Trauma — MCQs

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?

Q340Easy

Which of the following signs refers to splenic injury?

Trauma Indian Medical PG Practice Questions and MCQs

Question 331: Exposure treatment is done for burns of which body part?

A. Upper limb
B. Lower limbs
C. Thorax
D. Head & Neck (Correct Answer)

Explanation: ### Explanation In burn management, there are two primary methods of wound care: the **Closed (Occlusive) Method** and the **Open (Exposure) Method**. **The Correct Answer: D. Head & Neck** The **Exposure Method** is the treatment of choice for burns involving the **face, neck, and perineum**. The underlying medical rationale is twofold: 1. **Anatomical Complexity:** These areas have irregular contours that make applying and maintaining occlusive dressings difficult and uncomfortable. 2. **Infection Control:** The face and neck have an excellent blood supply, which promotes faster healing and provides natural resistance to infection. Keeping these areas open allows the wound to dry, forming a natural protective "crust" or scab, which inhibits bacterial growth (as bacteria thrive in the moist environment under dressings). **Why the other options are incorrect:** * **A & B (Upper and Lower Limbs):** Extremities are typically treated with the **Closed Method**. Dressings provide protection against mechanical trauma, absorb exudate, and allow for functional positioning (splinting) to prevent contractures. * **C (Thorax):** Circumferential or large trunk burns are generally dressed to prevent fluid loss and contamination, although specialized air-fluidized beds may sometimes be used. **High-Yield Clinical Pearls for NEET-PG:** * **Silver Sulfadiazine (1%):** The most common topical antibacterial; however, it is avoided on the face (risk of skin staining/graying) and in patients with sulfa allergies. * **Mafenide Acetate:** Used for deep burns and ear burns (penetrates cartilage) but can cause **metabolic acidosis** (carbonic anhydrase inhibition). * **Rule of Nines:** Remember that the Head and Neck together account for **9%** of Total Body Surface Area (TBSA) in adults. * **Silver Nitrate:** Can cause electrolyte imbalances like hyponatremia and hypochloremia.

Question 332: Cushing reflex is characterized by which of the following relationships between mean arterial pressure and intracranial pressure?

A. Mean arterial pressure increases with increased intracranial pressure (Correct Answer)
B. Mean arterial pressure decreases with decreased intracranial pressure
C. Mean arterial pressure increases with decreased intracranial pressure
D. Mean arterial pressure decreases with increased intracranial pressure

Explanation: **Explanation:** The **Cushing reflex** (or Cushing response) is a physiological nervous system response to increased intracranial pressure (ICP). It is a compensatory mechanism designed to maintain **Cerebral Perfusion Pressure (CPP)**. **The Underlying Concept:** CPP is calculated as **MAP – ICP**. When ICP rises (due to trauma, hemorrhage, or tumor), it compresses cerebral blood vessels, leading to brain ischemia. To overcome this high resistance and maintain blood flow to the brain, the body’s sympathetic nervous system triggers a massive increase in systemic vascular resistance. This results in an **increase in Mean Arterial Pressure (MAP)** to "push" blood into the cranium against the high ICP. Therefore, Option A is correct. **Analysis of Incorrect Options:** * **Option B:** Decreased ICP does not trigger this reflex; the body maintains normal MAP through standard homeostatic mechanisms. * **Option C:** If ICP is low, there is no physiological need for a compensatory pathological rise in MAP to maintain perfusion. * **Option D:** This is the opposite of the reflex. A decrease in MAP during high ICP would lead to immediate cerebral ischemia and brain death. **High-Yield Clinical Pearls for NEET-PG:** * **Cushing’s Triad:** A late sign of increased ICP consisting of: 1. **Hypertension** (widening pulse pressure) 2. **Bradycardia** (reflex response to hypertension via baroreceptors) 3. **Irregular Respirations** (due to brainstem compression) * **Clinical Significance:** The presence of Cushing’s triad often indicates impending **transtentorial herniation** and is a neurosurgical emergency. * **Contrast:** Do not confuse Cushing *Reflex* (Trauma/ICP) with Cushing *Syndrome* (Hypercortisolism).

Question 333: Which anatomical site is typically affected by a Curling's ulcer?

A. Duodenum (Correct Answer)
B. Stomach
C. Esophagus
D. Jejunum

Explanation: **Explanation:** **Curling’s Ulcer** is a stress-induced acute erosion or ulceration that occurs in patients with **severe burns**. The primary pathophysiology involves systemic hypovolemia and reduced splanchnic perfusion, leading to mucosal ischemia and the breakdown of the protective mucosal barrier. **Why Duodenum is Correct:** While stress ulcers can occur throughout the upper GI tract, **Curling’s ulcers classically involve the first part of the duodenum**. They are often deeper than other stress ulcers and carry a significant risk of perforation or hemorrhage. **Analysis of Incorrect Options:** * **Stomach:** While the stomach is the most common site for **Cushing’s ulcers** (associated with increased intracranial pressure and hyperacidity), Curling’s ulcers are traditionally associated with the duodenum. * **Esophagus:** Stress ulcers rarely primary manifest in the esophagus; esophageal lesions in burn patients are more likely due to GERD or prolonged intubation. * **Jejunum:** Stress-induced ulceration typically spares the small bowel distal to the duodenum, as the acid-pepsin factor required for ulcer formation is neutralized by pancreatic secretions in the jejunum. **High-Yield Clinical Pearls for NEET-PG:** * **Mnemonic:** **C**urling’s – **C**offee (burnt) / **C**alorie (burns). **C**ushing’s – **C**ushion (Brain/Head injury). * **Pathogenesis Difference:** Curling’s is due to **hypovolemia/ischemia**, whereas Cushing’s is due to **vagal stimulation** leading to gastric acid hypersecretion. * **Prophylaxis:** The incidence has significantly decreased due to the routine use of H2 blockers, Proton Pump Inhibitors (PPIs), and early enteral feeding in burn units.

Question 334: A patient presents with irritability and altered sensorium one month after an injury. What is the most likely diagnosis?

A. Extradural hematoma
B. Subdural hematoma (Correct Answer)
C. Intracerebral hemorrhage
D. Subarachnoid hemorrhage

Explanation: **Explanation:** The correct diagnosis is **Chronic Subdural Hematoma (cSDH)**. The key clinical indicator in this scenario is the **time interval** (one month) between the injury and the onset of symptoms. **1. Why Subdural Hematoma (SDH) is correct:** SDH occurs due to the tearing of **bridging veins** between the cerebral cortex and the dural sinuses. Unlike arterial bleeds, venous bleeding is slow. Chronic SDH typically presents **3 weeks to several months** after a seemingly minor head injury (often in elderly patients or those on anticoagulants). The gradual accumulation of blood and the subsequent formation of a semi-permeable membrane lead to osmotic fluid shift, causing delayed symptoms like irritability, altered sensorium, or focal deficits. **2. Why other options are incorrect:** * **Extradural Hematoma (EDH):** This is an acute emergency usually involving the **middle meningeal artery**. It presents within hours of injury, often characterized by a "Lucid Interval" followed by rapid deterioration. It does not present a month later. * **Intracerebral Hemorrhage (ICH):** This typically presents acutely with sudden neurological deficits or signs of increased intracranial pressure immediately following trauma or a hypertensive stroke. * **Subarachnoid Hemorrhage (SAH):** Classically presents as a "thunderclap headache" (worst headache of life) with immediate onset, often due to aneurysm rupture or acute trauma. **Clinical Pearls for NEET-PG:** * **Imaging Gold Standard:** Non-contrast CT (NCCT) head. Chronic SDH appears **hypodense (dark)** and crescent-shaped. * **Shape:** SDH is **Crescent-shaped** (concave); EDH is **Biconvex/Lens-shaped** (convex). * **Risk Factors for cSDH:** Elderly age, chronic alcoholism, and anticoagulation (due to brain atrophy increasing the tension on bridging veins). * **Management:** Symptomatic chronic SDH is usually treated via **burr-hole evacuation**.

Question 335: All of the following are true about diffuse axonal injuries except?

A. Injuries to axons by shearing force.
B. Most common location is lobar white matter at the junction of grey and white matter.
C. Associated with raised intracranial pressure in all cases. (Correct Answer)
D. MRI is the investigation of choice.

Explanation: **Explanation:** Diffuse Axonal Injury (DAI) is a severe form of traumatic brain injury caused by high-velocity rotational acceleration-deceleration forces. **Why Option C is the correct answer (False statement):** While DAI is a severe injury, it is **not associated with raised intracranial pressure (ICP) in all cases.** In fact, one of the hallmark clinical features of DAI is a "clinicoradiological dissociation," where the patient is in a deep coma (low GCS), but the initial CT scan appears relatively normal with no significant mass effect, midline shift, or evidence of raised ICP. Raised ICP usually only develops later due to secondary brain swelling. **Analysis of other options:** * **Option A:** DAI occurs due to **shearing forces** that cause stretching and tearing of axons at the time of impact. * **Option B:** The most common site is the **grey-white matter junction** (specifically the lobar white matter, often in the frontal and temporal lobes). Other high-yield sites include the corpus callosum (Grade II) and the brainstem (Grade III). * **Option D:** **MRI (specifically Susceptibility Weighted Imaging - SWI or FLAIR)** is the investigation of choice. CT scans often miss small "petechial" hemorrhages characteristic of DAI, whereas MRI is highly sensitive to these microhemorrhages. **Clinical Pearls for NEET-PG:** * **Mechanism:** Rotational acceleration/deceleration (e.g., RTA). * **Grading (Adams Classification):** * Grade I: Grey-white matter junction. * Grade II: Corpus callosum. * Grade III: Brainstem. * **Key Finding:** Patient is comatose from the moment of injury without a focal space-occupying lesion on imaging. * **Prognosis:** Generally poor; it is a leading cause of persistent vegetative state after trauma.

Question 336: A 30-year-old male presents after an accident with inability to move his legs and pass urine. Trauma to the cervical spine is suspected. What is the best initial approach?

A. X-ray of the cervical spine, lateral and AP views
B. The patient should be accompanied by a doctor and shifted to the X-ray table
C. Observation for any neurological deficit
D. Cervical collar immobilization followed by X-ray of the cervical spine (Correct Answer)

Explanation: ### Explanation **1. Why Option D is Correct:** In any trauma patient where a spinal cord injury is suspected (indicated here by paraplegia and urinary retention), the **primary goal is to prevent secondary injury**. The cervical spine is the most mobile and vulnerable segment. Any movement of an unstable fracture can lead to permanent neurological damage or respiratory arrest. Therefore, the **initial approach** must always be **rigid cervical collar immobilization** to stabilize the spine before any diagnostic imaging or transport is attempted. This follows the Advanced Trauma Life Support (ATLS) protocol of "protection before detection." **2. Why Other Options are Incorrect:** * **Option A:** While imaging is necessary, performing an X-ray without first stabilizing the neck is dangerous. Movement during positioning for the X-ray can worsen the injury. * **Option B:** Having a doctor accompany the patient is good practice, but it does not replace the mechanical stabilization provided by a cervical collar. Shifting a patient without immobilization is contraindicated. * **Option C:** The patient already presents with significant neurological deficits (inability to move legs/pass urine). Observation alone is passive and delays necessary stabilization and intervention. **3. High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Imaging:** While X-ray is often the initial step in exams, **Non-Contrast CT (NCCT)** is now the preferred gold standard for evaluating cervical spine trauma in the acute setting. * **Clearing the Spine:** A cervical spine can only be "cleared" clinically if the patient is awake, alert, sober, and has no midline tenderness or distracting injuries (NEXUS criteria). * **Priapism:** In trauma, involuntary erection (priapism) is a classic sign of complete spinal cord injury. * **Neurogenic Shock:** Characterized by the triad of **hypotension, bradycardia, and peripheral vasodilation** (warm extremities), distinguishing it from hypovolemic shock.

Question 337: What is true about Flail chest?

A. Involves two or more ribs fractured at two or more sites.
B. Characterized by paradoxical respiration on the affected side. (Correct Answer)
C. Intubation is contraindicated.
D. Chest strapping is recommended.

Explanation: ### Explanation **Flail Chest** is a life-threatening clinical condition occurring when a segment of the thoracic cage is separated from the rest of the chest wall. **1. Why Option B is Correct:** The hallmark of flail chest is **paradoxical respiration**. Under normal conditions, the chest expands during inspiration due to negative intrathoracic pressure. In flail chest, the detached segment is sucked **inward** during inspiration (as it follows the negative pressure) and pushed **outward** during expiration. This leads to inefficient ventilation and is often associated with underlying pulmonary contusion, which is the primary cause of hypoxia. **2. Analysis of Incorrect Options:** * **Option A:** By definition, flail chest involves **three or more** adjacent ribs fractured at **two or more** sites. Fracturing only two ribs usually does not provide enough instability to cause a true flail segment. * **Option C:** Intubation is **not contraindicated**. In fact, "internal pneumatic stabilization" via mechanical ventilation is indicated if the patient has respiratory distress, severe hypoxia (PaO₂ < 60 mmHg), or associated head injury. * **Option D:** Chest strapping or binding is **strongly discouraged**. While it may stabilize the segment, it restricts chest expansion, promotes atelectasis, and hinders the clearance of secretions, significantly increasing the risk of pneumonia. **Clinical Pearls for NEET-PG:** * **Most common cause of hypoxia:** Underlying **Pulmonary Contusion**, not the paradoxical movement itself. * **Management Priority:** Adequate analgesia (e.g., epidural anesthesia) and aggressive pulmonary toilet are the mainstays of treatment. * **Diagnosis:** Primarily **clinical** (visualizing the paradoxical movement). * **Indications for Surgery:** Failure to wean from the ventilator or severe chest wall deformity.

Question 338: What is the Muirs and Barclays formula used for?

A. Colloid resuscitation in burns (Correct Answer)
B. Polytrauma fluid resuscitation
C. Crystalloid in trauma
D. Dextran in burns

Explanation: ### Explanation **Correct Answer: A. Colloid resuscitation in burns** The **Muir and Barclay formula** is a historical but high-yield method specifically designed for **colloid-based fluid resuscitation** in burn patients. Unlike modern protocols that prioritize crystalloids, this formula calculates the volume of plasma (colloid) required to prevent burn shock by replacing protein-rich fluid lost from the intravascular compartment. The formula is calculated as: **Total Colloid (ml) = [Total Body Surface Area (TBSA) % × Weight (kg)] / 2** This amount represents one "aliquot." According to the protocol, six such aliquots are given over 36 hours at specific intervals (4, 4, 4, 6, 6, and 12 hours). **Why other options are incorrect:** * **B & C (Polytrauma/Crystalloid in trauma):** Standard trauma resuscitation (ATLS guidelines) utilizes isotonic crystalloids (e.g., Ringer’s Lactate) to restore volume. The Muir and Barclay formula is specific to the pathophysiology of burns (capillary leak) rather than hemorrhagic shock. * **D (Dextran in burns):** While Dextran is a colloid, the Muir and Barclay formula specifically advocated for the use of **plasma**. Dextran is more commonly associated with the **Evans formula** (which uses both saline and colloids). **High-Yield Clinical Pearls for NEET-PG:** * **Parkland Formula:** The most commonly used formula today. It uses **Crystalloids** (Ringer’s Lactate) at **4 ml × kg × % TBSA** over 24 hours. * **Modified Brooke’s Formula:** Uses **2 ml** × kg × % TBSA (Crystalloid). * **Galveston Formula:** Used for **pediatric** burn resuscitation based on Body Surface Area (BSA) rather than weight. * **Rule of 10:** A simplified modern resuscitation starting point: % TBSA × 10 = ml/hr (for patients 40–80 kg).

Question 339: 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?

A. Aspiration of the right chest cavity (Correct Answer)
B. Aspiration of the pericardium
C. Echocardiogram
D. Pericardial window

Explanation: ### Explanation This clinical scenario presents a classic diagnostic challenge in trauma: differentiating between **Tension Pneumothorax** and **Cardiac Tamponade**. **1. Why Option A is Correct:** The patient has hypotension, faint heart sounds, and pulsus paradoxus—features typically associated with Beck’s triad (cardiac tamponade). However, the critical finding is **decreased breath sounds on the right side**. In a penetrating injury to the lower chest (6th intercostal space), a tension pneumothorax can mimic tamponade by shifting the mediastinum, compressing the heart (leading to faint sounds), and reducing venous return (leading to hypotension and pulsus paradoxus). According to **ATLS guidelines**, any patient with respiratory distress and hypotension must first be evaluated for tension pneumothorax. **Aspiration of the right chest cavity (needle decompression/thoracostomy)** is the immediate priority. Relieving a tension pneumothorax is faster and more likely to stabilize the patient if breath sounds are absent. **2. Why Other Options are Incorrect:** * **B. Aspiration of the pericardium (Pericardiocentesis):** While the symptoms suggest tamponade, the absent breath sounds point toward a pleural issue first. Furthermore, in acute trauma, pericardiocentesis is often unsuccessful because the pericardium is filled with clotted blood. * **C. Echocardiogram:** While a FAST scan is useful, this patient is hemodynamically unstable (BP 80 mmHg). Clinical intervention (decompression) takes precedence over imaging in an unstable patient with clear physical findings. * **D. Pericardial Window:** This is a surgical procedure performed in the OR to diagnose/drain tamponade. It is not the "initial" bedside management for a patient in shock with absent breath sounds. **Clinical Pearls for NEET-PG:** * **Beck’s Triad:** Hypotension, JVP distension, and muffled heart sounds (indicates Tamponade). * **Differentiating Factor:** In **Tension Pneumothorax**, the trachea is deviated and breath sounds are **absent**. In **Tamponade**, breath sounds are **normal/bilateral**. * **Pulsus Paradoxus:** A drop in systolic BP >10 mmHg during inspiration; seen in both Tamponade and severe Tension Pneumothorax. * **Rule of Thumb:** Always decompress the chest first if breath sounds are diminished in a hypotensive trauma patient.

Question 340: Which of the following signs refers to splenic injury?

A. Balance's sign
B. Kehr's sign
C. Tenderness of the 9th and 10th left rib
D. All the above (Correct Answer)

Explanation: 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.

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Trauma — MCQs

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