Trauma — MCQs

A patient with a head injury presents with rapidly deteriorating sensorium and progressive dilatation and fixation of the pupil. As a surgeon in a primary care setting, with neurosurgical consultation and CT scan unavailable, you decide to perform an emergent burr hole to relieve intracranial pressure. Which of the following sites is most appropriate for the burr hole?

Q289Medium

All of the following are true about abdominal compartment syndrome except?

Q290Medium

A 62-year-old man presents to the emergency department following head trauma. He is receiving oxygen via a face mask and reservoir bag at 15 L/min, has a cervical collar in place, and an intravenous line. His Glasgow Coma Scale score is E1 (no eye opening except to pain), V2 (incomprehensible sounds), and M4 (flexion withdrawal to painful stimuli). He has no gag reflex when suctioned. What is the next best step in the management of this patient?

Trauma Indian Medical PG Practice Questions and MCQs

Question 281: True about blunt trauma abdomen are all, except?

A. Solid organ injury is more common in children than adults in blunt trauma
B. Liver injuries are more common than splenic injury (Correct Answer)
C. Diaphragmatic injuries are rare
D. Intraperitoneal gas shadows are pathognomonic of bowel perforation

Explanation: **Explanation:** In blunt trauma abdomen (BTA), the **Spleen** is the most commonly injured solid organ overall. While the Liver is the most commonly injured organ in *penetrating* trauma, it ranks second in blunt trauma. Therefore, the statement that liver injuries are more common than splenic injuries is incorrect, making it the right choice for this "except" question. **Analysis of Options:** * **Option A:** Solid organ injuries (Spleen/Liver) are indeed more common in children compared to adults. Children have thinner abdominal walls, less protective fat, and a more pliable rib cage that transmits energy directly to the underlying viscera. * **Option C:** Diaphragmatic injuries occur in <5% of blunt trauma cases. They are often occult and difficult to diagnose initially, making them relatively rare compared to solid organ injuries. * **Option D:** The presence of pneumoperitoneum (intraperitoneal gas) on an X-ray in the context of trauma is a pathognomonic sign of a hollow viscus (bowel) perforation and is a definitive indication for emergency laparotomy. **High-Yield Clinical Pearls for NEET-PG:** * **Most common organ injured in BTA:** Spleen (followed by Liver). * **Most common organ injured in Penetrating Trauma (Stab):** Liver. * **Most common organ injured in Firearm injury:** Small Bowel. * **Investigation of Choice (Stable patient):** CECT Abdomen. * **Investigation of Choice (Unstable patient):** FAST (Focused Assessment with Sonography for Trauma). * **Kehr’s Sign:** Referred pain to the left shoulder, highly suggestive of splenic rupture.

Question 282: What is the management of flail chest with respiratory failure?

A. Chest tube drainage
B. Oxygen administration
C. Intermittent positive pressure ventilation (IPPV) (Correct Answer)
D. Internal operative fixation of the fractured segments

Explanation: ### Explanation **Flail chest** occurs when three or more contiguous ribs are fractured in two or more places, creating a "floating" segment that moves paradoxically (inward during inspiration, outward during expiration). #### 1. Why IPPV is the Correct Answer The primary cause of respiratory failure in flail chest is not just the paradoxical movement, but the underlying **pulmonary contusion** and pain-induced splinting. **Intermittent Positive Pressure Ventilation (IPPV)** acts as an "internal pneumatic stabilizer." It provides positive pressure that pushes the flail segment outward during inspiration, correcting the paradoxical motion, improving alveolar recruitment, and ensuring adequate oxygenation despite the contused lung tissue. #### 2. Analysis of Incorrect Options * **A. Chest tube drainage:** This is the treatment for associated pneumothorax or hemothorax, but it does not address the mechanical instability or respiratory failure of the flail segment itself. * **B. Oxygen administration:** While necessary, simple oxygen supplementation is insufficient if the patient has progressed to **respiratory failure** (indicated by tachypnea, hypoxia, or hypercapnia). * **D. Internal operative fixation:** Though increasingly used for severe chest wall deformity or failure to wean from a ventilator, it is not the immediate first-line management for acute respiratory failure in a trauma setting. #### 3. NEET-PG High-Yield Pearls * **Diagnosis:** Clinical diagnosis (paradoxical chest wall movement). * **Most common cause of hypoxia:** Underlying pulmonary contusion (not the paradoxical movement itself). * **Management Strategy:** * *Stable patient:* Humidified O2, aggressive analgesia (Epidural is gold standard), and chest physiotherapy. * *Unstable/Respiratory failure:* **Intubation and IPPV.** * **Indication for Surgery:** Failure to wean from the ventilator, persistent pain, or severe chest wall deformity.

Question 283: Which of the following is NOT true about abdominal compartment syndrome?

A. Intra-abdominal pressure >15 cm of H2O
B. Decreased pulmonary venous pressure (Correct Answer)
C. Intra-abdominal pressure measured using Foley catheterization of the bladder
D. With >25-30 mm Hg intra-abdominal pressure, life-threatening hypoxia and ARDS can occur

Explanation: **Abdominal Compartment Syndrome (ACS)** is defined as a sustained increase in intra-abdominal pressure (IAP) >20 mmHg associated with new-onset organ dysfunction. ### **Explanation of Options** * **Why Option B is Correct (The False Statement):** In ACS, the elevated IAP pushes the diaphragm upward into the thoracic cavity. This increases **intrathoracic pressure**, which is transmitted to the heart and pulmonary vasculature. Consequently, **Pulmonary Capillary Wedge Pressure (PCWP)** and pulmonary venous pressure **increase**, not decrease. This can lead to a false elevation in CVP readings despite a state of low cardiac output. * **Option A:** Normal IAP is 0–5 mmHg. Intra-abdominal hypertension (IAH) starts at **>12 mmHg** (approx. 15 cm H2O). While ACS is formally diagnosed at >20 mmHg, pressures >15 cm H2O represent the pathological spectrum of IAH. * **Option C:** The **Gold Standard** for measuring IAP is the **trans-bladder technique** using a Foley catheter. A small volume of saline (approx. 25ml) is instilled into the bladder, which acts as a passive reservoir reflecting intra-abdominal pressure. * **Option D:** Severe IAP (>25 mmHg) causes cephalad displacement of the diaphragm, leading to decreased lung compliance, atelectasis, and shunting. This results in life-threatening **hypoxia, hypercapnia, and ARDS-like pictures.** ### **High-Yield Clinical Pearls for NEET-PG** * **Abdominal Perfusion Pressure (APP):** Calculated as MAP minus IAP. A target APP of **>60 mmHg** is associated with improved survival. * **Renal Effects:** Oliguria is one of the earliest signs of ACS (occurs at IAP >15–20 mmHg) due to direct compression of renal veins and parenchyma. * **Management:** Medical management includes gastric decompression and neuromuscular blockade. Definitive treatment for refractory ACS is **Surgical Decompression (Laparostomy/Open Abdomen).** * **Triad of ACS:** Tense distended abdomen + Oliguria + Increased peak airway pressure.

Question 284: What is true about intra-abdominal compartment syndrome?

A. Intra-abdominal pressure greater than 15 cm H2O is a diagnostic criterion. (Correct Answer)
B. Pneumoperitoneum can produce it.
C. It leads to decreased renal blood flow.
D. All of the above.

Explanation: **Abdominal Compartment Syndrome (ACS)** is defined as sustained intra-abdominal pressure (IAP) > 20 mmHg (with or without an abdominal perfusion pressure < 60 mmHg) that is associated with new organ dysfunction/failure. ### **Explanation of Options:** * **Option A (Correct):** While the World Society of the Abdominal Compartment Syndrome (WSACS) defines ACS at >20 mmHg, many surgical texts and exam standards (including Bailey & Love) traditionally use **15 cm H₂O (approx. 11-12 mmHg)** as the threshold for **Intra-abdominal Hypertension (IAH)**, which is the diagnostic precursor and essential criterion for the syndrome. In the context of this specific question, it represents the recognized pathological elevation of pressure. * **Option B (Incorrect):** While pneumoperitoneum (e.g., during laparoscopy) increases IAP, it is a controlled, transient physiological state. ACS typically refers to a **pathological, sustained** state resulting from trauma, massive fluid resuscitation, or retroperitoneal hemorrhage. * **Option C (Incorrect):** This is a distractor in the context of "All of the above." While ACS *does* lead to decreased renal blood flow (due to venous compression and reduced cardiac output), the primary diagnostic definition (Option A) is considered the most "true" fundamental statement regarding its identification. ### **High-Yield Clinical Pearls for NEET-PG:** 1. **Measurement:** The gold standard for measuring IAP is indirectly via **intra-vesical (bladder) pressure** using a Foley catheter (transducer method). 2. **Grading of IAH:** * Grade I: 12–15 mmHg * Grade II: 16–20 mmHg * Grade III: 21–25 mmHg * Grade IV: >25 mmHg 3. **Organ Effects:** ACS causes **decreased** cardiac output, **decreased** renal perfusion (oliguria), and **increased** peak airway pressure (due to diaphragmatic elevation). 4. **Management:** The definitive treatment for refractory ACS is **decompressive laparotomy** (leaving the abdomen open with a temporary dressing like a Bogota bag).

Question 285: In blunt trauma abdomen, what is the recommended approach for performing a laparotomy?

A. Depends on the organ injured
B. Always a midline incision (Correct Answer)
C. Always a transverse incision
D. Depends upon the type of injury

Explanation: In the management of blunt trauma abdomen (BTA), the primary goal of surgical intervention is rapid access, thorough visualization, and immediate control of hemorrhage or contamination. ### **Why "Always a Midline Incision" is Correct** A **long midline incision** (from the xiphoid process to the pubic symphysis) is the gold standard in trauma surgery for several critical reasons: 1. **Speed:** It is the fastest way to enter the peritoneal cavity as it passes through the relatively avascular linea alba. 2. **Versatility:** It provides excellent exposure to all four quadrants of the abdomen, the retroperitoneum, and the diaphragm. 3. **Extendability:** It can be easily extended superiorly into a median sternotomy or inferiorly if required. 4. **Bloodless Entry:** Minimizing muscle cutting reduces additional blood loss in an already hemodynamically unstable patient. ### **Why Other Options are Incorrect** * **Options A & D:** In trauma, the specific organ injured is often unknown prior to exploration. Even if a specific organ is suspected (e.g., splenic rupture), a midline incision is still preferred because multi-organ injuries are common in blunt trauma. * **Option C:** Transverse incisions are time-consuming to perform and close, offer limited access to the entire paracolic gutters, and are difficult to extend in an emergency. ### **High-Yield Clinical Pearls for NEET-PG** * **Indication for Laparotomy in BTA:** Hemodynamic instability with a positive DPL (Diagnostic Peritoneal Lavage) or FAST (Focused Assessment with Sonography for Trauma), or signs of peritonitis. * **Most Common Organ Injured (BTA):** Spleen (followed by Liver). * **Most Common Organ Injured (Penetrating Trauma):** Small Bowel. * **The "Damage Control" Sequence:** 1. Control hemorrhage/contamination → 2. Resuscitation in ICU → 3. Planned re-operation for definitive repair.

Question 286: Fracture of the mandible in an edentulous jaw is best treated with:

A. External fixator (Correct Answer)
B. Minerva plaster cast
C. Interdental wiring
D. Intermaxillary elastic traction

Explanation: ### Explanation **Correct Answer: A. External fixator** **Why it is correct:** In an edentulous patient (one without teeth), the primary challenge in managing mandibular fractures is the lack of a stable dental scaffold. Traditional methods like Intermaxillary Fixation (IMF) rely on teeth to provide anchorage and restore occlusion. In the absence of teeth, an **External Fixator** (e.g., Morris biphase or Gunning splints with external pins) is preferred because it provides rigid stabilization by anchoring directly into the bone from the outside, bypassing the need for dental support. It is particularly useful in comminuted fractures or when the patient’s dentures are unavailable or broken. **Why the other options are incorrect:** * **B. Minerva plaster cast:** This is used for cervical spine injuries (stabilizing the head, neck, and upper torso) and has no role in the management of mandibular fractures. * **C. Interdental wiring:** This technique requires the presence of healthy, stable teeth to anchor the wires. In an edentulous jaw, there are no teeth to wire together. * **D. Intermaxillary elastic traction:** Similar to wiring, this requires teeth or dental implants to apply the elastic force between the upper and lower jaws. **High-Yield Clinical Pearls for NEET-PG:** * **Gunning Splints:** These are specialized "denture-like" appliances used in edentulous patients to achieve IMF by wiring the splints to the alveolar bone (circum-mandibular and zygomatic wiring). * **Atrophic Mandible:** Edentulous jaws are often atrophic with reduced blood supply (centripetal flow). This makes them prone to non-union; hence, minimal periosteal stripping is vital. * **Most common site of Mandibular Fracture:** Condyle > Angle > Symphysis. * **Clinical Sign:** Derangement of occlusion is the most common sign of a mandibular fracture in dentate patients.

Question 287: A patient with a suspected pelvic fracture presents with urethral bleeding and an inability to pass urine. What is the most appropriate immediate management?

A. Encourage voiding after administering antibiotics and analgesics.
B. Immediate Foley catheterization in the ward.
C. Apply a hot water bottle and administer carbachol injection.
D. Prepare for surgery and attempt catheterization in the operating theatre. (Correct Answer)

Explanation: ### Explanation The clinical presentation of **urethral bleeding (blood at the meatus)** and inability to void following a pelvic fracture is a classic triad suggesting a **posterior urethral injury** (usually at the membranous urethra). **1. Why Option D is Correct:** In cases of suspected urethral injury, blind catheterization in the ward is strictly contraindicated as it can convert a partial tear into a complete transection. The most appropriate management is to prepare the patient for surgery. A single, gentle attempt at catheterization may be performed by an experienced surgeon in the **Operating Theatre (OT)** under sterile conditions. If this fails, a **Suprapubic Cystostomy (SPC)** is performed to divert urine. **2. Why Other Options are Wrong:** * **Option A:** Encouraging voiding is futile and dangerous; extravasation of urine into the pelvic space can lead to severe sepsis and cellulitis. * **Option B:** Blind Foley catheterization in the ward is the "never-event" in this scenario. It risks worsening the urethral trauma and introducing infection into a pelvic hematoma. * **Option C:** Carbachol (a cholinergic) and heat are used for functional urinary retention (e.g., post-operative atony), not for mechanical/traumatic disruptions. **3. High-Yield Clinical Pearls for NEET-PG:** * **Classic Signs of Urethral Injury:** Blood at the meatus, inability to void, and a **"high-riding" prostate** on Digital Rectal Examination (DRE). * **Gold Standard Investigation:** Retrograde Urethrogram (RUG). Perform this *before* any catheterization attempt if the patient is stable. * **Mechanism:** Posterior urethral injuries are associated with **pelvic fractures** (shearing at the puboprostatic ligaments), while anterior injuries (bulbar urethra) are associated with **straddle injuries**.

Question 288: A patient with a head injury presents with rapidly deteriorating sensorium and progressive dilatation and fixation of the pupil. As a surgeon in a primary care setting, with neurosurgical consultation and CT scan unavailable, you decide to perform an emergent burr hole to relieve intracranial pressure. Which of the following sites is most appropriate for the burr hole?

A. In the temporal region contralateral to the side of pupillary dilatation
B. In the midline if both pupils are equal or the side of pupillary dilatation is unknown
C. In the temporal region ipsilateral to the side of pupillary dilatation (Correct Answer)
D. Refer to a higher center if both pupils are equal or the side of pupillary dilatation is unknown

Explanation: ### Explanation **1. Why Option C is Correct:** In a patient with a head injury and a rapidly deteriorating sensorium, the classic sign of **uncal herniation** is a dilated, fixed pupil. This occurs because the expanding intracranial mass (most commonly an **Epidural Hematoma - EDH**) pushes the uncus of the temporal lobe over the tentorial notch, compressing the **ipsilateral 3rd cranial nerve (Oculomotor)**. Since the pupillary fibers are superficial, they are affected first, leading to ipsilateral mydriasis. Therefore, an emergent burr hole must be placed on the **ipsilateral side** (the same side as the dilated pupil) to evacuate the hematoma and decompress the brain. **2. Why Other Options are Incorrect:** * **Option A:** The pupillary dilatation is almost always ipsilateral to the lesion. Operating on the contralateral side would miss the hematoma and delay life-saving decompression. * **Option B:** While the midline is used for certain neurosurgical procedures, it is avoided in emergency burr holes for EDH due to the presence of the **Superior Sagittal Sinus**, which carries a high risk of catastrophic hemorrhage. * **Option C vs. D:** In a "rapidly deteriorating" patient where transfer time would lead to brain death, the standard surgical teaching (and NEET-PG preference) is to intervene. If the side is unknown, the surgeon should explore the side of the pupil first, then the contralateral side, rather than simply referring. **3. Clinical Pearls for NEET-PG:** * **Site of Burr Hole:** The most common site for an EDH is the **Pterion** (where the frontal, parietal, temporal, and sphenoid bones meet), as it overlies the **Middle Meningeal Artery**. * **Hutchinson’s Pupil:** The sequence of pupillary changes in EDH: (1) Ipsilateral constriction (transient), (2) Ipsilateral dilatation (classic), (3) Bilateral dilatation (terminal). * **Kernohan’s Notch Phenomenon:** A rare "false localizing sign" where the contralateral peduncle is compressed, causing hemiparesis on the *same* side as the lesion. However, the **pupil** remains the most reliable indicator of the side of the lesion.

Question 289: All of the following are true about abdominal compartment syndrome except?

A. Characterized by increased peak inspiratory pressure and decreased urinary output.
B. Can lead to fatal complications due to pulmonary failure and mesenteric vascular compromise.
C. A urinary bladder catheter is the gold standard indirect method used to measure intra-abdominal pressure.
D. Grade III abdominal compartment syndrome is managed by hypovolemic resuscitation. (Correct Answer)

Explanation: ### Explanation **Abdominal Compartment Syndrome (ACS)** is defined as a sustained intra-abdominal pressure (IAP) >20 mmHg associated with new-onset organ dysfunction. **Why Option D is the Correct Answer (The False Statement):** Grade III ACS (IAP 21–25 mmHg) is a surgical emergency. The management principle is **decompressive laparotomy**, not hypovolemic resuscitation. In fact, aggressive fluid resuscitation (hypervolemia) is often a *cause* of secondary ACS due to bowel wall edema. Management focuses on maintaining abdominal perfusion pressure (APP >60 mmHg) and surgical decompression when medical management fails. **Analysis of Other Options:** * **Option A:** Increased IAP pushes the diaphragm cephalad, reducing lung compliance and increasing **peak inspiratory pressure**. It also compresses the renal veins and parenchyma, leading to **decreased urinary output** (oliguria). * **Option B:** If untreated, ACS leads to Multi-Organ Dysfunction Syndrome (MODS). High pressures cause **pulmonary failure** (due to atelectasis) and **mesenteric vascular compromise**, leading to bowel ischemia and lactic acidosis. * **Option C:** Measuring **intra-vesical pressure** via a Foley catheter (using 25ml of saline) is the gold-standard indirect method for monitoring IAP, as the bladder wall acts as a passive membrane reflecting intra-abdominal tension. **NEET-PG High-Yield Pearls:** * **Normal IAP:** 5–7 mmHg in critically ill adults. * **Abdominal Perfusion Pressure (APP):** MAP – IAP. It is a better predictor of visceral perfusion than IAP alone. * **Grades of IAH (Intra-abdominal Hypertension):** * Grade I: 12–15 mmHg * Grade II: 16–20 mmHg * Grade III: 21–25 mmHg (Decompression usually required) * Grade IV: >25 mmHg (Immediate decompression) * **Classic Triad:** Tense distended abdomen + Increased airway pressure + Oliguria.

Question 290: A 62-year-old man presents to the emergency department following head trauma. He is receiving oxygen via a face mask and reservoir bag at 15 L/min, has a cervical collar in place, and an intravenous line. His Glasgow Coma Scale score is E1 (no eye opening except to pain), V2 (incomprehensible sounds), and M4 (flexion withdrawal to painful stimuli). He has no gag reflex when suctioned. What is the next best step in the management of this patient?

A. Intubate the patient (Correct Answer)
B. Urgent decompressive hemicraniectomy
C. Urgent non-contrast CT head
D. Administer mannitol and perform burr hole surgery

Explanation: ### Explanation The management of trauma follows the **ATLS (Advanced Trauma Life Support)** protocol, where the priority is always **ABCDE** (Airway, Breathing, Circulation, Disability, Exposure). **1. Why Intubation is the Correct Answer:** The patient’s Glasgow Coma Scale (GCS) score is **7** (E1 + V2 + M4 = 7). According to ATLS guidelines, any patient with a **GCS ≤ 8** requires definitive airway management (endotracheal intubation). Furthermore, the absence of a **gag reflex** indicates that the patient cannot protect his airway against aspiration. In head trauma, securing the airway is critical to prevent secondary brain injury caused by hypoxia and hypercapnia. **2. Why Other Options are Incorrect:** * **B & D (Surgical Interventions):** Decompressive hemicraniectomy or burr holes are neurosurgical interventions for raised intracranial pressure or hematomas. These are considered only *after* the airway is secured and the patient is stabilized. * **C (CT Head):** While a non-contrast CT is the gold standard for diagnosing intracranial hemorrhage, it should never precede the stabilization of the airway. Sending an unstable patient with a GCS of 7 to the radiology suite without a secured airway is a "fatal" mistake in trauma management. **3. Clinical Pearls for NEET-PG:** * **GCS ≤ 8 = Intubate:** This is a classic high-yield rule. * **Airway First:** In any trauma question, if the airway is compromised or the GCS is low, "Secure the Airway" or "Intubate" is almost always the next best step, regardless of other injuries. * **Cervical Spine:** During intubation in trauma, **Manual In-Line Stabilization (MILS)** must be maintained to protect the cervical spine. * **Secondary Brain Injury:** The primary goal of early intubation in head injury is to maintain PaO₂ > 60 mmHg and avoid hypotension, as these are the strongest predictors of poor outcome.

Practice by Chapter

Initial Assessment of Trauma Patient

Practice Questions

Advanced Trauma Life Support (ATLS) Principles

Practice Questions

Chest Trauma

Practice Questions

Abdominal Trauma

Practice Questions

Head Trauma

Practice Questions

Spinal Trauma

Practice Questions

Extremity Trauma

Practice Questions

Vascular Trauma

Practice Questions

Genitourinary Trauma

Practice Questions

Burns Management

Practice Questions

Mass Casualty Management

Practice Questions

Damage Control Surgery

Practice Questions

Want unlimited practice?

Get full access to all questions, explanations, and performance tracking.

Start For Free

Trauma — MCQs

Trauma — MCQs

On this page

Practice by Chapter

Want unlimited practice?