Trauma — MCQs
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What percentage of burns in a child involves the head region?
What is the initial step in the management of trauma?
An 81-year-old female falls and presents to the emergency department. What injury to a tissue or structure causes lower leg extremities to be externally rotated?
Which statement about diaphragmatic injury is true?
What is the management of grade 3 splenic trauma in a child?
A 27-year-old patient presented with left-sided abdominal pain to the emergency room, 6 hours after trauma. The patient is hemodynamically stable and FAST positive. A contrast-enhanced CT scan shows a contrast blush along with a Grade I laceration. What is the most appropriate management?
What is the most commonly injured organ in blast injury?
Which criteria indicate that a burn patient should be referred for specialized care?
What is the most common site for chest tube insertion in a case of pleural effusion?
What diameter of cerebellar hematoma requires surgical evacuation?
Trauma Indian Medical PG Practice Questions and MCQs
Question 371: What percentage of burns in a child involves the head region?
- A. 10%
- B. 20% (Correct Answer)
- C. 30%
- D. 40%
Explanation: **Explanation:** The assessment of burn surface area in children differs significantly from adults due to their unique body proportions. In adults, the **Rule of Nines** (Wallace) is used, where the head and neck account for 9%. However, children have a disproportionately larger head and smaller lower limbs. **1. Why 20% is Correct:** According to the modified Rule of Nines for infants/children, the **head and neck account for 18%** (often rounded to 20% in clinical exams). As a child grows, 1% is subtracted from the head and added to each leg for every year of age over one. By age 10, the child’s proportions approximate those of an adult. **2. Analysis of Incorrect Options:** * **A (10%):** This is closer to the adult value (9%). Selecting this would underestimate the fluid resuscitation requirements in a pediatric patient. * **C & D (30% & 40%):** These values are excessively high. Even in a neonate, the head does not exceed 18-20% of the total body surface area (TBSA). **3. Clinical Pearls for NEET-PG:** * **Lund and Browder Chart:** This is the **most accurate** method for calculating TBSA in children as it accounts for age-specific changes in body surface area. * **Palmar Method:** The patient’s palm (including fingers) represents approximately **1% TBSA**. This is useful for small or patchy burns. * **Fluid Resuscitation:** Children require more maintenance fluid than adults. The **Parkland Formula** (4ml/kg/% burn) is used, but in children, maintenance fluids (using the Holliday-Segar formula) must be added to the resuscitation volume to prevent hypoglycemia and dehydration. * **Critical Area:** In children, the head is a major source of heat loss; hence, keeping the head covered during burn management is vital to prevent hypothermia.
Question 372: What is the initial step in the management of trauma?
- A. Airway maintenance (Correct Answer)
- B. Intravenous fluids
- C. Fracture stabilization
- D. Do not shift
Explanation: **Explanation:** The management of a trauma patient follows the **ATLS (Advanced Trauma Life Support)** protocol, which prioritizes life-threatening conditions in a specific sequence known as the **Primary Survey**. The fundamental principle is to treat the most immediate threat to life first. **Why Airway Maintenance is Correct:** The sequence follows the **ABCDE mnemonic**, where **'A' stands for Airway maintenance with Cervical Spine protection**. Hypoxia resulting from a compromised airway can lead to brain death within minutes, making it the highest priority. Before addressing circulation or specific injuries, the clinician must ensure the airway is patent and the spinal cord is protected. **Analysis of Incorrect Options:** * **B. Intravenous fluids:** This falls under **'C' (Circulation)**. While critical for managing hemorrhagic shock, it is addressed only after the Airway (A) and Breathing (B) have been secured. * **C. Fracture stabilization:** This is part of the **Secondary Survey** or the 'D/E' phase of the primary survey (to prevent further hemorrhage). It is never prioritized over the airway. * **D. Do not shift:** While spinal immobilization is vital, "not shifting" the patient is a general precaution rather than the active initial management step required to save a life in a clinical setting. **Clinical Pearls for NEET-PG:** * **The "Golden Hour":** The first 60 minutes after trauma where prompt intervention significantly reduces mortality. * **Cervical Spine:** Always assume a cervical spine injury in any blunt trauma above the clavicle; maintain neutral immobilization during airway maneuvers (use **Jaw Thrust**, not Head Tilt-Chin Lift). * **The Lethal Triad:** Acidosis, Coagulopathy, and Hypothermia are the three conditions trauma surgeons strive to avoid during the initial resuscitation.
Question 373: An 81-year-old female falls and presents to the emergency department. What injury to a tissue or structure causes lower leg extremities to be externally rotated?
- A. Sacroiliac joint
- B. Neck of femur
- C. Lateral meniscus (Correct Answer)
- D. Intertrochanteric fracture
Explanation: **Explanation:** The correct answer is **Lateral meniscus**. This question focuses on the **"Screw-home mechanism"** of the knee joint. In the final stages of knee extension (the last 30 degrees), the femur undergoes internal rotation relative to the tibia to "lock" the knee. Conversely, to initiate flexion, the knee must "unlock." If there is a tear or displacement of the **lateral meniscus**, it can act as a mechanical wedge, preventing normal tracking and causing the tibia to remain in a position of **external rotation** (or the femur in internal rotation) to accommodate the displaced tissue. **Analysis of Options:** * **A. Sacroiliac joint:** Injuries here typically present with pelvic instability and pain but do not result in a characteristic external rotation of the lower leg. * **B. Neck of femur & D. Intertrochanteric fracture:** While these fractures classically present with external rotation and shortening of the limb, the rotation occurs at the **hip joint**, involving the entire lower extremity. The question specifically points toward a structure causing rotation of the **lower leg extremities** (distal to the knee), which is a classic sign of a "locked knee" due to meniscal pathology. **Clinical Pearls for NEET-PG:** * **Screw-home mechanism:** Medial rotation of the femur on the tibia during the terminal phase of extension. * **Unlocking the knee:** Performed by the **Popliteus muscle** (the "key" to the knee), which laterally rotates the femur on the tibia. * **Bucket-handle tears:** Most common cause of a "locked knee" where the patient cannot fully extend the leg, often held in slight external rotation.
Question 374: Which statement about diaphragmatic injury is true?
- A. Treatment is conservative
- B. It resolves spontaneously
- C. Left-sided injury is more common (Correct Answer)
- D. It is associated with pneumothorax
Explanation: **Explanation:** Diaphragmatic injuries typically result from blunt or penetrating trauma. **Option C is correct** because left-sided diaphragmatic ruptures are significantly more common (approx. 70-80% of cases). This is due to two primary factors: 1. **The Protective Effect of the Liver:** On the right side, the liver acts as a buffer, absorbing and distributing the kinetic energy of the impact. 2. **Congenital Weakness:** The left hemidiaphragm has a natural point of weakness at the posterolateral aspect (the site of embryonic fusion). **Analysis of Incorrect Options:** * **Options A & B:** Diaphragmatic injuries **never** resolve spontaneously and cannot be treated conservatively. Due to the pressure gradient between the positive-pressure abdomen and negative-pressure thorax, abdominal viscera will eventually herniate into the chest. Therefore, surgical repair (laparotomy or thoracotomy) is mandatory once diagnosed. * **Option D:** While a pneumothorax *can* coexist with trauma, diaphragmatic injury is classically associated with **hemothorax** or the presence of **bowel sounds/hollow viscera** in the thoracic cavity, rather than being defined by pneumothorax itself. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Investigation:** Diagnostic Laparoscopy (especially for small penetrating wounds). * **Chest X-ray Finding:** Look for the "Gurgle sign" (bowel loops in the chest) or a nasogastric tube coiled in the thorax. * **Surgical Approach:** In acute cases, **Laparotomy** is preferred to inspect for associated intra-abdominal organ injuries. In chronic/delayed presentations, a **Thoracotomy** is often preferred due to adhesions.
Question 375: What is the management of grade 3 splenic trauma in a child?
- A. Embolization (Correct Answer)
- B. Partial splenectomy
- C. Total splenectomy
- D. Conservative management
Explanation: In pediatric trauma, the management of splenic injury is heavily biased toward **Splenic Salvage** to avoid the lifelong risk of Overwhelming Post-Splenectomy Infection (OPSI). **Why Embolization is the Correct Choice:** For a Grade 3 splenic injury (laceration 1–3 cm deep or subcapsular hematoma involving 10–50% surface area), the standard of care is **Non-Operative Management (NOM)**. In the context of modern trauma protocols, if a patient is hemodynamically stable but shows evidence of active extravasation (blush) on CT or has high-grade injuries, **Angio-embolization** is the preferred intervention. It allows for hemorrhage control while preserving the functional splenic parenchyma, aligning with the goal of avoiding a splenectomy. **Analysis of Incorrect Options:** * **Conservative Management (D):** While NOM is the overall strategy, "Embolization" is a specific *active* component of NOM for higher-grade injuries. In many recent NEET-PG patterns, if embolization is an option for Grade 3+ injuries, it is favored as the definitive non-surgical intervention to prevent failure of observation. * **Partial Splenectomy (B):** This is technically demanding and rarely performed in acute trauma settings; it is usually reserved for elective cases or specific polar injuries when NOM fails. * **Total Splenectomy (C):** This is the last resort, reserved only for Grade 5 injuries or hemodynamically unstable patients (Class IV shock) who do not respond to resuscitation. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Investigation:** Contrast-Enhanced CT (CECT) is the investigation of choice for stable blunt trauma abdomen. * **The "90% Rule":** Over 90% of pediatric splenic injuries are managed non-operatively. * **Vaccination:** If splenectomy is unavoidable, vaccinate against *H. influenzae*, *S. pneumoniae*, and *N. meningitidis* (ideally 14 days post-op). * **Kehr’s Sign:** Referred pain to the left shoulder due to diaphragmatic irritation (classic for splenic rupture).
Question 376: A 27-year-old patient presented with left-sided abdominal pain to the emergency room, 6 hours after trauma. The patient is hemodynamically stable and FAST positive. A contrast-enhanced CT scan shows a contrast blush along with a Grade I laceration. What is the most appropriate management?
- A. Splenectomy
- B. Splenorrhaphy
- C. Splenic Artery Embolization (Correct Answer)
- D. Conservative management
Explanation: ### **Explanation** The management of splenic trauma is primarily dictated by the patient's **hemodynamic stability** rather than the grade of injury alone. **1. Why Splenic Artery Embolization (SAE) is Correct:** The patient is **hemodynamically stable**, which is the prerequisite for Non-Operative Management (NOM). However, the presence of a **"contrast blush"** on CECT indicates active extravasation of contrast (active bleeding) or a pseudoaneurysm. In a stable patient, a contrast blush is a specific indication for **Angiography and Embolization**. SAE increases the success rate of NOM by stopping the focal bleed while preserving splenic immune function. **2. Why the other options are incorrect:** * **Splenectomy (A) & Splenorrhaphy (B):** These are operative interventions. Surgery is indicated only if the patient is hemodynamically **unstable**, has peritonitis, or if NOM/Embolization fails. * **Conservative Management (D):** While Grade I injuries are often managed conservatively (observation), the presence of a **contrast blush** is a "red flag" that significantly increases the risk of delayed rupture and failure of simple observation. Therefore, active intervention via embolization is required. --- ### **High-Yield Clinical Pearls for NEET-PG** * **Gold Standard Investigation:** CECT (only for stable patients). * **Most Common Organ Injured:** Spleen (in Blunt Abdominal Trauma). * **Indications for SAE:** Hemodynamically stable patient with CECT showing contrast blush, pseudoaneurysm, or high-grade injury (Grade IV/V). * **Kehr’s Sign:** Referred pain to the left shoulder due to diaphragmatic irritation (classic for splenic rupture). * **Post-Splenectomy Prophylaxis:** Vaccination against encapsulated organisms (*H. influenzae, B. meningitidis, S. pneumoniae*) should be given 14 days after emergency surgery or 14 days before elective surgery.
Question 377: What is the most commonly injured organ in blast injury?
- A. Lung (Correct Answer)
- B. Liver
- C. Spleen
- D. Pancreas
Explanation: ### Explanation **Why Lung is the Correct Answer:** Blast injuries are categorized into four types. **Primary blast injuries** are caused by the pressure wave (overpressure) generated by an explosion. This wave specifically targets **air-filled organs** and air-fluid interfaces. The **lung** is the most commonly injured internal organ in primary blast injuries (often referred to as "Blast Lung"). The sudden pressure change causes alveolar rupture, pulmonary contusion, and systemic air embolism, which is the most common cause of death among those who survive the initial blast. **Why Other Options are Incorrect:** * **B. Liver & C. Spleen:** These are solid organs. While they are the most commonly injured organs in **blunt abdominal trauma** (Spleen > Liver), they are relatively resistant to the pressure waves of a primary blast. They are more likely to be injured in *secondary* (shrapnel) or *tertiary* (body displacement) blast injuries. * **D. Pancreas:** The pancreas is a retroperitoneal organ and is rarely injured in isolation during blast events. **High-Yield Clinical Pearls for NEET-PG:** * **Most common organ injured overall (Primary Blast):** Lung. * **Most common hollow viscus injured:** Small Intestine (specifically the cecum and terminal ileum). * **Most common permanent injury/Most sensitive indicator:** Tympanic Membrane (TM) rupture. A normal TM usually rules out significant primary blast injury. * **Blast Injury Classification:** 1. **Primary:** Pressure wave (Lungs, TM, Bowel). 2. **Secondary:** Flying debris/shrapnel (Penetrating trauma). 3. **Tertiary:** Victim thrown by wind (Fractures, Head injury). 4. **Quaternary:** Burns, toxic fumes, or crush injuries.
Question 378: Which criteria indicate that a burn patient should be referred for specialized care?
- A. 10% superficial burn in a child
- B. Scald burn on the face
- C. 25% superficial burn in an adult
- D. 25% deep burn in an adult (Correct Answer)
Explanation: **Explanation:** The American Burn Association (ABA) has established specific criteria for referral to a specialized Burn Center. These criteria are based on the severity, extent, and location of the injury, as well as the patient's age and comorbidities. **Why Option D is Correct:** According to ABA guidelines, a **Major Burn** (requiring specialized care) is defined as a partial-thickness (deep) burn involving **>20% Total Body Surface Area (TBSA)** in adults aged 10–50 years. Therefore, a 25% deep burn in an adult significantly exceeds this threshold and carries a high risk of systemic complications, fluid shifts, and infection, necessitating expert management. **Analysis of Incorrect Options:** * **Option A:** In children (<10 years), the threshold for referral is **>10% TBSA**. A 10% superficial burn is considered a moderate burn but does not strictly meet the "greater than 10%" criteria for mandatory specialized referral unless it involves critical areas. * **Option B:** While burns to the face are often referred, a simple "scald burn" without specifying depth or TBSA is less definitive than a 25% deep burn. However, in clinical practice, any partial-thickness burn to the face, hands, feet, or perineum is a referral criterion. * **Option C:** Superficial (first-degree) burns (like sunburns) are **not** included in the TBSA calculation for burn severity or fluid resuscitation (Parkland formula). Only partial and full-thickness burns are counted. **High-Yield Clinical Pearls for NEET-PG:** * **Referral Criteria:** >10% TBSA in children/elderly; >20% TBSA in adults; full-thickness burns >5%; burns to face, hands, feet, genitalia, or major joints; electrical, chemical, or inhalation injuries. * **Rule of Nines:** Used for rapid TBSA estimation (Head 9%, Each Arm 9%, Each Leg 18%, Anterior Trunk 18%, Posterior Trunk 18%, Perineum 1%). * **Fluid of Choice:** Ringer’s Lactate is the preferred crystalloid for resuscitation.
Question 379: What is the most common site for chest tube insertion in a case of pleural effusion?
- A. 2nd intercostal space, midclavicular line
- B. 7th intercostal space, midaxillary line (Correct Answer)
- C. 5th intercostal space, midclavicular line
- D. None of the above
Explanation: The correct answer is **B. 7th intercostal space, midaxillary line.** ### **Explanation** The primary principle of chest tube (intercostal drainage) placement depends on the nature of the substance being drained. * **Fluid (Pleural Effusion/Hemothorax):** Due to gravity, fluid accumulates in the dependent (lower) parts of the pleural cavity. Therefore, a lower insertion site is required. The **7th intercostal space (ICS) in the midaxillary line** is the preferred site for effusions as it ensures effective drainage of the basal collection while remaining safely above the diaphragm. * **Air (Pneumothorax):** Air rises to the apex. Traditionally, the **2nd ICS in the midclavicular line** was used, though current ATLS guidelines now favor the **4th/5th ICS anterior to the midaxillary line** (the "Safe Triangle") for both air and fluid. ### **Analysis of Incorrect Options** * **Option A (2nd ICS, MCL):** This is the classic site for **needle decompression** of a tension pneumothorax, not for draining fluid/effusions. * **Option C (5th ICS, MCL):** This is anatomically inappropriate. The midclavicular line at this level risks injury to the internal mammary artery, the heart (on the left), or the liver (on the right). ### **Clinical Pearls for NEET-PG** * **The Safe Triangle:** Defined by the anterior border of the latissimus dorsi, the lateral border of the pectoralis major, and a line superior to the horizontal level of the nipple (5th ICS). This is the gold standard zone for chest tube insertion to avoid injury to the long thoracic nerve and internal organs. * **Safety Rule:** Always insert the tube **immediately above the rib** (superior border) to avoid damaging the **intercostal neurovascular bundle** (VAN), which runs along the inferior groove of the rib. * **Most common complication:** Malposition of the tube. * **Most serious complication:** Injury to the lung parenchyma or subdiaphragmatic organs (liver/spleen).
Question 380: What diameter of cerebellar hematoma requires surgical evacuation?
- A. Greater than 0.5 cm
- B. Greater than 1 cm
- C. Greater than 2 cm
- D. Greater than 3 cm (Correct Answer)
Explanation: **Explanation:** The management of cerebellar hematomas is a critical topic in neurotrauma because the posterior fossa is a confined space. Unlike supratentorial bleeds, even small increases in volume here can rapidly lead to brainstem compression, obstructive hydrocephalus, or tonsillar herniation. **Why Option D is Correct:** According to the **Guidelines for the Management of Spontaneous Intracerebral Hemorrhage**, surgical evacuation is indicated for patients with a cerebellar hemorrhage greater than **3 cm in diameter** who are experiencing neurological deterioration or who have brainstem compression and/or hydrocephalus. A 3 cm threshold is the established clinical "cutoff" where the risk of fatal brainstem herniation outweighs the risks of suboccipital craniectomy. **Why Other Options are Incorrect:** * **Options A & B (0.5 cm and 1 cm):** These are considered small hematomas. They are typically managed conservatively with close neurological monitoring and serial CT scans, as they rarely cause significant mass effect. * **Option C (2 cm):** While a 2 cm bleed requires vigilant observation, it does not meet the standard surgical criteria unless accompanied by significant clinical deterioration or acute hydrocephalus. **High-Yield Clinical Pearls for NEET-PG:** 1. **The "Rule of 3":** For cerebellar hematomas, think of **3 cm** as the magic number for surgery. 2. **Clinical Presentation:** Look for the triad of ataxia, headache, and vomiting. 3. **GCS vs. Size:** Even if a patient has a high GCS, a hematoma >3 cm is often treated surgically because "talk and die" syndrome is common due to sudden brainstem compression. 4. **Associated Findings:** Always check for **obstructive hydrocephalus** (due to 4th ventricle compression), which may require an EVD (External Ventricular Drain) in addition to or before evacuation.
Practice by Chapter
Initial Assessment of Trauma Patient
Practice Questions
Advanced Trauma Life Support (ATLS) Principles
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Chest Trauma
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Abdominal Trauma
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Head Trauma
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Spinal Trauma
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Extremity Trauma
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Vascular Trauma
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Genitourinary Trauma
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Burns Management
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Mass Casualty Management
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Damage Control Surgery
Practice Questions
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