Trauma — MCQs

Trauma Indian Medical PG Practice Questions and MCQs

Question 421: A patient sustained a bullet injury to the left side of the colon and presented to the casualty department after 12 hours. What is the most appropriate management?

A. Proximal defunctioning colostomy
B. Primary closure
C. Proximal colostomy and bringing out the distal end as a mucus fistula (Correct Answer)
D. Resection and primary anastomosis

Explanation: **Explanation:** The management of colonic trauma depends on two critical factors: the **mechanism of injury** and the **time elapsed since the injury**. **Why Option C is Correct:** In this scenario, the patient presented **12 hours** after a penetrating injury (bullet wound). In colonic trauma, a delay of more than 6–8 hours is considered a "late presentation." By this time, significant fecal contamination and established peritonitis are likely. In the presence of gross contamination, shock, or delayed presentation, **primary repair is contraindicated** due to the high risk of anastomotic leak. The safest approach is a **Hartmann’s procedure** or a **diverting stoma** (Proximal colostomy with a distal mucus fistula). This exteriorizes the fecal stream, prevents further contamination, and allows the infection to subside. **Why Other Options are Incorrect:** * **Option B & D:** Primary closure or resection with primary anastomosis are preferred for "clean" cases (e.g., stab wounds, presentation <6 hours, minimal contamination, and hemodynamic stability). They are avoided in delayed presentations like this one. * **Option A:** A proximal defunctioning colostomy alone leaves the injured segment in situ, which may continue to leak or cause an abscess. Bringing the ends out (Option C) is more definitive for a bullet injury. **Clinical Pearls for NEET-PG:** * **The "6-Hour Rule":** Generally, primary repair is safe if the injury is treated within 6 hours. * **Right vs. Left Colon:** Historically, the left colon was always exteriorized, but modern guidelines prioritize the **physiological state** of the patient over the anatomical location. * **Destructive vs. Non-destructive:** Small wounds (<50% circumference) are non-destructive; large wounds or devascularized segments are destructive and usually require resection.

Question 422: Electrical injury results in all of the following except?

A. Gas gangrene
B. Alkalosis (Correct Answer)
C. Ventricular fibrillation
D. Always a deep burn

Explanation: **Explanation:** Electrical injuries cause extensive internal tissue damage that is often far more severe than the surface appearance suggests. **Why Alkalosis is the correct answer:** Electrical injury typically results in **Metabolic Acidosis**, not alkalosis. The massive destruction of skeletal muscle (rhabdomyolysis) releases intracellular contents into the bloodstream, including lactic acid from ischemic tissue and organic acids. Furthermore, the release of myoglobin can lead to acute tubular necrosis (ATN) and renal failure, further exacerbating the acidotic state. **Analysis of other options:** * **Gas Gangrene:** High-voltage electricity causes deep muscle necrosis and creates an anaerobic environment. This is a perfect nidus for *Clostridium perfringens* (Gas gangrene), making it a known complication of electrical trauma. * **Ventricular Fibrillation:** This is the most common cause of immediate death in electrical injuries. Alternating current (AC) is particularly dangerous as it can interfere with the cardiac conduction system, triggering arrhythmias. * **Always a Deep Burn:** Electricity follows the path of least resistance (nerves, blood vessels, and muscle). While the skin entry and exit points may look small, the internal resistance generates significant heat, leading to deep, full-thickness burns (4th-degree burns) involving muscle and bone. **NEET-PG High-Yield Pearls:** 1. **Myoglobinuria:** The most critical early management step is aggressive fluid resuscitation to maintain a urine output of **75–100 mL/hr** to prevent renal failure. 2. **Cataracts:** A unique late complication of electrical injury (especially if the entry point is near the head). 3. **Posterior Shoulder Dislocation:** Can occur due to powerful tetanic muscle contractions during the shock. 4. **Rule of Nines:** This is **not** accurate for calculating fluid requirements in electrical burns; fluids are titrated based on urine output.

Question 423: What is the definition of splenosis?

A. Infection of the spleen
B. Presence of accessory spleens
C. Rupture of the spleen with distribution of its tissue on the peritoneum (Correct Answer)
D. A non-functioning spleen

Explanation: ### Explanation **Splenosis** is an acquired condition characterized by the autotransplantation of splenic pulp onto various surfaces (most commonly the peritoneum, omentum, or pleura) following **splenic trauma or surgery**. **1. Why the Correct Answer is Right:** When the splenic capsule ruptures (Option C), fragments of splenic tissue are released into the surrounding cavity. These fragments derive their blood supply from adjacent tissues (neovascularization) and grow into functional nodules. Unlike the original spleen, these nodules lack a structured hilum and are supplied by local arteries rather than the splenic artery. **2. Analysis of Incorrect Options:** * **Option A (Infection):** Infection of the spleen is termed a **splenic abscess**. * **Option B (Accessory Spleens):** These are congenital (present at birth) and result from the failure of splenic buds to fuse in the dorsal mesogastrium. They are usually found near the splenic hilum or tail of the pancreas and have a normal splenic blood supply. * **Option D (Non-functioning spleen):** This is termed **asplenia** (congenital absence) or **hyposplenism** (functional loss, e.g., in Sickle Cell Anemia). **3. High-Yield Clinical Pearls for NEET-PG:** * **Clinical Presentation:** Usually asymptomatic and discovered incidentally during laparotomy or imaging. It can occasionally cause intestinal obstruction or be mistaken for peritoneal carcinomatosis or endometriosis. * **Diagnostic Gold Standard:** **Heat-damaged RBC scintigraphy** (Technetium-99m labeled) is the most specific test to confirm functional splenic tissue. * **Protective Effect:** Splenosis may provide some degree of immune protection against **Overwhelming Post-Splenectomy Infection (OPSI)**, though it is rarely as effective as a whole spleen. * **Key Distinction:** Accessory spleens are **congenital**; Splenosis is **acquired/traumatic**.

Question 424: A patient developed hemoperitoneum following trauma, with BP 90/60 mmHg and pulse 140/min. Which of the following should be done?

A. Diagnostic peritoneal lavage (DPL) to be done
B. The liver is the most common organ to rupture
C. Ultrasound (USG) is better than CT scan for imaging (Correct Answer)
D. X-ray to be taken in supine position

Explanation: ### Explanation The patient presents with **hemodynamic instability** (BP 90/60 mmHg, Pulse 140/min) and signs of hemoperitoneum. In trauma management, the choice of imaging is dictated by the patient's stability. **Why Option C is Correct:** In an **unstable** patient, **FAST (Focused Assessment with Sonography for Trauma)** is the investigation of choice. It is rapid, non-invasive, and can be performed at the bedside during resuscitation. **CT Scan**, while more accurate for identifying specific organ injuries, is contraindicated in unstable patients because it requires moving the patient to the radiology suite ("Death in the CT suite"). Therefore, USG (FAST) is "better" in this specific clinical context. **Analysis of Incorrect Options:** * **Option A:** DPL was historically used but has been largely replaced by FAST. It is invasive and carries a risk of iatrogenic injury. It is now reserved for cases where FAST is inconclusive in an unstable patient. * **Option B:** In blunt trauma abdomen, the **Spleen** is the most commonly injured organ. The liver is the second most common. * **Option C:** For detecting pneumoperitoneum (hollow viscus injury), an X-ray should be taken in the **erect** position (to see air under the diaphragm) or left lateral decubitus, not supine. **Clinical Pearls for NEET-PG:** * **Stable Patient + Blunt Trauma:** CT Scan is the Gold Standard. * **Unstable Patient + Blunt Trauma:** FAST is the initial investigation. If FAST is positive $\rightarrow$ Laparotomy. * **FAST Zones:** Pericardial, Perihepatic (Morison’s Pouch), Perisplenic, and Pelvic (Pouch of Douglas). * **E-FAST:** Includes the thorax to rule out PTX/Hemothorax.

Question 425: What is the first priority in the management of a case of head injury with an open fracture of the shaft of the femur?

A. Neurosurgery consultation
B. Administer IV fluids
C. Intubation (Correct Answer)
D. Splintage of the fracture

Explanation: **Explanation:** The management of a polytrauma patient (head injury combined with a femur fracture) must strictly follow the **ATLS (Advanced Trauma Life Support) guidelines**, which prioritize the **ABCDE** sequence. **1. Why Intubation is the Correct Answer:** In any trauma patient, **Airway (A)** is the first priority. A patient with a significant head injury often has a decreased level of consciousness (GCS ≤ 8), which compromises the airway and the gag reflex, leading to potential obstruction or aspiration. Furthermore, maintaining adequate oxygenation and preventing hypercapnia is the most critical step in preventing **secondary brain injury**. Therefore, securing the airway via intubation takes precedence over all other interventions. **2. Analysis of Incorrect Options:** * **Administer IV fluids (B):** This addresses **Circulation (C)**. While fluid resuscitation is vital for a femur fracture (which can cause significant occult blood loss), it follows Airway and Breathing in the priority sequence. * **Splintage of the fracture (D):** This is part of the secondary survey or the end of the primary survey (**Disability/Exposure**). While it helps with pain and hemorrhage control, it is never prioritized over the airway. * **Neurosurgery consultation (A):** This is a definitive care step that occurs only after the patient has been stabilized via the primary survey. **Clinical Pearls for NEET-PG:** * **The Golden Rule:** "Treat the greatest threat to life first." Airway always tops the list. * **GCS & Intubation:** A GCS score of **8 or less** is a classic indication for formal airway management ("GCS of 8, we intubate"). * **Femur Fracture Blood Loss:** A shaft of femur fracture can lead to **1–1.5 liters** of internal blood loss; however, the ABC sequence remains unchanged. * **Cervical Spine:** Always assume a cervical spine injury in any head injury patient; intubation should be performed with manual in-line stabilization (MILS).

Question 426: A 25-year-old male presents after a road traffic accident with a blood pressure of 100/80 mm Hg and a pulse of 84/min. What is the best fluid for resuscitation?

A. Colloid
B. Crystalloid (Correct Answer)
C. Packed Red Blood Cells
D. Whole Blood

Explanation: **Explanation:** The patient is currently hemodynamically stable (BP 100/80 mm Hg, Pulse 84/min), falling into **Class I Hemorrhage** (blood loss <15%). According to the **ATLS (Advanced Trauma Life Support) guidelines**, the initial fluid of choice for resuscitation in trauma patients is an **isotonic crystalloid**, specifically **Balanced Salt Solutions** like Ringer’s Lactate (RL) or Normal Saline (0.9% NaCl). **Why Crystalloids are preferred:** Crystalloids are the first-line choice because they are inexpensive, readily available, and effective for initial volume expansion. In trauma, Ringer’s Lactate is often preferred over Normal Saline to avoid hyperchloremic metabolic acidosis. **Analysis of Incorrect Options:** * **Colloids (A):** These are not recommended for initial resuscitation as they are expensive, can cause coagulopathy, and have not shown any survival benefit over crystalloids in trauma settings. * **Packed Red Blood Cells (C) & Whole Blood (D):** These are indicated in **Class III and IV Hemorrhage** (shock) or when there is a "transient response" or "no response" to initial crystalloid boluses. Since this patient is stable, blood products are not yet indicated. **Clinical Pearls for NEET-PG:** * **Initial Bolus:** ATLS 10th edition recommends an initial bolus of **1 Liter** of warmed isotonic crystalloid for adults. * **3:1 Rule:** Traditionally, 3 mL of crystalloid is given for every 1 mL of blood lost (though modern protocols favor earlier blood products in massive hemorrhage). * **Lethal Triad of Trauma:** Hypothermia, Acidosis, and Coagulopathy. * **Best indicator of resuscitation:** Urine output (Target: 0.5 mL/kg/hr in adults).

Question 427: A man with blunt abdominal injury following a road traffic accident presents with a blood pressure of 100/80 mm Hg and a pulse rate of 120 bpm. Airway has been established and respiration has been stabilized. What is the next best step in management?

A. Immediate blood transfusion
B. Send blood for cross-matching and initiate intravenous fluids (Correct Answer)
C. Ventilate the patient
D. Rush the patient to the operating theatre

Explanation: ### Explanation This patient presents with signs of **Class II Hemorrhagic Shock** (tachycardia and narrowed pulse pressure, though systolic BP is still maintained). According to the **ATLS (Advanced Trauma Life Support)** protocol, once the Airway (A) and Breathing (B) are stabilized, the next priority is **Circulation (C)**. **Why Option B is Correct:** The immediate goal in Circulation is to control hemorrhage and restore intravascular volume. The standard protocol for a hemodynamically unstable trauma patient (or one showing signs of compensated shock) is to establish large-bore intravenous access, initiate **crystalloid fluid resuscitation** (e.g., 1L of Ringer’s Lactate), and simultaneously **send blood for type and cross-match**. This prepares the team for potential transfusion while assessing the patient's response to initial fluids. **Why Other Options are Incorrect:** * **Option A:** Blood transfusion is typically reserved for patients who do not respond to initial crystalloid boluses (non-responders) or those in Class III/IV shock. It is not the *first* step before initiating fluids and cross-matching. * **Option C:** The question states that the airway is established and respiration is stabilized; therefore, further ventilation is not the immediate priority over circulatory resuscitation. * **Option D:** Surgery (Laparotomy) is indicated if the patient is hemodynamically unstable and non-responsive to fluids, or if there is a positive FAST/DPL. Rushing to the OT is premature before initiating resuscitation and assessment. ### High-Yield Clinical Pearls for NEET-PG: * **Class II Shock:** Characterized by tachycardia (>100 bpm) and decreased pulse pressure. Systolic BP usually remains normal due to compensatory mechanisms. * **Fluid of Choice:** Isotonic crystalloids (Warm Ringer’s Lactate) are the initial fluids of choice in trauma. * **The "Golden Hour":** Emphasizes that rapid resuscitation and surgical intervention within the first hour significantly improve survival. * **Lethal Triad of Trauma:** Acidosis, Coagulopathy, and Hypothermia. Resuscitation aims to prevent this cycle.

Question 428: Tension pneumothorax is associated with which of the following findings?

A. Mediastinal displacement away from the affected side (Correct Answer)
B. Decreased percussion note on the side of the lesion
C. Increased blood pressure
D. Stridor

Explanation: **Explanation:** **Tension Pneumothorax** is a life-threatening clinical emergency 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 buildup of intrapleural pressure. **Why Option A is Correct:** As the pressure in the affected pleural cavity exceeds atmospheric pressure, it causes a mass effect. This high pressure pushes the mobile mediastinum (including the heart and great vessels) and the trachea **away from the affected side** toward the contralateral (healthy) lung. This displacement is a hallmark radiological and clinical sign. **Analysis of Incorrect Options:** * **B. Decreased percussion note:** In tension pneumothorax, the pleural space is filled with air under tension. This produces a **hyper-resonant** (tympanic) percussion note, not a decreased (dull) note. * **C. Increased blood pressure:** Tension pneumothorax causes **hypotension**. The shifted mediastinum kinks the inferior vena cava, reducing venous return to the heart (preload), leading to obstructive shock. * **D. Stridor:** Stridor is a sign of upper airway obstruction (e.g., laryngeal edema or foreign body). While tension pneumothorax causes respiratory distress, the primary signs are tachypnea and absent breath sounds, not stridor. **Clinical Pearls for NEET-PG:** * **Diagnosis:** It is a **clinical diagnosis**. Do NOT wait for a Chest X-ray if suspected. * **Classic Triad:** Hypotension, jugular venous distension (JVD), and absent breath sounds on the affected side. * **Immediate Management:** Needle thoracocentesis (decompression). * *Adults:* 5th intercostal space, mid-axillary line (ATLS 10th ed. update). * *Alternative/Pediatrics:* 2nd intercostal space, mid-clavicular line. * **Definitive Management:** Insertion of an Intercostal Drainage (ICD) tube.

Question 429: The most important factor that influences the outcome of penetrating cardiac injuries is:

A. Comminuted tear of a single chamber.
B. Multiple-chamber injuries.
C. Coronary artery injury. (Correct Answer)
D. Tangential injuries.

Explanation: **Explanation:** The outcome of penetrating cardiac injuries is determined by the severity of anatomical damage and the resulting physiological compromise (tamponade vs. exsanguination). Among the given options, **Coronary Artery Injury (Option C)** is the most critical prognostic factor. **Why Coronary Artery Injury is the Correct Answer:** Coronary artery involvement (occurring in 5-9% of cases) significantly increases mortality. It leads to immediate myocardial ischemia or infarction, resulting in acute pump failure and lethal arrhythmias. Unlike simple chamber wall injuries, which can often be managed with rapid suturing or staples, a proximal coronary injury requires complex bypass or microvascular repair, which is difficult to perform in an emergency trauma setting. **Analysis of Incorrect Options:** * **A & B (Single/Multiple Chamber Injuries):** While multiple chamber injuries are more severe than single ones, the primary cause of death is usually cardiac tamponade or hemorrhage. If the patient reaches the OR alive, these can often be repaired with pledgeted sutures. * **D (Tangential Injuries):** These are injuries that do not penetrate the endocardium. They are generally the least severe form of cardiac trauma and carry the best prognosis. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site of injury:** Right Ventricle (due to its anterior position). * **Beck’s Triad (Cardiac Tamponade):** Hypotension, JVD, and muffled heart sounds. * **Management:** The procedure of choice for a patient in extremis is an **Emergency Department Thoracotomy (EDT)** via a left anterolateral incision. * **Prognostic Factor:** Penetrating injuries with **cardiac tamponade** actually have a *better* prognosis than those with free hemorrhage, as the tamponade prevents immediate exsanguination, allowing time for surgical intervention.

Question 430: What is the most common type of shock?

A. Cardiogenic (Correct Answer)
B. Vagal
C. Neurogenic
D. Distributive

Explanation: **Explanation:** Shock is defined as a state of cellular and tissue hypoxia due to reduced oxygen delivery or increased oxygen consumption. In the context of general medical emergencies and clinical practice, **Cardiogenic shock** is frequently cited as the most common type of shock, primarily due to the high global prevalence of Myocardial Infarction (MI). **1. Why Cardiogenic Shock is Correct:** Cardiogenic shock occurs when the heart fails to pump sufficient blood to meet the body's metabolic demands despite adequate intravascular volume. The most common cause is a massive Myocardial Infarction (pump failure). Given the high incidence of ischemic heart disease in the adult population, it remains a leading cause of shock-related mortality and frequency in hospital settings. **2. Analysis of Incorrect Options:** * **Vagal Shock:** This is a form of syncope (vasovagal attack) rather than a true state of persistent circulatory collapse. It is transient and usually self-limiting. * **Neurogenic Shock:** This is a subtype of distributive shock occurring after high spinal cord injuries. While high-yield for exams, it is statistically rare compared to cardiac or septic causes. * **Distributive Shock:** This category includes Septic, Anaphylactic, and Neurogenic shock. While **Septic shock** is the most common type of shock in the ICU setting, "Distributive" as a broad category is often ranked second to cardiogenic or hypovolemic causes depending on the clinical population. **3. NEET-PG High-Yield Pearls:** * **Most common shock overall:** Cardiogenic (often cited in standard textbooks like Bailey & Love for general medical contexts). * **Most common shock in Trauma:** Hypovolemic shock (specifically Hemorrhagic). * **Most common shock in the ICU:** Septic shock. * **Hemodynamic Profile:** Cardiogenic shock is characterized by **increased** Pulmonary Capillary Wedge Pressure (PCWP) and **increased** Systemic Vascular Resistance (SVR), but **decreased** Cardiac Output (CO).

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Trauma — MCQs

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