Trauma — MCQs

Trauma Indian Medical PG Practice Questions and MCQs

Question 31: All of the following are true about chronic subdural hematoma except:

A. Immediate recovery after surgery (Correct Answer)
B. Presents weeks after head trauma
C. Patient can be completely asymptomatic
D. Use of a subdural drain is associated with a decreased need for repeat surgery

Explanation: **Explanation:** Chronic Subdural Hematoma (cSDH) typically occurs in elderly patients or those on anticoagulants, following minor head trauma. **1. Why Option A is the correct answer (False statement):** Unlike acute SDH or epidural hematomas, recovery after surgical evacuation of a **chronic** SDH is often **gradual**, not immediate. The underlying brain has been compressed for weeks, leading to reduced cerebral blood flow and potential cortical atrophy. The brain takes time to re-expand and fill the space previously occupied by the hematoma. Furthermore, the elderly brain has less "compliance," making rapid clinical reversal less common. **2. Analysis of Incorrect Options (True statements):** * **Option B:** By definition, cSDH presents **weeks to months** (typically >3 weeks) after the initial inciting event, which may be so trivial the patient forgets it. * **Option C:** Small collections may be **completely asymptomatic** and discovered incidentally on imaging. Symptoms only arise when the hematoma reaches a critical volume or causes a significant midline shift. * **Option D:** High-quality evidence (including the Santarius et al. trial) confirms that placing a **subdural drain** for 24–48 hours post-burr hole evacuation significantly reduces the rate of recurrence and the need for re-operation. **Clinical Pearls for NEET-PG:** * **Imaging:** Appears as a **crescent-shaped, hypodense (dark)** collection on NCCT. * **Risk Factors:** Chronic alcoholism, elderly age (due to brain atrophy stretching bridging veins), and anticoagulation. * **Management:** Burr-hole craniostomy is the gold standard for symptomatic cases. * **The "Great Mimicker":** cSDH is often confused with dementia, stroke, or TIA in the elderly due to its insidious onset of cognitive decline and focal deficits.

Question 32: Which of the following is the earliest sign that appears in hemorrhagic shock?

A. Hypotension
B. Tachycardia (Correct Answer)
C. Hypertension
D. Syncope

Explanation: **Explanation:** In the setting of acute blood loss (hemorrhagic shock), the body initiates a compensatory response to maintain cardiac output and tissue perfusion. The correct answer is **Tachycardia** because it is the earliest physiological response mediated by the sympathetic nervous system. **1. Why Tachycardia is the earliest sign:** When blood volume decreases, venous return and stroke volume drop. This is sensed by baroreceptors in the carotid sinus and aortic arch, triggering a sympathetic surge. This leads to an increase in heart rate (tachycardia) to compensate for the reduced stroke volume ($CO = HR \times SV$). According to the **ATLS Classification of Hemorrhagic Shock**, tachycardia (HR >100 bpm) typically appears in **Class II shock** (15–30% blood loss), whereas blood pressure remains normal due to compensatory mechanisms. **2. Why other options are incorrect:** * **Hypotension:** This is a **late sign** of shock. It typically does not occur until **Class III shock** (30–40% blood loss), when compensatory mechanisms like tachycardia and peripheral vasoconstriction are no longer sufficient to maintain pressure. * **Hypertension:** While a transient rise in diastolic pressure may occur due to catecholamine-mediated vasoconstriction (narrowing pulse pressure), true hypertension is not a feature of hemorrhagic shock. * **Syncope:** This indicates significant cerebral hypoperfusion and usually occurs in very late stages or during rapid, massive exsanguination. **Clinical Pearls for NEET-PG:** * **Narrow Pulse Pressure:** Often precedes the drop in systolic blood pressure. * **Class I Shock:** Heart rate is usually normal (<100); the only sign might be mild anxiety. * **Urine Output:** A sensitive indicator of perfusion; it starts decreasing in Class II and drops significantly (<15 ml/hr) in Class III. * **Golden Hour:** The critical period where resuscitation can prevent irreversible organ damage.

Question 33: Battle's sign is indicative of which of the following?

A. Hemorrhage around the eyes
B. Mastoid ecchymosis (Correct Answer)
C. Umbilical ecchymosis
D. Vaginal ecchymosis

Explanation: **Explanation:** **Battle’s sign** is a classic clinical indicator of a **Basilar Skull Fracture**, specifically involving the **petrous portion of the temporal bone**. It manifests as ecchymosis (bruising) over the **mastoid process**, caused by blood tracking along the path of the posterior auricular artery. It typically takes 24–72 hours to appear after the initial trauma. **Analysis of Options:** * **Option B (Correct):** Mastoid ecchymosis is the definition of Battle’s sign. It signifies a fracture in the posterior cranial fossa. * **Option A:** Hemorrhage around the eyes (periorbital ecchymosis) is known as **Raccoon Eyes**. While also a sign of basilar skull fracture, it specifically indicates a fracture of the **anterior cranial fossa**. * **Option B:** Umbilical ecchymosis is known as **Cullen’s sign**, which indicates intraperitoneal hemorrhage, most commonly associated with acute hemorrhagic pancreatitis or ruptured ectopic pregnancy. * **Option D:** Vaginal ecchymosis is not a named clinical sign related to skull trauma; it may be seen in pelvic fractures or local trauma. **High-Yield Clinical Pearls for NEET-PG:** 1. **Associated Findings:** Basilar skull fractures are often associated with **CSF Otorrhea** (leakage from the ear) or **CSF Rhinorrhea** (leakage from the nose). 2. **Halo Sign:** If CSF is mixed with blood, placing a drop on filter paper creates a central red spot with a clear outer ring (the "Halo" or "Target" sign). 3. **Cranial Nerve Involvement:** The most common cranial nerves injured in temporal bone fractures are **CN VII (Facial)** and **CN VIII (Vestibulocochlear)**. 4. **Management:** Most CSF leaks resolve spontaneously with conservative management (head elevation); however, **nasogastric tubes are strictly contraindicated** in these patients due to the risk of intracranial insertion.

Question 34: Potts surgery involves the anastomosis between which two structures?

A. Left pulmonary artery and descending aorta (Correct Answer)
B. Left pulmonary artery and ascending aorta
C. Main pulmonary artery and aorta
D. Left pulmonary artery and subclavian artery

Explanation: **Explanation:** The **Potts shunt** is a palliative surgical procedure historically used to increase pulmonary blood flow in cyanotic congenital heart diseases with decreased pulmonary perfusion (e.g., Tetralogy of Fallot). 1. **Why Option A is correct:** The procedure involves a side-to-side anastomosis between the **Left Pulmonary Artery (LPA)** and the **Descending Thoracic Aorta**. By creating this systemic-to-pulmonary shunt, oxygen-poor blood from the aorta is directed into the pulmonary circulation for oxygenation, thereby improving systemic oxygen saturation. 2. **Why other options are incorrect:** * **Option B:** An anastomosis between the ascending aorta and the Right Pulmonary Artery (RPA) is known as the **Waterston-Cooley shunt**. * **Option C:** This is a generalized description of a systemic-to-pulmonary shunt but does not specify the anatomical landmarks of the Potts procedure. * **Option D:** An anastomosis between the subclavian artery and the pulmonary artery is the **Blalock-Taussig (BT) shunt** (Classic: subclavian artery; Modified: GORE-TEX graft between the two). **High-Yield Clinical Pearls for NEET-PG:** * **The "Problem" with Potts:** It is rarely performed today because it is technically difficult to reverse during definitive repair and carries a high risk of causing pulmonary hypertension (due to excessive flow) and heart failure. * **Mnemonic for Shunts:** * **P**otts = **P**osterior (Descending) Aorta + LPA. * **W**aterston = **A**scending Aorta + RPA (W comes after A). * **B**lalock-Taussig = **S**ubclavian Artery + PA. * **Glenn Shunt:** Superior Vena Cava (SVC) to Right Pulmonary Artery (RPA).

Question 35: Which of the following should be avoided initially in hemorrhagic shock?

A. Ringer lactate
B. Dextrose 5% (Correct Answer)
C. Normal saline
D. None of the above

Explanation: In the management of hemorrhagic shock, the primary goal is **volume expansion** to restore tissue perfusion. ### Why Dextrose 5% (D5W) is Avoided Dextrose 5% is an **isohypotonic solution**. Once infused, the glucose is rapidly metabolized by the body, leaving behind "free water." This free water distributes throughout the total body water compartments (2/3rd intracellular, 1/3rd extracellular). Consequently, only about **1/12th (approx. 8%)** of the infused volume remains in the intravascular space. In hemorrhagic shock, D5W fails to expand the plasma volume effectively and can lead to cellular edema (including cerebral edema). Therefore, it has no role in acute volume resuscitation. ### Why Other Options are Incorrect * **Ringer Lactate (RL):** This is the **fluid of choice** for initial resuscitation in trauma. It is an isotonic crystalloid that stays in the intravascular compartment longer than dextrose and has a composition similar to plasma. * **Normal Saline (0.9% NaCl):** This is also an acceptable isotonic crystalloid for initial resuscitation. However, in very large volumes, it carries a risk of hyperchloremic metabolic acidosis. ### NEET-PG High-Yield Pearls * **ATLS Guidelines:** The initial fluid bolus for an adult in hemorrhagic shock is **1 Liter of warmed isotonic crystalloid** (RL is preferred). * **Permissive Hypotension:** In non-compressible torso hemorrhage, the goal is to maintain a Mean Arterial Pressure (MAP) of ~65 mmHg to prevent "popping the clot" until definitive surgical control is achieved. * **Lethal Triad of Trauma:** Hypothermia, Acidosis, and Coagulopathy. * **Transfusion Ratio:** In massive transfusion protocols, the recommended ratio of PRBC:FFP:Platelets is **1:1:1**.

Question 36: A 70-year-old gentleman sustained an injury. He can point to the site of pain, opens his eyes when pinched, and is confused about his location and the circumstances of the accident. What is his minimum Glasgow Coma Scale (GCS) score?

A. 11 (Correct Answer)
B. 10
C. 9
D. 8

Explanation: ### Explanation The Glasgow Coma Scale (GCS) is a clinical tool used to assess a patient's level of consciousness based on three parameters: Eye Opening (E), Verbal Response (V), and Motor Response (M). **Breakdown of the Patient’s Score:** 1. **Eye Opening (E):** The patient opens his eyes "when pinched" (response to pain). This corresponds to a score of **2**. 2. **Verbal Response (V):** The patient is "confused" about location and circumstances. This corresponds to a score of **4**. 3. **Motor Response (M):** The patient "can point to the site of pain." This indicates **localizing pain**, which corresponds to a score of **5**. **Total GCS = E2 + V4 + M5 = 11.** --- ### Why the other options are incorrect: * **Option B (10):** This would be the score if the patient had a lower motor response (e.g., withdrawal from pain, M4) or was only making sounds (V2). * **Option C (9):** This score would suggest a more severe impairment, such as no verbal response or abnormal posturing. * **Option D (8):** A GCS of ≤ 8 is the clinical definition of a **coma** and usually necessitates endotracheal intubation. --- ### High-Yield Clinical Pearls for NEET-PG: * **Minimum vs. Maximum:** The minimum GCS score is **3** (not zero), and the maximum is **15**. * **Motor Component:** The Motor (M) score is the most reliable predictor of clinical outcome. * **GCS in Trauma:** * 13–15: Mild Head Injury * 9–12: Moderate Head Injury * 3–8: Severe Head Injury (Coma) * **Modified GCS:** If a patient is intubated, the verbal score is recorded as 'T' (e.g., GCS 10T). * **Mnemonic for Motor (M6 to M1):** **C**an **L**ift **W**ithout **A**ny **E**xtra **N**othing (Obeys **C**ommands, **L**ocalizes, **W**ithdraws, **A**bnormal flexion, **E**xtension, **N**one).

Question 37: Which formula is used for burn resuscitation?

A. 4 mL/kg/% TBSA (Correct Answer)
B. 5 mL/kg/% TBSA
C. 6 mL/kg/% TBSA
D. 8 mL/kg/% TBSA

Explanation: The correct answer is **4 mL/kg/% TBSA**, which refers to the **Parkland Formula**, the most widely used protocol for fluid resuscitation in burn patients during the first 24 hours. ### **Explanation of the Correct Answer** The Parkland Formula calculates the total volume of Crystalloid (specifically **Ringer’s Lactate**) required as: **4 mL × Body Weight (kg) × Total Body Surface Area (TBSA) affected by burns.** The physiological basis is to counteract the massive fluid shift from the intravascular to the interstitial space (edema) caused by increased capillary permeability after thermal injury. * **Timing:** Half of the calculated volume is administered in the first 8 hours (from the time of injury), and the remaining half is given over the next 16 hours. ### **Analysis of Incorrect Options** * **B, C, and D (5, 6, 8 mL/kg/% TBSA):** These values are not standard for initial adult resuscitation. While higher volumes may be required in specific cases (e.g., electrical burns or inhalation injury), they are not the baseline Parkland constant. Over-resuscitation can lead to "fluid creep," causing pulmonary edema and abdominal compartment syndrome. ### **High-Yield Clinical Pearls for NEET-PG** 1. **Fluid of Choice:** Ringer’s Lactate (RL) is preferred because its composition is most similar to extracellular fluid and it helps buffer the metabolic acidosis common in burns. 2. **Rule of Nines:** Used to calculate TBSA. Note that 1st-degree burns (erythema only) are **excluded** from the calculation. 3. **Modified Brooke’s Formula:** Uses **2 mL/kg/% TBSA**. 4. **Best Indicator of Resuscitation:** Adequate **Urine Output** (0.5 mL/kg/hr in adults; 1 mL/kg/hr in children). 5. **Pediatric Consideration:** Children require maintenance fluids (Dextrose-containing) in addition to the Parkland formula due to limited glycogen stores.

Question 38: According to AHA 2010 guidelines, what are the recommended energy settings for defibrillation during CPR?

A. Monophasic 120-200 Joules, Biphasic 360 Joules
B. Monophasic 200 Joules, Biphasic 360 Joules
C. Monophasic 120 Joules, Biphasic 200 Joules
D. Monophasic 360 Joules, Biphasic 120-200 Joules (Correct Answer)

Explanation: **Explanation:** The core principle of defibrillation is to deliver a sufficient electrical current to the myocardium to depolarize a critical mass of cells, allowing the heart's natural pacemaker to resume a normal rhythm. The energy required depends on the waveform of the shock: * **Monophasic Waveform:** This older technology delivers current in one direction. Because it is less efficient at lower energies, a higher initial dose of **360 Joules** is required to achieve successful defibrillation. * **Biphasic Waveform:** This modern technology reverses the polarity of the current during the shock. It is more effective at lower energy levels and causes less myocardial damage. The AHA 2010 (and subsequent 2015/2020) guidelines recommend an initial dose of **120–200 Joules**. If the specific effective dose for a device is unknown, the maximum available dose should be used. **Analysis of Incorrect Options:** * **Options A & B:** These incorrectly suggest that Biphasic shocks require higher energy (360J) than Monophasic shocks. In clinical practice, Biphasic is always lower or equal to Monophasic energy levels. * **Option C:** This incorrectly lists 120J for Monophasic, which is sub-therapeutic and unlikely to terminate ventricular fibrillation. **High-Yield Clinical Pearls for NEET-PG:** * **Shockable Rhythms:** Only Ventricular Fibrillation (VF) and Pulseless Ventricular Tachycardia (pVT) are shockable. PEA and Asystole are NOT. * **Sequence:** Give 1 shock followed immediately by 2 minutes of CPR (starting with chest compressions) before re-checking the rhythm. * **Pediatric Dosing:** Initial dose is **2 J/kg**; second dose is **4 J/kg**; subsequent doses $\geq$ 4 J/kg (max 10 J/kg or adult dose). * **Drug of Choice:** Epinephrine (1mg every 3-5 mins) is the primary vasopressor; Amiodarone (300mg bolus) is the preferred anti-arrhythmic for refractory VF/pVT.

Question 39: Fracture of the body of the mandible with a full arch of teeth, which is undisplaced, is treated by:

A. Intermaxillary fixation (IMF) (Correct Answer)
B. Open reduction and internal fixation
C. Close reduction and internal fixation
D. External pin fixation

Explanation: **Explanation:** The management of mandibular fractures is guided by the location of the fracture, the degree of displacement, and the presence of teeth for stabilization. **Why Option A is Correct:** For an **undisplaced fracture** of the body of the mandible where a **full arch of teeth** is present, the teeth themselves act as a natural guide for occlusion. **Intermaxillary Fixation (IMF)**, also known as MMF (Maxillomandibular Fixation), involves wiring the upper and lower teeth together to immobilize the jaw. In undisplaced fractures, this conservative approach provides sufficient stability for primary bone healing without the risks associated with surgery. **Why Other Options are Incorrect:** * **Option B (ORIF):** Open Reduction and Internal Fixation (using plates and screws) is the gold standard for **displaced** fractures or cases where IMF is contraindicated (e.g., seizure disorders, respiratory issues). It is unnecessarily invasive for a stable, undisplaced fracture. * **Option C (CRIF):** This is a contradictory term in this context; "Internal fixation" by definition requires an "Open" approach to place hardware. * **Option D (External Pin Fixation):** This is reserved for complex, comminuted fractures, infected non-unions, or "war injuries" where there is significant bone loss and internal hardware cannot be used. **Clinical Pearls for NEET-PG:** * **Most common site of Mandible Fracture:** Condyle (followed by Angle and Symphysis). * **Favored vs. Unfavored Fractures:** This depends on the direction of the fracture line relative to the pull of the masseter and digastric muscles. * **Indication for ORIF:** Displaced fractures, edentulous mandible (no teeth for IMF), or multiple facial fractures ("Smash injury"). * **Duration of IMF:** Usually 4–6 weeks for adults.

Question 40: When the mandible is protruded during a subcondylar fracture, to which side does it deviate?

A. Same side (Correct Answer)
B. Opposite side
C. Does not move
D. Retrudes

Explanation: In a **subcondylar fracture**, the deviation of the mandible occurs due to the loss of support and the unopposed action of the masticatory muscles. ### 1. Why the Correct Answer is Right (Same Side) The primary muscle responsible for protruding and opening the jaw is the **Lateral Pterygoid**. This muscle inserts into the pterygoid fovea on the neck of the condyle and the articular disc. * **Mechanism:** Under normal conditions, the bilateral lateral pterygoids act together to pull the condyles forward (protrusion). * **In Fracture:** When a subcondylar fracture occurs, the lateral pterygoid on the injured side can no longer effectively pull the mandible forward. Meanwhile, the lateral pterygoid on the **intact side** continues to function, pushing its side of the mandible forward and across the midline. This results in the chin deviating **toward the side of the injury**. ### 2. Why Other Options are Wrong * **Opposite side:** Deviation to the opposite side would require the injured side to have stronger protrusive force than the healthy side, which is physiologically impossible in a fracture. * **Does not move:** The mandible remains mobile because the muscles on the unaffected side and the remaining muscles of mastication (masseter, medial pterygoid) are still functional. * **Retrudes:** While the fractured segment may be displaced medially and forward by the lateral pterygoid, the clinical hallmark during active protrusion is lateral deviation, not simple retrusion. ### 3. Clinical Pearls for NEET-PG * **The "Rule of Deviation":** In the head and neck, remember: 1. **Mandibular Nerve (CN V3) Lesion:** Jaw deviates to the **same side** (weakness of pterygoids). 2. **Hypoglossal Nerve (CN XII) Lesion:** Tongue deviates to the **same side** (weakness of genioglossus). 3. **Vagus Nerve (CN X) Lesion:** Uvula deviates to the **opposite side**. * **Clinical Sign:** Patients with subcondylar fractures often present with **premature contact of posterior teeth** on the injured side and an **anterior open bite** due to the shortening of the ramus height.

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