Trauma — MCQs

Trauma Indian Medical PG Practice Questions and MCQs

Question 291: All of the following are synthetic dressings used in burn wound management EXCEPT?

A. Opsite
B. Biobrane
C. Dacron (Correct Answer)
D. Integra

Explanation: **Explanation:** The management of burn wounds often requires specialized dressings to provide a barrier against infection, reduce pain, and promote healing. These are broadly classified into **synthetic**, **biological**, and **biosynthetic** dressings. **Why Dacron is the correct answer:** **Dacron (Polyethylene terephthalate)** is a synthetic polyester fiber primarily used in surgery for **vascular grafts** (e.g., aortic repair) and non-absorbable sutures. It is not used as a topical burn dressing because it does not possess the necessary properties for wound coverage, such as moisture vapor permeability or the ability to adhere to a raw wound surface. **Analysis of Incorrect Options:** * **Opsite:** A common **synthetic** polyurethane film dressing. It is transparent, adhesive, and semi-permeable, allowing for moisture vapor exchange while remaining waterproof and bacteria-proof. It is used for superficial burns and donor sites. * **Biobrane:** A **biosynthetic** dressing consisting of a silicone film (synthetic) bonded to a nylon mesh coated with porcine Type I collagen (biological). It is widely used for clean partial-thickness burns. * **Integra:** A **complex synthetic/biosynthetic** dermal regeneration template. It consists of a bovine collagen-glycosaminoglycan mesh (dermal layer) and a temporary polysiloxane (silicone) epidermal layer. It is used for deep-thickness burns to encourage dermal regeneration. **High-Yield Clinical Pearls for NEET-PG:** * **Silver Sulfadiazine (Flamazine):** The gold standard topical agent for burns, but contraindicated in patients with sulfa allergies and near term in pregnancy. * **Mafenide Acetate:** Penetrates eschar well (useful in ear burns/cartilage) but can cause **metabolic acidosis** due to carbonic anhydrase inhibition. * **Biological dressings:** Include **Allografts** (cadaveric skin - temporary) and **Xenografts** (usually porcine/pig skin). * **Rule of 9s:** Always remember the Wallace Rule of Nines for initial assessment of Total Body Surface Area (TBSA) in adults.

Question 292: Tension pneumothorax results in what physiological change?

A. Alkalosis
B. Increased cardiac output
C. Decreased venous return (Correct Answer)
D. All of the above

Explanation: ### Explanation **Tension Pneumothorax** is a life-threatening condition 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 accumulation of intrapleural pressure. **1. Why "Decreased Venous Return" is Correct:** As the intrapleural pressure exceeds atmospheric pressure, it causes a **mediastinal shift** toward the contralateral (opposite) side. This shift results in the compression and kinking of the **Superior and Inferior Vena Cava**. Since these are low-pressure vessels, the mechanical obstruction severely impairs venous return to the right atrium (preload). This is the primary physiological driver of the obstructive shock seen in these patients. **2. Why the Other Options are Incorrect:** * **Increased Cardiac Output:** Due to the drastic reduction in venous return (preload), the stroke volume falls significantly, leading to **decreased cardiac output** and hypotension. * **Alkalosis:** Tension pneumothorax causes a ventilation-perfusion (V/Q) mismatch and lung collapse, leading to hypoxia and hypercapnia (CO2 retention). This typically results in **respiratory acidosis**, not alkalosis. **3. High-Yield Clinical Pearls for NEET-PG:** * **Clinical Triad:** Respiratory distress, hypotension (shock), and distended neck veins (JVP). * **Diagnosis:** It is a **clinical diagnosis**. Never wait for a Chest X-ray if tension pneumothorax is suspected. * **Immediate Management:** Needle decompression. The ATLS 10th edition recommends the **5th intercostal space** just anterior to the mid-axillary line (the 2nd ICS in the mid-clavicular line is an alternative, especially in children). * **Definitive Management:** Insertion of a chest tube (Intercostal Drainage).

Question 293: All of the following are true about trauma management except:

A. Primary survey is aimed at detecting and simultaneously treating immediately life-threatening injuries.
B. AMPLE history should be taken during the secondary survey.
C. Tertiary survey is a comprehensive patient evaluation after the initial resuscitation period.
D. Tertiary survey is usually performed about 48 hours after admission. (Correct Answer)

Explanation: **Explanation:** The goal of trauma management follows the Advanced Trauma Life Support (ATLS) protocols, which prioritize life-saving interventions through a tiered survey system. **Why Option D is the correct answer (False statement):** The **Tertiary Survey** is a comprehensive re-evaluation of the patient to identify "missed injuries" (often musculoskeletal or subtle neurological deficits). It is ideally performed **within 24 hours** of admission, once the patient is conscious and cooperative, or after the initial physiological derangement has stabilized. Waiting 48 hours is considered a delay that could lead to increased morbidity. **Analysis of other options:** * **Option A (True):** The **Primary Survey (ABCDE)** focuses on identifying and treating life-threatening conditions simultaneously (e.g., intubating for airway obstruction or needle decompression for tension pneumothorax). * **Option B (True):** The **Secondary Survey** is a head-to-toe examination performed only after the primary survey is complete and the patient is hemodynamically stable. The **AMPLE** history (Allergies, Medications, Past illness, Last meal, Events) is a key component. * **Option C (True):** The **Tertiary Survey** involves a formal review of all clinical findings and radiology reports to ensure no injuries were overlooked during the chaotic initial resuscitation phase. **High-Yield Clinical Pearls for NEET-PG:** * **Golden Hour:** The first 60 minutes after trauma where prompt intervention significantly reduces mortality. * **Trimodal Distribution of Death:** 1. *Immediate:* Seconds to minutes (Brain/Great vessel injury). 2. *Early:* Minutes to hours (Hemorrhage/Tension pneumothorax). 3. *Late:* Days to weeks (Sepsis/MODS). * **Missed Injuries:** Most commonly missed injuries in trauma are small fractures (hands/feet) and blunt abdominal trauma. The tertiary survey is specifically designed to catch these.

Question 294: "Panda facies" is commonly seen after which type of fracture?

A. Le fort I fractures
B. Le fort II fractures (Correct Answer)
C. Mandible fractures
D. None of the above

Explanation: **Explanation:** **Panda Facies** (also known as "Raccoon eyes" or periorbital ecchymosis) refers to the bilateral bruising around the eyes caused by blood tracking into the periorbital soft tissues. **Why Le Fort II is the correct answer:** Le Fort II fractures are **pyramidal fractures** that involve the nasal bones, maxillary sinuses, and the **infraorbital rim**. Because the fracture line passes through the orbital floor and the bridge of the nose, it causes significant hemorrhage and edema in the periorbital area. This results in the characteristic "Panda Facies," often accompanied by a "dish-face" deformity (midface retrusion). **Analysis of Incorrect Options:** * **Le Fort I:** This is a horizontal fracture (Guerin’s fracture) separating the alveolar process from the rest of the maxilla. It involves only the lower maxilla and palate; it does not involve the orbits, so Panda facies is absent. * **Mandible Fractures:** These involve the lower jaw. While they cause swelling and malocclusion, they do not involve the midface or orbital structures required to produce periorbital ecchymosis. **High-Yield Clinical Pearls for NEET-PG:** * **Le Fort III:** Also presents with Panda facies and dish-face deformity, as it involves complete craniofacial disjunction (including the zygomatic arch and lateral orbital wall). * **Battle’s Sign:** Post-auricular ecchymosis indicating a fracture of the **petrous temporal bone** (base of skull). * **CSF Rhinorrhea:** Most common in Le Fort II and III due to involvement of the ethmoid bone/cribriform plate. * **Guérin’s Sign:** Ecchymosis in the region of the greater palatine vessels, specifically seen in **Le Fort I**.

Question 295: Which one of the following veins should be avoided for intravenous infusion in the management of abdominal trauma?

A. Cubital
B. Cephalic
C. Long saphenous (Correct Answer)
D. External jugular

Explanation: ### Explanation **Correct Option: C (Long saphenous)** In the management of **abdominal trauma**, the primary concern is a potential injury to the **Inferior Vena Cava (IVC)** or its major tributaries. If the IVC is lacerated or obstructed, any fluid or blood administered via the veins of the lower limbs (like the long saphenous vein) will leak into the retroperitoneum or peritoneal cavity before reaching the heart. This results in ineffective resuscitation and can exacerbate an internal hemorrhage. Therefore, intravenous access should be established in the territory of the **Superior Vena Cava (SVC)**. **Analysis of Incorrect Options:** * **A & B (Cubital and Cephalic):** These are veins of the upper limb. They drain into the SVC. In abdominal trauma, the SVC remains intact and provides a direct, unobstructed route to the right atrium, making these the preferred sites for resuscitation. * **D (External jugular):** This vein drains into the subclavian vein and subsequently the SVC. While it is a central vein and carries risks like pneumothorax during cannulation, it is physiologically superior to lower limb veins in the context of suspected IVC injury. **NEET-PG High-Yield Pearls:** 1. **Golden Rule:** For trauma below the diaphragm, use veins above the diaphragm. For trauma above the diaphragm, use veins below the diaphragm (though SVC injury is rarer). 2. **ATLS Protocol:** The preferred initial access is **two large-bore (14 or 16 gauge) peripheral IV lines** in the upper extremities. 3. **Saphenous Cutdown:** While the long saphenous vein at the ankle is a classic site for emergency venous cutdown, it is contraindicated if an IVC injury is suspected. 4. **Fluid Choice:** In trauma, the initial fluid of choice is **Isotonic Crystalloids** (e.g., Ringer’s Lactate), followed by early blood products (Balanced Resuscitation).

Question 296: All of the following clinical features are seen in isolated head injury except?

A. Vomiting
B. Hypertension (Correct Answer)
C. Airway compromise
D. Seizures

Explanation: In an **isolated head injury**, the primary concern is increased intracranial pressure (ICP). While the Cushing’s triad (Hypertension, Bradycardia, and Irregular respirations) is a classic sign of raised ICP, it is a **late and inconsistent finding** in isolated head trauma. **Why Hypertension is the correct answer (the 'Except'):** In the acute setting of trauma, if a patient presents with **hypotension** or **persistent hypertension**, the clinician must first rule out extracranial causes. Isolated head injury rarely causes systemic hemodynamic instability (like significant hypertension or shock) unless there is terminal brainstem herniation. If a head injury patient is hypotensive, look for occult hemorrhage (e.g., intra-abdominal or pelvic). If they are hypertensive, it is often a physiological response to pain or pre-existing conditions rather than the head injury itself. **Analysis of Incorrect Options:** * **Vomiting:** A very common early sign of raised ICP due to stimulation of the postrema in the medulla. * **Airway Compromise:** Common in severe head injury (GCS ≤ 8) due to loss of protective reflexes, tongue fallback, or neurogenic respiratory depression. * **Seizures:** Post-traumatic seizures occur frequently due to cortical irritation from contusions, hematomas (EDH/SDH), or depressed skull fractures. **NEET-PG High-Yield Pearls:** * **Cushing’s Triad:** Hypertension (widened pulse pressure), Bradycardia, and Bradypnea/Irregular breathing. It indicates impending transtentorial herniation. * **Hypotension + Head Injury:** "Head injury does not cause shock" (except in infants with open sutures or terminal stages). Always look for another source of bleeding. * **GCS:** The most important indicator of severity and the need for definitive airway management (Intubate if GCS < 8).

Question 297: Cricothyroidotomy is contraindicated in which age group?

A. Children below 5 years of age (Correct Answer)
B. Individuals between 15-20 years of age
C. Individuals between 20-30 years of age
D. Individuals between 30-40 years of age

Explanation: **Explanation:** **Cricothyroidotomy** is a life-saving emergency procedure used to establish an airway when endotracheal intubation fails. However, it is strictly contraindicated in **children below 5 years of age** (some guidelines extend this up to 10–12 years). **Why Option A is Correct:** In young children, the **cricoid cartilage** is the only circumferential support for the upper airway. It is small, funnel-shaped, and highly pliable. Performing a cricothyroidotomy in this age group carries a high risk of: 1. **Subglottic Stenosis:** Damage to the cricoid cartilage during the procedure often leads to permanent scarring and narrowing of the airway. 2. **Anatomical Difficulty:** The cricothyroid membrane is extremely narrow in infants and toddlers, making it technically difficult to identify and cannulate without causing laryngeal trauma. *Note: In children under 5, **Needle Cricothyroidotomy** (Percutaneous Transtracheal Ventilation) is the preferred temporary emergency measure, followed by a formal tracheostomy.* **Why Options B, C, and D are Incorrect:** In individuals aged 15 and above, the larynx is fully developed, and the cricoid cartilage is robust. The cricothyroid membrane is wider and easily palpable, making surgical cricothyroidotomy the standard "cannot intubate, cannot oxygenate" (CICO) rescue maneuver in adults. **High-Yield Clinical Pearls for NEET-PG:** * **Preferred Emergency Airway (Adults):** Surgical Cricothyroidotomy. * **Preferred Emergency Airway (Children <5-12 yrs):** Needle Cricothyroidotomy. * **Landmark:** The cricothyroid membrane is located between the thyroid cartilage (Adam's apple) and the cricoid cartilage. * **Most Common Complication:** Subglottic stenosis (long-term) and hemorrhage (acute). * **Definitive Airway:** Cricothyroidotomy is a temporary measure; it should be converted to a formal tracheostomy within 24–72 hours to prevent laryngeal injury.

Question 298: An 8-year-old boy presents with a gradually progressing swelling and pain over the upper tibia for 6 months. An X-ray shows a lytic lesion with sclerotic margins in the upper tibial metaphysis. What is the most likely diagnosis?

A. Osteogenic sarcoma
B. Osteoclastoma
C. Brodie's abscess (Correct Answer)
D. Ewing's sarcoma

Explanation: **Explanation:** The clinical presentation and radiological findings point towards **Brodie’s abscess**, which is a form of **subacute or chronic osteomyelitis**. **Why Brodie’s Abscess is Correct:** Brodie’s abscess is a localized pyogenic abscess within the bone, typically caused by *Staphylococcus aureus*. It characteristically presents in children and young adults with a long-standing (chronic), dull aching pain and swelling. Radiologically, it appears as a **well-defined lytic lesion** surrounded by a **sclerotic (radio-opaque) margin**, representing the body's attempt to wall off the infection. It most commonly affects the **metaphysis** of long bones, particularly the tibia. **Why Other Options are Incorrect:** * **Osteogenic Sarcoma:** While it occurs in the metaphysis of children, it typically presents with a rapidly progressing mass, a "sunburst" periosteal reaction, or Codman’s triangle, rather than a well-defined sclerotic lytic lesion. * **Osteoclastoma (Giant Cell Tumor):** This is an **epiphyseal** lesion that occurs in skeletally mature individuals (20–40 years). It has a characteristic "soap bubble" appearance and lacks a sclerotic rim. * **Ewing’s Sarcoma:** This typically involves the **diaphysis** of long bones and presents with a characteristic "onion-skin" periosteal reaction. **High-Yield NEET-PG Pearls:** * **Most common site:** Upper end of Tibia (Metaphysis). * **Most common organism:** *Staphylococcus aureus*. * **Pathognomonic X-ray finding:** A radiolucent nidus >1 cm with a surrounding zone of reactive sclerosis. * **Treatment:** Surgical curettage and antibiotics. If the lesion is small and asymptomatic, conservative management may be considered.

Question 299: What does a positive Kehr's sign indicate?

A. Hemoperitoneum (Correct Answer)
B. Acute cholecystitis
C. Acute pancreatitis
D. Amoebic abscess

Explanation: **Explanation:** **Kehr’s sign** is a classic clinical finding defined as **referred pain to the left shoulder** caused by irritation of the undersurface of the diaphragm. 1. **Why Hemoperitoneum is correct:** The most common cause of Kehr’s sign is **splenic rupture** leading to hemoperitoneum. Blood in the peritoneal cavity accumulates in the subdiaphragmatic space, irritating the phrenic nerve (C3-C5). Because the phrenic nerve shares the same spinal origin as the supraclavicular nerves, the brain misinterprets the pain as originating from the shoulder (referred pain). 2. **Why other options are incorrect:** * **Acute cholecystitis:** Typically presents with **Boas’ sign** (referred pain to the right scapula/shoulder) due to phrenic nerve irritation on the right side. * **Acute pancreatitis:** Characteristically presents with epigastric pain radiating to the **back**. * **Amoebic abscess:** If located in the superior surface of the liver, it may cause right-sided shoulder pain, but it is not associated with Kehr’s sign. **High-Yield Clinical Pearls for NEET-PG:** * **Positioning:** Kehr’s sign is often elicited or intensified by placing the patient in the **Trendelenburg position** (head down), which encourages blood to pool under the diaphragm. * **Specificity:** While classic for splenic rupture, it can occur with any subdiaphragmatic irritant (e.g., ruptured ectopic pregnancy or perforated peptic ulcer). * **Balance’s Sign:** Another splenic injury sign—fixed dullness to percussion in the left flank and shifting dullness in the right flank. * **Phrenic Nerve Origin:** Remember "C3, 4, 5 keep the diaphragm alive."

Question 300: Which of the following is NOT true about flail chest?

A. Ultimately leads to respiratory failure
B. Paradoxical respiration
C. Fracture of three or more consecutive ribs
D. Mediastinal shift (Correct Answer)

Explanation: **Explanation:** **Flail chest** is a clinical diagnosis defined by the fracture of **three or more consecutive ribs** in at least two places, creating a segment of the chest wall that is no longer in bony continuity with the rest of the thoracic cage. 1. **Why "Mediastinal Shift" is NOT true:** Mediastinal shift is a hallmark of **Tension Pneumothorax**, not flail chest. In flail chest, the pressure dynamics within the pleural space remain relatively balanced between the two sides. While the flail segment moves, it does not generate enough unilateral pressure to displace the mediastinum. 2. **Paradoxical Respiration:** This is the pathognomonic sign. During inspiration, the negative intrathoracic pressure sucks the detached segment **inward**, and during expiration, it is pushed **outward**. 3. **Respiratory Failure:** The primary cause of respiratory failure in flail chest is not the paradoxical movement itself, but the underlying **Pulmonary Contusion**. Pain-induced splinting and decreased lung compliance lead to hypoxia and hypercapnia. 4. **Rib Fractures:** The standard definition requires $\geq 3$ consecutive ribs fractured in $\geq 2$ places. **Clinical Pearls for NEET-PG:** * **Most common cause of hypoxia:** Pulmonary contusion (not the paradoxical movement). * **Management:** The mainstay is **adequate analgesia** (e.g., epidural) and aggressive pulmonary toilet. Internal fixation (surgery) is indicated only if the patient cannot be weaned from a ventilator or has severe chest wall deformity. * **Initial Treatment:** Humidified oxygen and fluid restriction (to prevent worsening of pulmonary edema in the contused lung).

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