Trauma — MCQs

A 42-year-old man presents with fractures of the left tenth, eleventh, and twelfth ribs and left tibia and fibula fractures following trauma. His vital signs are: blood pressure 120/90 mm Hg, pulse rate 100 bpm, and respiration rate 24 breaths per minute. He has hematuria and left flank pain. Intravenous pyelography shows no excretion from the left kidney but normal excretion from the right. What is the next step in management?

Q395Medium

A patient with spine, chest, and abdominal injury in a road traffic accident developed hypotension and bradycardia. What is the most likely reason?

Q396Medium

A patient presents with irritability and altered sensorium 4 weeks after head trauma. What is the most common cause of these symptoms?

Q397Easy

A fracture mandible should be immobilized for an average of how many weeks?

Q398Easy

Which is the most common neurofibroma in the posterior mediastinum?

Q399Medium

Which of the following wiring is indicated in case of symphysis fracture of the mandible?

Q400Medium

A 24-year-old male, a victim of a road traffic accident, is brought to the casualty department with breathlessness and tachypnea. Examination reveals tracheal deviation to the left and a hyperresonant sound on the right side of the chest. How should this patient be managed?

Trauma Indian Medical PG Practice Questions and MCQs

Question 391: A 10-year-old boy sustained a burn injury on his back. What percentage of his Total Body Surface Area (TBSA) does this injury represent?

A. 13%
B. 15%
C. 19%
D. 16% (Correct Answer)

Explanation: ***16%*** - In pediatric burn assessment, the **Lund and Browder chart** is used for accurate TBSA calculation, where the back (posterior trunk) of a 10-year-old represents **16% TBSA**. - This differs from adult calculations due to **age-specific body proportions**, with children having relatively smaller trunk surface areas compared to adults. *13%* - This percentage corresponds to the **anterior trunk** (chest and abdomen) in pediatric patients using the Lund and Browder chart. - It underestimates the **posterior trunk** surface area, which is larger than the anterior trunk in children. *15%* - This value does not correspond to any specific anatomical region in standard **pediatric TBSA calculations**. - It falls between the anterior trunk (13%) and posterior trunk (16%) values, making it an incorrect intermediate estimate. *19%* - This percentage overestimates the posterior trunk surface area and may reflect **adult Rule of Nines** calculations inappropriately applied to children. - The Rule of Nines is **not accurate for pediatric patients** due to different body proportions, particularly larger head and smaller trunk percentages.

Question 392: A 40-year-old man with severe maxillofacial trauma following a motor vehicle accident presents to the emergency department one hour after the incident. His vital signs are: Pulse rate 120/min, BP 100/70 mm Hg, and SpO2 80% on oxygen. What is the most appropriate immediate management?

A. Nasotracheal intubation
B. Orotracheal intubation (Correct Answer)
C. Intravenous fluid resuscitation
D. Tracheostomy

Explanation: **Explanation:** The primary objective in trauma management follows the **ATLS (Advanced Trauma Life Support) protocol**, where **Airway (A)** with cervical spine protection takes precedence over Breathing (B) and Circulation (C). This patient presents with severe maxillofacial trauma and respiratory distress (SpO2 80%), indicating an immediate need for a definitive airway. **Why Orotracheal Intubation is correct:** Orotracheal intubation is the preferred and most rapid method for securing a definitive airway in most trauma patients. Despite the maxillofacial injuries, it remains the first-line approach. It allows for direct visualization and is safer than nasotracheal routes in the acute setting. **Analysis of Incorrect Options:** * **Nasotracheal Intubation:** This is **contraindicated** in severe maxillofacial or mid-face trauma due to the high risk of cribriform plate fracture. Attempting this could result in accidental intracranial tube placement. * **Intravenous Fluid Resuscitation:** While the patient is tachycardic (120/min), addressing "Circulation" comes after "Airway." Hypoxia (SpO2 80%) will kill the patient faster than compensated shock. * **Tracheostomy:** This is a surgical airway usually reserved for long-term ventilation or when a cricothyroidotomy cannot be performed. In an emergency where intubation fails, a **surgical cricothyroidotomy** is the preferred "emergency surgical airway," not a tracheostomy. **High-Yield Clinical Pearls for NEET-PG:** * **Definitive Airway Definition:** A tube placed in the trachea with the cuff inflated below the vocal cords, connected to oxygen-enriched ventilation. * **Maxillofacial Trauma Rule:** Always assume a cervical spine injury; perform intubation with **Manual Inline Stabilization (MILS)**. * **Cricothyroidotomy vs. Tracheostomy:** In the ED, if you "cannot intubate, cannot ventilate," the answer is Cricothyroidotomy. Tracheostomy is an elective/semi-elective procedure performed in the OR.

Question 393: A patient with head injury opens eyes on painful stimulus, uses inappropriate words and localizes pain. What is his GCS score?

A. 8
B. 10 (Correct Answer)
C. 12
D. 14

Explanation: The Glasgow Coma Scale (GCS) is a critical objective tool used to assess a patient's level of consciousness based on three parameters: Eye opening (E), Verbal response (V), and Motor response (M). ### **Step-by-Step Calculation:** 1. **Eye Opening (E):** The patient opens eyes only to **painful stimulus**. This corresponds to **E2**. (Spontaneous = 4, To speech = 3, To pain = 2, None = 1). 2. **Verbal Response (V):** The patient uses **inappropriate words** (random or exclamatory speech without sustained conversation). This corresponds to **V3**. (Oriented = 5, Confused = 4, Inappropriate words = 3, Incomprehensible sounds = 2, None = 1). 3. **Motor Response (M):** The patient **localizes pain** (moves limb to the site of noxious stimulus). This corresponds to **M5**. (Obeys commands = 6, Localizes pain = 5, Normal flexion/Withdrawal = 4, Abnormal flexion/Decorticate = 3, Extension/Decerebrate = 2, None = 1). **Total GCS = E2 + V3 + M5 = 10.** ### **Analysis of Incorrect Options:** * **Option A (8):** This score would indicate a more severe injury (e.g., E2, V2, M4). A GCS ≤ 8 is the classic threshold for defining a "Coma" and usually requires intubation. * **Option C (12):** This would imply higher functioning, such as opening eyes to speech (E3) and confused conversation (V4). * **Option D (14):** This represents a near-normal score, typically seen in mild head injuries where the patient is oriented but perhaps slightly confused or slow to respond. ### **High-Yield Clinical Pearls for NEET-PG:** * **Minimum score is 3; Maximum is 15.** There is no score of 0. * **GCS Classification:** 13–15 (Mild), 9–12 (Moderate), 3–8 (Severe). * **Motor Component:** This is the most significant predictor of neurological outcome. * **Modified GCS:** For intubated patients, the verbal score is recorded as 'T' (e.g., GCS 10T).

Question 394: A 42-year-old man presents with fractures of the left tenth, eleventh, and twelfth ribs and left tibia and fibula fractures following trauma. His vital signs are: blood pressure 120/90 mm Hg, pulse rate 100 bpm, and respiration rate 24 breaths per minute. He has hematuria and left flank pain. Intravenous pyelography shows no excretion from the left kidney but normal excretion from the right. What is the next step in management?

A. Exploratory laparotomy
B. CT scan with intravenous contrast
C. Arteriography (Correct Answer)
D. Cystogram

Explanation: **Explanation:** The patient presents with a classic triad suggesting a **renal artery injury (pedicle injury)**: blunt trauma to the lower ribs/flank, hematuria, and a **"non-visualized" or "silent" kidney** on Intravenous Pyelography (IVP). **1. Why Arteriography is the Correct Choice:** In the setting of a stable patient (BP 120/90) where IVP shows no excretion of contrast, the primary concern is a traumatic dissection or thrombosis of the renal artery. **Arteriography** is the gold standard for diagnosing renal vascular injuries. It confirms the diagnosis and assesses the feasibility of surgical repair or endovascular intervention. In renal pedicle injuries, the "warm ischemia time" is critical (usually <4-6 hours), making rapid definitive diagnosis via angiography essential. **2. Why Other Options are Incorrect:** * **Exploratory Laparotomy:** The patient is hemodynamically stable. Surgery is indicated for unstable patients or those with expanding hematomas. In a stable patient, imaging must precede surgery to define the injury. * **CT Scan with IV Contrast:** While CT is the initial investigation of choice for most stable blunt abdominal traumas, the specific finding of a "non-visualized kidney" on IVP strongly points toward a vascular pedicle injury, for which arteriography provides superior diagnostic and potentially therapeutic (stenting) utility. * **Cystogram:** This is used to evaluate bladder rupture (suggested by pelvic fractures or suprapubic pain), not renal parenchymal or vascular injury. **Clinical Pearls for NEET-PG:** * **Lower rib fractures (10th–12th):** Always suspect injury to the spleen (left) or liver (right) and the kidneys. * **Non-visualized kidney on IVP:** Highly suggestive of renal artery thrombosis, severe contusion, or congenital absence. * **Management Rule:** Hemodynamically **unstable** renal trauma → Laparotomy; **Stable** renal trauma → CT scan/Arteriography.

Question 395: A patient with spine, chest, and abdominal injury in a road traffic accident developed hypotension and bradycardia. What is the most likely reason?

A. Hypovolemic shock
B. Distributive shock
C. Hypovolemic and septicemic shock
D. Neurogenic shock (Correct Answer)

Explanation: ### Explanation The clinical presentation of **hypotension associated with bradycardia** in the setting of trauma is the classic hallmark of **Neurogenic Shock**. #### Why Neurogenic Shock is Correct Neurogenic shock occurs due to a sudden loss of sympathetic outflow, typically following a spinal cord injury above the **T6 level**. This results in: 1. **Loss of Vasomotor Tone:** Massive peripheral vasodilation leads to decreased systemic vascular resistance (SVR) and hypotension. 2. **Loss of Cardiac Sympathetic Tone:** Unopposed vagal (parasympathetic) activity leads to **bradycardia**. In most other forms of shock, the body compensates for hypotension with tachycardia; neurogenic shock is a notable exception where the heart rate remains low or normal. #### Why Other Options are Incorrect * **Hypovolemic Shock:** This is the most common shock in trauma (due to abdominal/chest injury). However, it typically presents with **tachycardia** (compensatory) and cold, clammy extremities. * **Distributive Shock:** While neurogenic shock is a *type* of distributive shock, "Neurogenic Shock" is the more specific and clinically accurate diagnosis given the history of spine injury. * **Septicemic Shock:** This is a form of distributive shock caused by infection. It is unlikely to manifest immediately following a road traffic accident. #### High-Yield Clinical Pearls for NEET-PG * **The "Warm" Shock:** Unlike hypovolemic shock, patients with neurogenic shock often have **warm, dry skin** due to vasodilation. * **Level of Injury:** Neurogenic shock usually occurs with injuries at or above **T6**. * **Spinal Shock vs. Neurogenic Shock:** Do not confuse the two. Spinal shock refers to the loss of reflexes and flaccid paralysis (neurological), while neurogenic shock refers to hemodynamic instability (circulatory). * **Management:** Initial treatment involves aggressive fluid resuscitation followed by vasopressors (e.g., Norepinephrine or Phenylephrine) if fluids fail to restore MAP. Atropine may be used for symptomatic bradycardia.

Question 396: A patient presents with irritability and altered sensorium 4 weeks after head trauma. What is the most common cause of these symptoms?

A. Chronic subdural hematoma (Correct Answer)
B. Extradural hematoma
C. Intraparenchymal bleed
D. Electrolyte imbalance

Explanation: ### Explanation **1. Why Chronic Subdural Hematoma (cSDH) is correct:** The hallmark of a chronic subdural hematoma is a **latent period** of weeks to months (typically >3 weeks) between the initial trauma and the onset of symptoms. It occurs due to the tearing of **bridging veins** in the subdural space. In elderly patients or those with brain atrophy, even minor trauma can cause a slow venous leak. Over time, the clot liquefies and an osmotic gradient draws in fluid, increasing intracranial pressure and leading to "neuropsychiatric" presentations like irritability, altered sensorium, or dementia-like symptoms. **2. Why the other options are incorrect:** * **Extradural Hematoma (EDH):** This is an acute emergency usually involving the **middle meningeal artery**. It presents within hours of trauma, often characterized by a "lucid interval" followed by rapid deterioration. It does not present 4 weeks later. * **Intraparenchymal Bleed:** These typically occur acutely at the time of injury (coup or contrecoup) and present with focal neurological deficits or immediate coma, not a delayed 4-week presentation. * **Electrolyte Imbalance:** While hyponatremia (SIADH) can occur post-trauma and cause altered sensorium, it is a secondary complication. In the context of a 4-week post-traumatic window, a structural lesion like cSDH must be ruled out first as it is the classic surgical cause. **3. Clinical Pearls for NEET-PG:** * **Imaging of Choice:** Non-contrast CT (NCCT) Head. cSDH appears as a **crescent-shaped, hypodense (dark)** collection. * **Risk Factors:** Elderly patients, chronic alcoholics, and those on anticoagulants (due to brain atrophy stretching the bridging veins). * **Management:** Symptomatic cSDH is treated via **burr-hole evacuation**. * **Key Differentiator:** Acute SDH is hyperdense (white); Chronic SDH is hypodense (black).

Question 397: A fracture mandible should be immobilized for an average of how many weeks?

A. 3 weeks
B. 6 weeks (Correct Answer)
C. 9 weeks
D. 12 weeks

Explanation: **Explanation:** The standard duration for the immobilization of a mandibular fracture is **6 weeks**. This timeframe is based on the physiological process of bone healing. In the mandible, primary callus formation and sufficient clinical union typically occur within 4 to 6 weeks, allowing the bone to withstand the functional stresses of mastication. * **Why 6 weeks is correct:** Most mandibular fractures are treated via **Maxillomandibular Fixation (MMF)** or **Open Reduction and Internal Fixation (ORIF)**. For a healthy adult, 6 weeks provides the optimal balance between ensuring bony stability and preventing joint stiffness. * **Why 3 weeks is incorrect:** This is generally too short for adequate mineralization. While pediatric mandibular fractures heal faster (often requiring only 2–3 weeks of immobilization), in adults, premature mobilization leads to non-union or malunion. * **Why 9 and 12 weeks are incorrect:** Prolonged immobilization beyond 6–8 weeks is unnecessary for most simple fractures and significantly increases the risk of **ankylosis** of the Temporomandibular Joint (TMJ) and muscle atrophy. **Clinical Pearls for NEET-PG:** 1. **Pediatric Mandible:** Healing is rapid; immobilization is usually required for only **2–3 weeks**. 2. **Condylar Fractures:** These require **early mobilization** (usually after 1–2 weeks) to prevent TMJ ankylosis, unlike body or symphysis fractures. 3. **Commonest Site:** The **condyle** is the most common site of fracture in the mandible, followed by the angle and symphysis. 4. **Nerve Involvement:** The **inferior alveolar nerve** is the most common nerve injured in mandibular body fractures, leading to numbness of the lower lip.

Question 398: Which is the most common neurofibroma in the posterior mediastinum?

A. Neurofibroma (Correct Answer)
B. Teratoma
C. Lymphoma
D. Bronchogenic cyst

Explanation: **Explanation:** The mediastinum is anatomically divided into compartments, each associated with specific types of tumors. The **posterior mediastinum** is the space located between the pericardium and the spine. **Why Neurofibroma is correct:** Neurogenic tumors are the most common primary tumors of the posterior mediastinum, accounting for approximately 75% of masses in this region. Among these, **Neurofibromas** and Neurilemmomas (Schwannomas) are the most frequent benign varieties. They typically arise from the intercostal nerves or the sympathetic chain. In the context of NEET-PG, if "Neurogenic tumor" is not an option, Neurofibroma is the specific histological subtype most frequently cited. **Why the other options are incorrect:** * **Teratoma:** These are germ cell tumors most commonly found in the **anterior mediastinum**. * **Lymphoma:** While lymphoma can involve any compartment, it is most classically associated with the **anterior or middle mediastinum** (lymph node chains). * **Bronchogenic Cyst:** These are the most common primary cysts of the mediastinum but are typically located in the **middle mediastinum**, near the subcarinal region or tracheobronchial tree. **High-Yield Clinical Pearls for NEET-PG:** * **Rule of 3Ts for Anterior Mediastinum:** Thymoma (most common), Teratoma, Thyroid (Ectopic/Retrosternal), and "Terrible" Lymphoma. * **Dumbbell Tumor:** A classic presentation of posterior mediastinal neurogenic tumors where the tumor extends through the intervertebral foramen, causing both spinal cord compression and a mediastinal mass. * **Pediatric vs. Adult:** In children, posterior mediastinal neurogenic tumors are more likely to be malignant (e.g., Neuroblastoma), whereas in adults, they are predominantly benign.

Question 399: Which of the following wiring is indicated in case of symphysis fracture of the mandible?

A. Ivy eyelet method
B. Gilmer's wiring
C. Risdon's wiring (Correct Answer)
D. None

Explanation: **Explanation:** In the management of mandibular fractures, **Risdon’s wiring** is specifically indicated for **symphysis and parasymphysis fractures**. The technique involves placing a heavy-gauge wire around the most posterior teeth (usually the molars) on both sides. these wires are then twisted and brought forward to the midline (symphysis), where they are twisted together. This creates a stable "arch bar" effect that provides excellent horizontal stability and counteracts the distracting forces of the digastric muscles, which tend to pull symphyseal fragments apart. **Analysis of Options:** * **Ivy Eyelet Wiring (Option A):** This is a simple method used to achieve Intermaxillary Fixation (IMF) by joining two adjacent teeth. It is used for temporary stabilization or minimally displaced fractures but does not provide the horizontal tension required to stabilize a symphysis fracture. * **Gilmer’s Wiring (Option B):** This is the oldest form of IMF where wires are passed directly around the necks of the teeth of both jaws and then twisted together. It is rarely used today because it prevents the patient from opening their mouth even for emergencies (e.g., vomiting) and does not stabilize the fracture line itself. **High-Yield Clinical Pearls for NEET-PG:** * **Symphysis Fracture:** Often associated with bilateral condylar fractures (the "Guardsman fracture"). * **Risdon’s Wiring:** Key advantage is providing **horizontal stability** in the anterior mandible. * **Champy’s Line:** Refers to the ideal lines of osteosynthesis for plate fixation; in the symphysis, two plates are often required to resist torsional forces. * **Most common site of Mandible Fracture:** Condyle (overall), though the body or symphysis are common in specific trauma types.

Question 400: A 24-year-old male, a victim of a road traffic accident, is brought to the casualty department with breathlessness and tachypnea. Examination reveals tracheal deviation to the left and a hyperresonant sound on the right side of the chest. How should this patient be managed?

A. Immediately intubate the patient and transfer them to the Intensive Care Unit (ICU).
B. Immediately send the patient for a chest X-ray and obtain a sample for Arterial Blood Gas (ABG) analysis.
C. Insert a large-bore intravenous needle into the 2nd intercostal space on the right midclavicular line. (Correct Answer)
D. Immediate decompression using chest tube insertion in the right midaxillary line, 4th intercostal space.

Explanation: ### **Explanation** **Diagnosis: Tension Pneumothorax** The clinical triad of **respiratory distress (tachypnea/breathlessness)**, **tracheal deviation** (away from the affected side), and **hyperresonance** on percussion is pathognomonic for a tension pneumothorax. In this condition, a one-way valve effect allows air into the pleural space but prevents its escape, leading to increased intrapleural pressure, mediastinal shift, and eventual cardiovascular collapse due to decreased venous return. **Why Option C is Correct:** Tension pneumothorax is a **clinical diagnosis**. Management must be immediate and life-saving. The first step is **needle decompression** to convert a tension pneumothorax into a simple pneumothorax. According to ATLS guidelines (traditionally), this is done using a large-bore needle in the **2nd intercostal space (ICS) at the midclavicular line** (though the 5th ICS at the midaxillary line is now also preferred in newer guidelines, Option C remains the classic standard for exams). **Why Other Options are Incorrect:** * **Option A:** Intubation and positive pressure ventilation can worsen a tension pneumothorax by forcing more air into the pleural space, potentially causing rapid cardiac arrest. * **Option B:** You must **never wait for an X-ray** in a suspected tension pneumothorax. The delay can be fatal. Diagnosis is purely clinical. * **Option D:** While a chest tube (tube thoracostomy) is the definitive treatment, it takes longer to set up. Needle decompression is the immediate "stop-gap" measure required in an unstable patient. **Clinical Pearls for NEET-PG:** * **Classic Signs:** Distended neck veins (JVP), hypotension, absent breath sounds, and hyperresonance. * **Tracheal Deviation:** A late sign; its absence does not rule out the diagnosis. * **Definitive Treatment:** Chest tube insertion (Tube Thoracostomy) in the **"Triangle of Safety"** (5th ICS, anterior to the midaxillary line). * **Golden Rule:** If the question describes an unstable trauma patient with respiratory distress and tracheal shift, **Decompress First, X-ray Later.**

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Trauma — MCQs

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