Trauma Practice Questions

Q: Which of the following signs refers to splenic injury?

All the above. The spleen is the most commonly injured organ in blunt abdominal trauma. The correct answer is **All the above** because each option represents a classic clinical manifestation of splenic rupture or irritation. ### **Explanation of Signs:** 1. **Kehr’s Sign:** This is **referred pain to the left shoulder** caused by diaphragmatic irritation from a hemoperitoneum (splenic blood). It is mediated by the phrenic nerve (C3-C5). It is often more pronounced when the patient is in the Trendelenburg position. 2. **Balance’s Sign:** This refers to **fixed dullness to percussion in the left flank** and **shifting dullness in the right flank**. The fixed dullness on the left is due to the presence of large, coagulated blood clots near the ruptured spleen, while the shifting dullness on the right represents fluid (non-clotted) blood moving within the peritoneal cavity. 3. **Tenderness of the 9th–11th Left Ribs:** The spleen lies deep to these ribs. Fractures or significant tenderness in this region are high-yield indicators of underlying splenic parenchymal injury. ### **Clinical Pearls for NEET-PG:** * **Investigation of Choice:** **CECT Abdomen** is the gold standard for hemodynamically stable patients to grade the injury (AAST Grading). * **Initial Investigation:** **FAST (Focused Assessment with Sonography for Trauma)** is used in hemodynamically unstable patients to detect free fluid. * **OPSI (Overwhelming Post-Splenectomy Infection):** The most common causative organism is *Streptococcus pneumoniae*. Vaccination against *S. pneumoniae*, *H. influenzae*, and *N. meningitidis* is mandatory post-splenectomy. * **Saegesser’s Sign:** Another splenic sign involving pressure on the left phrenic nerve in the neck, causing pain.

Q: Which of the following is NOT a management strategy for raised intracranial pressure?

Hypercapnia. ### Explanation The management of raised intracranial pressure (ICP) is governed by the **Monro-Kellie Doctrine**, which states that the cranial vault is a fixed volume; an increase in one component (blood, CSF, or brain parenchyma) must be compensated by a decrease in another to prevent herniation. **Why Hypercapnia is the Correct Answer:** Hypercapnia (increased $PaCO_2$) is a potent **vasodilator** of cerebral arterioles. Vasodilation increases cerebral blood flow (CBF) and cerebral blood volume, which directly **increases ICP**. Therefore, hypercapnia is contraindicated. Conversely, controlled **hypocapnia** (via therapeutic hyperventilation) causes vasoconstriction and is used as a short-term measure to acutely lower ICP. **Analysis of Other Options:** * **Hypothermia:** Therapeutic hypothermia (32°C–34°C) reduces the cerebral metabolic rate of oxygen ($CMRO_2$), which in turn reduces CBF and ICP. * **Decompressive Craniectomy:** This is a surgical "salvage" procedure where a portion of the skull is removed to allow the swollen brain to expand outward, directly reducing pressure. * **Barbiturate Coma:** High-dose barbiturates (e.g., Thiopental) suppress cerebral metabolism and are used in refractory intracranial hypertension when other medical and surgical treatments fail. **High-Yield Clinical Pearls for NEET-PG:** * **First-line medical management:** Head elevation (30°), sedation, and osmotic therapy (Mannitol or Hypertonic saline). * **Mannitol:** Works via an osmotic effect and by reducing blood viscosity (rheological effect). It is contraindicated in renal failure and pulmonary edema. * **Cushing’s Triad (Sign of impending herniation):** Hypertension, Bradycardia, and Irregular respirations. * **Target $PaCO_2$:** During therapeutic hyperventilation, $PaCO_2$ should be maintained between **30–35 mmHg**. Dropping below 25 mmHg can cause excessive vasoconstriction and cerebral ischemia.

Q: Which of the following is NOT a typical feature of extradural hemorrhage?

Severe hypotension. **Explanation:** **1. Why Severe Hypotension is the Correct Answer:** In neurosurgery, the "Monro-Kellie doctrine" explains that the cranial vault is a rigid box. An extradural hemorrhage (EDH) increases intracranial pressure (ICP), which triggers the **Cushing Reflex** (hypertension, bradycardia, and irregular respiration). Therefore, patients with isolated head injuries typically present with **hypertension**, not hypotension. If a patient with EDH is hypotensive, the clinician must look for extracranial causes of bleeding (e.g., intra-abdominal or thoracic hemorrhage), as the adult skull cannot lose enough blood into the epidural space to cause systemic shock. **2. Analysis of Incorrect Options:** * **Deteriorating consciousness:** This is a hallmark of EDH. While some patients experience a "Lucid Interval," the subsequent hematoma expansion leads to rapid neurological decline due to brain compression. * **Fixed dilated pupil on the same side:** This occurs due to **uncal herniation**. The expanding hematoma pushes the temporal lobe (uncus) medially, compressing the ipsilateral 3rd cranial nerve (Oculomotor), leading to a dilated, non-reactive pupil. * **Fracture line crossing the temporal bone:** EDH is most commonly caused by a tear in the **middle meningeal artery** (85% of cases), which lies beneath the pterion. A temporal bone fracture is the classic inciting event. **Clinical Pearls for NEET-PG:** * **Classic Imaging:** CT scan shows a **Biconvex/Lenticular** hyperdense shape (does not cross suture lines). * **Source of Bleed:** Middle Meningeal Artery (most common) or Dural Venous Sinuses. * **Lucid Interval:** A period of temporary improvement followed by rapid deterioration; highly characteristic of EDH. * **Management:** Immediate surgical evacuation via burr hole or craniotomy if the hematoma is significant.

Q: Skull base fracture is associated with all of the following except?

Hemiparesis. **Explanation:** The diagnosis of a **Skull Base Fracture** is primarily clinical, characterized by specific signs resulting from the tearing of the dura mater and the seepage of blood or cerebrospinal fluid (CSF) into surrounding tissues. **Why Hemiparesis is the correct answer:** Hemiparesis (weakness on one side of the body) is a **focal neurological deficit** typically caused by parenchymal brain injury, such as an intracranial hemorrhage (EDH, SDH), contusion, or stroke. While a skull base fracture can coexist with these injuries, it is not a direct clinical sign of the fracture itself. Skull base fractures involve the bones at the bottom of the skull, not the motor cortex or pyramidal tracts directly. **Analysis of incorrect options:** * **Racoon eyes (Periorbital ecchymosis):** A classic sign of an **anterior cranial fossa** fracture. It occurs as blood tracks from the fracture site into the periorbital soft tissue. (Note: Tarsal plate sparing is characteristic). * **CSF Rhino-otorrhea:** Fractures of the ethmoid bone (anterior fossa) lead to **Rhinorrhea** (CSF from the nose), while fractures of the petrous temporal bone (middle fossa) lead to **Otorrhea** (CSF from the ear). * **Battle sign (Mastoid ecchymosis):** Post-auricular bruising indicative of a **middle cranial fossa** fracture (specifically the petrous temporal bone). **High-Yield Clinical Pearls for NEET-PG:** 1. **Halo/Ring Sign:** If CSF is mixed with blood, dropping it on gauze creates a central red spot with a clear outer ring. 2. **Cranial Nerve Palsy:** The most common CN injured in skull base fractures is the **Facial Nerve (CN VII)**, followed by the Vestibulocochlear (CN VIII). 3. **Management:** Most CSF leaks resolve spontaneously with conservative management (head elevation). Prophylactic antibiotics are generally **not** recommended. 4. **Investigation of Choice:** Non-contrast High-Resolution CT (HRCT) of the brain with bone windows.

Q: The 'sterile needle test' helps in differentiating what?

Depth of burns. ### Explanation The **sterile needle test** (also known as the pinprick test) is a clinical bedside method used to assess the **depth of a burn injury** by evaluating the integrity of the dermal nerve endings. **1. Why the correct answer is right:** Burn depth is categorized based on the level of tissue destruction. The needle test relies on the presence or absence of pain sensation: * **Superficial (Partial-thickness) Burns:** These involve the epidermis and upper dermis. The sensory nerve endings remain intact and exposed, making the area **exquisitely painful** to a needle prick. * **Deep (Full-thickness) Burns:** These extend through the entire dermis, destroying the nerve endings. Consequently, the area is **anaesthetic** (painless) to a needle prick. Differentiating between these is crucial because superficial burns usually heal spontaneously, whereas deep burns often require surgical intervention (skin grafting). **2. Why the incorrect options are wrong:** * **A & C (Healing/Degenerative process):** While nerve regeneration can be part of healing, the needle test is a diagnostic tool for acute assessment, not a longitudinal measure of cellular repair or degeneration. * **D (Infection):** Infection in burns is diagnosed via clinical signs (pus, foul smell, fever) or quantitative wound biopsies/cultures, not by sensory testing. **3. NEET-PG High-Yield Pearls:** * **Jackson’s Burn Zones:** Zone of Coagulation (irreversible necrosis), Zone of Stasis (potentially salvageable), and Zone of Hyperemia (will heal). * **Capillary Refill:** Present in superficial burns (blanching); absent in deep burns. * **Appearance:** Superficial burns are typically red and moist with blisters; deep burns appear leathery, charred, or waxy white. * **Rule of 9s:** Used for calculating the Total Body Surface Area (TBSA) to guide fluid resuscitation (Parkland Formula).

Q: Chronic subdural hematoma is caused by which of the following?

Rupture of bridging veins. **Explanation:** **1. Why "Rupture of bridging veins" is correct:** Chronic Subdural Hematoma (cSDH) typically occurs due to the tearing of **bridging veins** as they traverse the subdural space to drain into the dural venous sinuses. In elderly patients or those with chronic alcoholism, brain atrophy leads to an increase in the distance between the brain surface and the skull. This stretches the bridging veins, making them highly susceptible to rupture even from minor, often forgotten, head trauma. The bleeding is venous (low pressure), allowing the hematoma to accumulate slowly over weeks to months. **2. Why the other options are incorrect:** * **Fracture of skull bones:** While fractures can cause intracranial bleeding, they are most classically associated with **Epidural Hematomas (EDH)** due to the rupture of the Middle Meningeal Artery (MMA). * **Hypertension:** This is the leading cause of **Spontaneous Intracerebral Hemorrhage** (e.g., in the basal ganglia or thalamus), not typically subdural hematomas. * **Subarachnoid hemorrhage:** This is most commonly caused by the rupture of **berry aneurysms** or Arteriovenous Malformations (AVMs), resulting in bleeding into the subarachnoid space rather than the subdural space. **High-Yield Clinical Pearls for NEET-PG:** * **Imaging:** On CT scan, cSDH appears as a **crescent-shaped (concave)**, **hypodense** (dark) collection. Acute SDH is hyperdense (white). * **Risk Factors:** Elderly age, chronic alcoholism, and use of anticoagulants. * **Clinical Presentation:** Often presents as a "Great Imitator" with fluctuating levels of consciousness, progressive dementia, or focal neurological deficits. * **Management:** Symptomatic cSDH is treated via **burr-hole evacuation**.

Q: Acute flaccid paralysis with areflexia and loss of perianal reflexes below the level of spinal cord injury is most likely due to which of the following?

Spinal shock. **Explanation:** The correct answer is **Spinal Shock**. **1. Why Spinal Shock is Correct:** Spinal shock refers to the immediate, temporary loss of all neurological activity (motor, sensory, and autonomic) below the level of an acute spinal cord injury. It is characterized by **flaccid paralysis**, **areflexia** (loss of deep tendon reflexes), and loss of **sacral reflexes** (such as the bulbocavernosus and perianal reflexes). This occurs due to the sudden withdrawal of tonic facilitatory impulses from the higher brain centers. The hallmark of the end of spinal shock is the return of the bulbocavernosus reflex. **2. Why Incorrect Options are Wrong:** * **Denervation:** This refers to the loss of nerve supply to a specific muscle or organ. While it causes flaccidity, it is a permanent anatomical state rather than the acute, systemic physiological response seen immediately after spinal trauma. * **Malingering:** This is the intentional feigning of symptoms for secondary gain. While a patient may mimic paralysis, they cannot voluntarily suppress involuntary autonomic reflexes like the perianal or bulbocavernosus reflexes. * **Upper Motor Neuron (UMN) Paralysis:** While spinal cord injury eventually results in UMN signs (spasticity, hyperreflexia, and Babinski sign), these features only develop **after** the phase of spinal shock has resolved (usually 24–72 hours to weeks later). **3. NEET-PG High-Yield Pearls:** * **First reflex to return:** Bulbocavernosus reflex (S3-S4). * **Spinal Shock vs. Neurogenic Shock:** Spinal shock is a *neurological* state (loss of reflexes); Neurogenic shock is a *hemodynamic* state (hypotension and bradycardia due to loss of sympathetic tone, typically seen in injuries above T6). * **Duration:** Spinal shock typically lasts 24 hours to several weeks. * **Priapism:** May be seen during spinal shock due to uncontrolled parasympathetic activity.

Question 1

An 18-year-old man presents to the emergency department with a stab wound just to the right of the sternum in the sixth intercostal space. His blood pressure is 80 mm Hg. Faint heart sounds and pulsus paradoxus are noted. Auscultation of the right chest reveals decreased breath sounds. What is the initial management for this patient?

Accepted Answer

Aspiration of the right chest cavity

Answer

Aspiration of the pericardium

Answer

Echocardiogram

Answer

Pericardial window

Question 2

Which of the following signs refers to splenic injury?

Accepted Answer

All the above

Answer

Balance's sign

Answer

Kehr's sign

Answer

Tenderness of the 9th and 10th left rib

Question 3

Which of the following is NOT a management strategy for raised intracranial pressure?

Accepted Answer

Hypercapnia

Answer

Hypothermia

Answer

Decompressive craniectomy

Answer

Barbiturate coma

Question 4

Fracture of the mandible not involving the dental arch is treated by which method?

Accepted Answer

Open reduction

Answer

Closed reduction

Answer

No treatment required

Answer

None of the above

Question 5

Which of the following is NOT a typical feature of extradural hemorrhage?

Accepted Answer

Severe hypotension

Answer

Deteriorating consciousness

Answer

Fixed dilated pupil on the same side

Answer

Fracture line crossing the temporal bone

Question 6

Skull base fracture is associated with all of the following except?

Accepted Answer

Hemiparesis

Answer

Racoon eyes

Answer

CSF Rhino-otorrhea

Answer

Battle sign

Question 7

The 'sterile needle test' helps in differentiating what?

Accepted Answer

Depth of burns

Answer

Healing process

Answer

Degenerative process

Answer

Infection

Question 8

Chronic subdural hematoma is caused by which of the following?

Accepted Answer

Rupture of bridging veins

Answer

Fracture of skull bones

Answer

Hypertension

Answer

Subarachnoid hemorrhage

Question 9

Acute flaccid paralysis with areflexia and loss of perianal reflexes below the level of spinal cord injury is most likely due to which of the following?

Accepted Answer

Spinal shock

Answer

Denervation

Answer

Malingering

Answer

Upper motor neuron paralysis

Question 10

A patient presents 48 hours after blunt abdominal trauma. Ultrasound is normal, but the patient has tenderness in the left lumbar region. What is the most appropriate diagnostic investigation?

Accepted Answer

CECT abdomen (Contrast-Enhanced Computed Tomography of the abdomen)

Answer

MCU (Micturating Cystourethrogram)

Answer

IVP (Intravenous Pyelogram)

Answer

Repeat USG (Ultrasound)

Trauma — MCQs

Trauma — MCQs

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