-Yield Clinical Pearls for NEET-PG:** * **Normal ICP:** 5 – 15 mm Hg. Treatment for intracranial hypertension is usually initiated when ICP > 20–22 mm Hg. * **Cushing’s Triad (Sign of increased ICP):** Hypertension, Bradycardia, and Irregular respirations. * **Monro-Kellie Doctrine:** The cranial vault is a fixed volume; an increase in one constituent (blood, CSF, or brain) must be compensated by a decrease in another, or ICP will rise. * **First-line management for raised ICP:** Head elevation (30°), sedation, and osmotic therapy (Mannitol or Hypertonic saline).

Q: A patient with blunt abdominal trauma presents with a blood pressure of 90/60 mm Hg and a pulse rate of 124. What is the most appropriate initial investigation to perform in this patient?

Focused Assessment with Sonography for Trauma (FAST). ### Explanation The patient presents with **hemodynamic instability** (hypotension and tachycardia) following blunt abdominal trauma, indicating a **Class III hemorrhagic shock**. In an unstable patient, the primary goal is to identify the source of bleeding rapidly without moving the patient out of the resuscitation area. **1. Why FAST is the Correct Answer:** **Focused Assessment with Sonography for Trauma (FAST)** is the initial investigation of choice for hemodynamically unstable patients. It is a rapid, non-invasive, bedside tool used to detect free intraperitoneal fluid (hemoperitoneum) or pericardial tamponade. It assesses four areas: Morrison’s pouch (RUQ), splenorenal recess (LUQ), pelvis (pouch of Douglas), and the pericardium. **2. Why Other Options are Incorrect:** * **CT Abdomen:** While it is the "Gold Standard" for diagnosing solid organ injuries, it requires the patient to be **hemodynamically stable**. Moving an unstable patient to the CT suite is dangerous ("Death in the Donut Hole"). * **MRI Abdomen:** MRI has no role in acute trauma management due to the long acquisition time and incompatibility with resuscitation equipment. * **Diagnostic Peritoneal Lavage (DPL):** Although useful in unstable patients when FAST is unavailable or inconclusive, it is invasive and has been largely superseded by FAST. **Clinical Pearls for NEET-PG:** * **Stable + Blunt Trauma:** Initial investigation is **FAST**; if positive, proceed to **CECT**. * **Unstable + Blunt Trauma:** Initial investigation is **FAST**; if positive, proceed to **Emergency Laparotomy**. * **FAST Limitations:** It cannot detect <250 ml of fluid, retroperitoneal bleeds, or hollow viscus perforation. * **E-FAST:** Includes views of the thorax to rule out pneumothorax or hemothorax.

Q: Which of the following methods is NOT used to lower intracranial pressure in patients with head injury?

Administration of Nifedipine. **Explanation:** The management of raised intracranial pressure (ICP) in head injury focuses on the **Monro-Kellie doctrine**, which states that the cranial vault is a fixed volume; an increase in one component (blood, CSF, or brain tissue) must be compensated by a decrease in another. **Why Nifedipine is the correct answer:** Nifedipine is a Calcium Channel Blocker (CCB) that acts as a **potent peripheral and cerebral vasodilator**. Vasodilation in the cerebral vasculature increases cerebral blood volume, which directly **increases intracranial pressure**. Furthermore, it can cause systemic hypotension, which reduces Cerebral Perfusion Pressure (CPP = MAP - ICP), potentially worsening secondary brain ischemia. Therefore, it is contraindicated in acute head injury. **Analysis of other options:** * **Hyperventilation:** This reduces PaCO2, leading to cerebral vasoconstriction. This decreases cerebral blood volume and rapidly lowers ICP. It is typically used as a short-term emergency measure. * **Mannitol:** An osmotic diuretic that draws fluid from the brain parenchyma into the intravascular space, reducing cerebral edema. It also improves blood rheology. * **Hypothermia:** Therapeutic hypothermia reduces the cerebral metabolic rate of oxygen (CMRO2), which in turn reduces cerebral blood flow and ICP. **High-Yield Clinical Pearls for NEET-PG:** * **Target ICP:** Should be maintained below **20–22 mmHg**. * **Target CPP:** Should be maintained between **60–70 mmHg**. * **First-line Osmotherapy:** Hypertonic saline (3%) is increasingly preferred over Mannitol in hemodynamically unstable patients. * **Cushing’s Triad (Late sign of raised ICP):** Hypertension, Bradycardia, and Irregular respirations.

Q: According to the "rule of nine" in burns, what is the percentage of burns if both the upper limbs and lower limbs are involved?

54%. ### Explanation The **Wallace Rule of Nines** is a standardized clinical tool used to estimate the Total Body Surface Area (TBSA) involved in burn injuries. It divides the body into sections representing 9% or multiples of 9%. **Calculation for this question:** * **Each Upper Limb:** 9% (Left 9% + Right 9% = **18%**) * **Each Lower Limb:** 18% (Left 18% + Right 18% = **36%**) * **Total:** 18% (Upper) + 36% (Lower) = **54%** #### Analysis of Options: * **A. 24%:** This is an incorrect calculation. It might result from misremembering the limbs as 6% each or confusing pediatric scales. * **B. 6%:** This does not correspond to any major anatomical division in the Rule of Nines. * **C. 54% (Correct):** As calculated above, the sum of both upper (18%) and lower (36%) limbs equals 54%. * **D. 72%:** This overestimates the area, likely by doubling the lower limb percentage or including the trunk. #### NEET-PG High-Yield Pearls: 1. **Pediatric Variation:** In children, the head is larger (18%) and the lower limbs are smaller (14% each). For every year of age over 1, subtract 1% from the head and add 0.5% to each leg. 2. **Lund and Browder Chart:** This is the **most accurate** method for TBSA estimation, especially in children, as it accounts for age-related changes in body proportions. 3. **Palmar Method:** The patient’s palm (including fingers) represents approximately **1% TBSA**. This is useful for small or patchy burns. 4. **Exclusion:** First-degree burns (erythema only) are **not** included in the TBSA calculation for fluid resuscitation. 5. **Parkland Formula:** Remember that TBSA is the critical variable in the Parkland formula ($4 \text{ mL} \times \text{weight in kg} \times \% \text{ TBSA}$) for initial fluid management.

Q: What is the minimum possible score on the Glasgow Coma Scale?

3. The Glasgow Coma Scale (GCS) is a clinical tool used to assess a patient's level of consciousness following a head injury. It evaluates three specific categories of responses: **Eye Opening (E), Verbal Response (V), and Motor Response (M).** ### **Why Option A (3) is Correct:** The GCS is calculated by summing the scores of the three components. The minimum score for each component is **1** (indicating no response), and the maximum scores vary: * **Eye Opening (E):** 1 to 4 * **Verbal Response (V):** 1 to 5 * **Motor Response (M):** 1 to 6 Therefore, the minimum possible total score is **E1 + V1 + M1 = 3**. Even in a state of deep coma or brain death, a patient cannot score lower than 3. ### **Why Other Options are Incorrect:** * **Options B, C, and D (1, 0, 2):** These are incorrect because the scale does not assign a value of zero to any category. Even if a patient is completely unresponsive, they are assigned a score of 1 in each category. ### **High-Yield Clinical Pearls for NEET-PG:** * **Maximum Score:** 15 (Fully conscious). * **Intubation Threshold:** A GCS score of **≤ 8** is the classic indication for securing the airway (Intubate if GCS is 8). * **Severity Classification:** * **Severe Head Injury:** GCS 3–8 * **Moderate Head Injury:** GCS 9–12 * **Mild Head Injury:** GCS 13–15 * **Modified GCS for Intubated Patients:** If a patient is intubated, the Verbal (V) component cannot be assessed. It is recorded as **'T'** (e.g., GCS 10T), where the maximum score becomes 10T and the minimum becomes 2T. * **Most Important Component:** The **Motor (M)** score is considered the most reliable predictor of clinical outcome.

Q: What percentage of burns in a child involve the head region?

20%. In pediatric burn assessment, the **Rule of Nines** used for adults is modified because children have a disproportionately larger head and smaller lower extremities compared to adults. ### Why 20% is Correct According to the **Lund and Browder chart** (the most accurate method for pediatric surface area calculation), the head of a newborn or infant accounts for approximately **18-19%** of the Total Body Surface Area (TBSA). In clinical practice and for standardized examinations like NEET-PG, this is rounded to **20%**. As the child grows, the head's relative surface area decreases by 1% for every year of age, while the legs increase in percentage. ### Explanation of Incorrect Options * **A (10%):** This is closer to the adult value. In adults, the head and neck represent only **9%** of the TBSA. * **C & D (30% & 40%):** These values significantly overestimate the cranial surface area. Even in a neonate, the head does not exceed 20% of the total body surface. ### High-Yield Clinical Pearls for NEET-PG * **The "1% Rule":** For children, subtract 1% from the head for every year over age 1 and add 0.5% to each leg. By age 10, a child’s proportions closely resemble an adult's. * **Palmar Method:** The patient’s entire palm (including fingers) represents approximately **1% TBSA**. This is useful for small or patchy burns. * **Fluid Resuscitation:** The **Parkland Formula** (4ml x kg x %TBSA) is used, but in children, **maintenance fluids** (using the 4-2-1 rule) must be added to the resuscitation volume to prevent hypoglycemia and electrolyte imbalance. * **Critical Area:** Any burn involving the face/head in a child is considered a major burn due to the risk of airway involvement and cosmetic deformity.

Q: A 42-year-old female is admitted to the hospital after a traumatic landing while skydiving. Radiographic examination reveals a ruptured spleen. An emergency splenectomy is performed. Which of the following peritoneal structures must be carefully manipulated to prevent intraperitoneal bleeding?

Splenorenal ligament. **Explanation:** The **splenorenal (lienorenal) ligament** is a critical structure in splenic surgery. It is a fold of peritoneum that connects the hilum of the spleen to the left kidney. Its clinical significance lies in its contents: it houses the **splenic artery, splenic vein**, and the **tail of the pancreas**. During an emergency splenectomy, failure to carefully ligate these major vessels within the ligament or accidental injury to them leads to massive intraperitoneal hemorrhage. **Analysis of Incorrect Options:** * **A. Coronary ligament:** This attaches the liver to the diaphragm. While important in hepatic surgery, it is anatomically distant from the spleen. * **B. Gastrocolic ligament:** This is part of the greater omentum connecting the stomach to the transverse colon. While it must be divided to access the lesser sac, it does not contain the primary blood supply to the spleen. * **D. Phrenocolic ligament:** This attaches the left colic flexure to the diaphragm. It serves as a "shelf" for the spleen but is relatively avascular and does not contain major vessels. **NEET-PG High-Yield Pearls:** * **Tail of the Pancreas:** It is the most commonly injured structure during a "hurried" splenectomy because it lies within the splenorenal ligament near the splenic hilum. * **Gastrosplenic Ligament:** Contains the **short gastric vessels** and left gastroepiploic vessels. These must also be ligated but are secondary to the main splenic artery in the splenorenal ligament. * **Kehr’s Sign:** Referred pain to the left shoulder due to diaphragmatic irritation from a ruptured spleen (phrenic nerve, C3-C5).

Q: Extradural haemorrhage is most commonly caused by the rupture of which of the following vessels?

Middle meningeal artery. **Explanation:** **1. Why Middle Meningeal Artery (MMA) is Correct:** Extradural Hemorrhage (EDH) occurs when blood collects between the inner table of the skull and the dura mater. The most common cause (85-90% of cases) is an arterial bleed, specifically from the **Middle Meningeal Artery**. This vessel is particularly vulnerable where it underlies the **pterion**—the thinnest part of the skull where the frontal, parietal, temporal, and sphenoid bones meet. A blow to the temple often fractures this area, lacerating the artery. Because it is an arterial bleed, the hematoma expands rapidly under high pressure. **2. Why the Other Options are Incorrect:** * **Middle Meningeal Vein:** While it can be involved in EDH, it is far less common than its arterial counterpart. * **Bridging Veins:** Rupture of these veins (which drain the cerebral cortex into the dural venous sinuses) is the classic cause of **Subdural Hemorrhage (SDH)**, not EDH. * **Internal Carotid Artery:** Injury to the ICA within the skull is rare in trauma and usually leads to a carotid-cavernous fistula or massive subarachnoid hemorrhage, rather than a localized extradural collection. **3. High-Yield Clinical Pearls for NEET-PG:** * **Classic Presentation:** A "Lucid Interval" (temporary recovery of consciousness before rapid deterioration) is pathognomonic for EDH. * **CT Appearance:** EDH appears as a **Biconvex (Lentiform/Lens-shaped)** hyperdense opacity. It does *not* cross skull sutures because the dura is firmly attached there. * **Source of Bleed in Children:** In pediatric cases, EDH can occur without a fracture due to the elasticity of the skull; here, the source is often the dural venous sinuses. * **Management:** Urgent burr-hole evacuation or craniotomy is required to prevent transtentorial herniation.

Question 1

In traumatic brain injury, what is the target cerebral perfusion pressure that should be maintained?

Accepted Answer

70 - 90 mm Hg

Answer

35 - 50 mm Hg

Answer

50 - 70 mm Hg

Answer

> 90 mm Hg

Question 2

What is the most important step in the primary management of a patient with a fractured vertebral column?

Accepted Answer

Maintenance of the airway

Answer

Careful transportation of the patient

Answer

Treatment of shock

Answer

None of the above

Question 3

A patient with blunt abdominal trauma presents with a blood pressure of 90/60 mm Hg and a pulse rate of 124. What is the most appropriate initial investigation to perform in this patient?

Accepted Answer

Focused Assessment with Sonography for Trauma (FAST)

Answer

CT abdomen

Answer

MRI abdomen

Answer

Diagnostic Peritoneal Lavage (DPL)

Question 4

Which of the following methods is NOT used to lower intracranial pressure in patients with head injury?

Accepted Answer

Administration of Nifedipine

Answer

Hyperventilation

Answer

Administration of Mannitol

Answer

Hypothermia

Question 5

According to the "rule of nine" in burns, what is the percentage of burns if both the upper limbs and lower limbs are involved?

Accepted Answer

54%

Answer

24%

Answer

6%

Answer

72%

Question 6

What is the minimum possible score on the Glasgow Coma Scale?

Accepted Answer

3

Answer

1

Answer

0

Answer

2

Question 7

What percentage of burns in a child involve the head region?

Accepted Answer

20%

Answer

10%

Answer

30%

Answer

40%

Question 8

A 42-year-old female is admitted to the hospital after a traumatic landing while skydiving. Radiographic examination reveals a ruptured spleen. An emergency splenectomy is performed. Which of the following peritoneal structures must be carefully manipulated to prevent intraperitoneal bleeding?

Accepted Answer

Splenorenal ligament

Answer

Coronary ligament

Answer

Gastrocolic ligament

Answer

Phrenocolic ligament

Question 9

Extradural haemorrhage is most commonly caused by the rupture of which of the following vessels?

Accepted Answer

Middle meningeal artery

Answer

Middle meningeal vein

Answer

Bridging veins

Answer

Internal carotid artery

Question 10

A 26-year-old man presents to the emergency department following a vehicular accident where a truck ran over him. A chest X-ray reveals an air-fluid level in the left lung and a nasogastric tube coiled upward into the left chest. What is the next best step in the management of this patient?

Accepted Answer

Laparotomy

Answer

Placement of a chest tube on the left side

Answer

Thoracotomy

Answer

Diagnostic peritoneal lavage

Trauma — MCQs

Trauma — MCQs

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