Trauma Practice Questions

Q: All of the following are indications for CT scan in a patient with head injury except?

An episode of vomiting. In the management of head injuries, the decision to perform a CT scan is guided by clinical decision rules like the **Canadian CT Head Rule (CCHR)** and **NICE guidelines**. **Why "An episode of vomiting" is the correct answer:** According to the Canadian CT Head Rule, **two or more episodes** of vomiting are required to justify a CT scan. A single, isolated episode of vomiting in an otherwise stable patient is not a high-risk indicator for intracranial hemorrhage and does not mandate immediate imaging. **Explanation of Incorrect Options:** * **Focal neurological deficit:** This is a "High Risk" criteria. Any deficit (e.g., limb weakness, cranial nerve palsy) suggests a localized brain injury or mass effect (like an EDH or SDH), requiring urgent CT. * **GCS <13 at presentation:** A GCS score of <13 at any point, or <15 two hours after injury, indicates a significant risk of neurosurgical intervention. * **Patient is on warfarin:** Patients on anticoagulants (Warfarin, NOACs) or antiplatelets are at high risk for "delayed intracranial hemorrhage," even after minor trauma. Imaging is mandatory regardless of the GCS score. **High-Yield Clinical Pearls for NEET-PG:** * **Canadian CT Head Rule (High Risk for Intervention):** GCS 30 minutes before the impact is an indication for CT. * **Gold Standard:** Non-Contrast CT (NCCT) Head is the investigation of choice for acute head trauma to rule out hemorrhage.

Q: Pyramidal fracture of the maxilla is:

Le Fort II. **Explanation:** The Le Fort classification system is used to categorize fractures of the midface based on the lines of weakness in the facial skeleton. **Le Fort II (Pyramidal Fracture):** This is the correct answer because the fracture line takes a pyramidal shape. It extends from the nasal bridge through the frontal process of the maxilla, lacrimal bones, and inferior orbital rim, then passes through the zygomaticomaxillary suture and into the pterygoid plates. The result is a pyramid-shaped segment of the midface (including the nose and palate) that becomes mobile. **Incorrect Options:** * **Le Fort I (Guerin’s Fracture):** This is a **horizontal** fracture. It separates the alveolar process and palate from the rest of the maxilla. It is often called a "floating palate." * **Le Fort III (Craniofacial Disjunction):** This is a complete separation of the facial bones from the cranial base. The fracture line passes through the frontonasal suture, orbits, and zygomatic arches. * **Craniofacial Disruption:** This is a general descriptive term often used synonymously with Le Fort III, but it is not the specific anatomical name for a pyramidal fracture. **Clinical Pearls for NEET-PG:** * **Key Clinical Sign:** In Le Fort II and III, "dish-face" deformity and CSF rhinorrhea (due to cribriform plate involvement) may be seen. * **Airway Management:** In severe midface trauma, avoid blind nasotracheal intubation if a cribriform plate fracture is suspected. * **Pterygoid Plates:** All three Le Fort fractures involve the pterygoid plates; if these are not fractured, it is not a classic Le Fort injury. * **Sensory Deficit:** Infraorbital nerve anesthesia is most common in Le Fort II due to the involvement of the inferior orbital rim.

Q: What is the best predictor in the Glasgow Coma Scale?

Motor response. **Explanation:** The **Motor Response (M)** is considered the most reliable and powerful predictor of clinical outcome in the Glasgow Coma Scale (GCS). This is because the motor component correlates most closely with the severity of brain injury and has the highest prognostic value for survival and functional recovery. * **Why Motor Response is the best predictor:** Unlike eye-opening or verbal responses, the motor score (ranging from 1 to 6) provides a more granular assessment of brainstem and cortical function. It is less likely to be confounded by factors like periorbital edema (which affects eye-opening) or intubation (which affects verbal response). In many trauma protocols, the motor score alone is used as a simplified tool (the Simplified Motor Score) because it retains almost the same predictive accuracy as the full GCS. **Analysis of Incorrect Options:** * **Eye Opening (E):** This primarily reflects the activity of the Reticular Activating System (arousal). While important, it does not necessarily reflect the depth of coma or the integrity of the motor pathways. * **Verbal Response (V):** This assesses higher cortical function and orientation. However, it is frequently "untestable" in trauma patients who are intubated or have facial trauma, making it a less consistent predictor across all clinical scenarios. **Clinical Pearls for NEET-PG:** * **GCS Range:** 3 (minimum) to 15 (maximum). A score of **≤ 8** is the classic indication for intubation ("8, isolate the bait/intubate"). * **Order of Assessment:** The GCS is recorded as E+V+M. If a component cannot be assessed (e.g., eyes swollen shut), it is marked as "1c" or "NT" (Not Testable). * **Prognosis:** A decreasing motor score is often the first sign of impending transtentorial herniation.

Q: All of the following statements regarding mandibular fractures are true EXCEPT:

C.S.F. rhinorrhea is a common finding in mandibular fractures.. **Explanation:** The correct answer is **D**. C.S.F. rhinorrhea is a classic sign of a **Le Fort II or III fracture** or a fracture of the anterior cranial fossa (cribriform plate). It is not a feature of mandibular fractures because the mandible is a separate bone that does not articulate with the skull base in a way that would involve the dural membranes or paranasal sinuses. **Analysis of Options:** * **Option A:** The **angle of the mandible** is one of the most common sites for fractures (along with the condyle and symphysis), especially when impacted by lateral forces. * **Option B:** The mandible is the attachment site for powerful muscles of mastication (masseter, temporalis, medial/lateral pterygoids). These muscles exert significant pull, leading to the classification of fractures as **"favorable"** (muscle pull stabilizes the fragments) or **"unfavorable"** (muscle pull displaces the fragments). * **Option C:** **Sublingual hematoma** (Coleman’s Sign) is considered a pathognomonic clinical sign of a mandibular fracture, particularly involving the body or symphysis. **High-Yield Facts for NEET-PG:** * **Most common site of Mandibular Fracture:** Condyle (overall), though the angle is highly frequent in assaults. * **Nerve Injury:** The **Inferior Alveolar Nerve** is most commonly at risk in body/angle fractures, leading to numbness of the lower lip. * **Guardsman Fracture:** A midline symphysis fracture combined with bilateral condylar fractures, usually caused by a fall on the chin. * **Management:** Most displaced fractures require **Open Reduction and Internal Fixation (ORIF)** with miniplates.

Q: What is the most effective treatment for frostbite on the lower extremities?

Rewarming with immersion in warm water. **Explanation:** The primary goal in treating frostbite is to restore tissue temperature rapidly and uniformly to prevent further ice crystal formation and minimize tissue necrosis. **Why Option C is Correct:** **Rapid Active Rewarming** via immersion in a controlled water bath is the gold standard. The water should be maintained at a temperature of **40°C to 42°C (104°F to 108°F)**. This temperature range is warm enough to thaw tissues efficiently but not hot enough to cause thermal burns. Rewarming should continue until the distal part of the extremity becomes flushed (hyperemic), which typically takes 20–30 minutes. **Why Incorrect Options are Wrong:** * **Option A (Friction/Massage):** This is strictly contraindicated. Frostbitten tissue contains ice crystals; mechanical friction or massage can cause significant mechanical trauma and worsen tissue damage. * **Option B (Blankets):** This is a form of passive rewarming. While useful for systemic hypothermia, it is too slow for frostbite and increases the risk of progressive ischemia. * **Option D (Walking):** Weight-bearing on a frostbitten limb causes mechanical "grinding" of frozen tissues, leading to irreversible damage. Patients should be kept non-weight-bearing until the limb is fully thawed. **High-Yield Clinical Pearls for NEET-PG:** 1. **Thaw-Refreeze Cycle:** Never initiate rewarming if there is a risk of the tissue refreezing before reaching definitive care. Refreezing causes the most severe tissue damage. 2. **Analgesia:** Rapid rewarming is extremely painful; parenteral opioids are often required. 3. **Blister Management:** Clear blisters (contain prostaglandins/thromboxanes) should be aspirated or debrided, while hemorrhagic blisters (indicate deeper damage) should be left intact to prevent infection. 4. **Prophylaxis:** Tetanus prophylaxis is mandatory in all frostbite cases.

Q: What does flail chest refer to?

Fracture of multiple ribs. **Explanation:** **Flail Chest** is a clinical diagnosis defined by the fracture of **three or more adjacent ribs in two or more places**. This creates a segment of the chest wall that is no longer in bony continuity with the rest of the thoracic cage. **Why Option B is Correct:** The hallmark of flail chest is **paradoxical respiration**. During inspiration, the negative intra-thoracic pressure causes the "flail segment" to be sucked inward, while during expiration, it is pushed outward. This leads to inefficient ventilation and severe pain. However, the primary cause of hypoxia in these patients is usually the underlying **pulmonary contusion** rather than the mechanical movement of the chest wall itself. **Why Other Options are Incorrect:** * **Option A:** A sternal fracture alone does not constitute a flail chest, though it can be part of a "central flail" if associated with bilateral rib fractures. * **Option C & D:** Open and tension pneumothoraces are pleural space pathologies involving air entry. While they may coexist with a flail chest in polytrauma, they are distinct clinical entities with different pathophysiological mechanisms. **High-Yield NEET-PG Pearls:** * **Diagnosis:** Primarily clinical (observation of paradoxical movement). * **Most Common Complication:** Pulmonary contusion (leads to V/Q mismatch). * **Management:** The priority is **adequate analgesia** (often epidural) and aggressive pulmonary toilet. * **Indications for Intubation:** Not all patients need a ventilator. Intubation is reserved for those with persistent hypoxia (PaO2 <60 mmHg), severe respiratory distress, or shock. * **Internal Stabilization:** Refers to positive pressure ventilation, which acts as a "pneumatic splint."

Q: During renal rupture, nephrectomy is NOT attempted until:

Contralateral renal function is ascertained. **Explanation:** In the management of renal trauma, the primary goal is renal preservation. However, if life-threatening hemorrhage or extensive devitalization necessitates a nephrectomy, the most critical prerequisite is ensuring the presence and functionality of the **contralateral kidney**. **Why Option C is Correct:** Performing a nephrectomy on a patient with a solitary functioning kidney or bilateral renal agenesis would result in immediate, permanent renal failure requiring lifelong dialysis or transplant. In emergency trauma settings, this is traditionally confirmed via a **"One-shot IVP"** (Intravenous Pyelogram) on the operating table or preoperative CT imaging. This ensures that the patient can survive post-nephrectomy. **Why Other Options are Incorrect:** * **A & B:** While fluid resuscitation and antibiotics are standard components of trauma care, they are supportive measures. They do not dictate the surgical decision to remove an organ. * **D:** A renal angiogram is a diagnostic tool used for stable patients (e.g., to identify bleeding for embolization). In an emergency rupture requiring nephrectomy, waiting for an angiogram would cause fatal delays. **High-Yield Clinical Pearls for NEET-PG:** * **Indications for Surgery in Renal Trauma:** Hemodynamic instability (most common), expanding/pulsatile hematoma, and Grade V vascular pedicle avulsion. * **The "One-Shot IVP":** Performed by injecting 2 ml/kg of non-ionic contrast followed by a single abdominal X-ray at 10 minutes to confirm a functional contralateral kidney. * **Grading:** Most renal injuries (Grades I-III and some IV) are managed **conservatively**. * **AAST Grading:** Grade V involves a completely shattered kidney or ureteropelvic avulsion.

Question 1

A 25-year-old man presented to the emergency department with severe colicky abdominal pain and vomiting after blunt abdominal trauma due to assault. CECT reveals an obstruction of the duodenum with a coiled spring appearance of the 2nd and 3rd parts of the duodenum. What is the next best step in the management of this patient?

Accepted Answer

Nasogastric suction and observation

Answer

Gastrojejunostomy

Answer

Duodenal resection

Answer

Duodenojejunostomy

Question 2

All of the following are indications for CT scan in a patient with head injury except?

Accepted Answer

An episode of vomiting

Answer

Focal neurological deficit

Answer

Glasgow Coma Scale <13 at presentation

Answer

Patient is on warfarin

Question 3

Pyramidal fracture of the maxilla is:

Accepted Answer

Le Fort II

Answer

Le Fort I

Answer

Le Fort III

Answer

Craniofacial disruption

Question 4

Animal and clinical studies have shown that administration of lactated Ringer's solution to patients with hypovolemic shock may what?

Accepted Answer

Improve hemodynamics by alleviating the deficit in the interstitial fluid compartment

Answer

Increase serum lactate concentration

Answer

Impair liver function

Answer

Increase metabolic acidosis

Question 5

What is the best predictor in the Glasgow Coma Scale?

Accepted Answer

Motor response

Answer

Eye opening

Answer

Verbal response

Answer

All of the above

Question 6

All of the following statements regarding mandibular fractures are true EXCEPT:

Accepted Answer

C.S.F. rhinorrhea is a common finding in mandibular fractures.

Answer

Mandibular fractures are common at the angle of the mandible.

Answer

Mandibular fractures are affected by muscle pull.

Answer

Mandibular fractures are usually characterized by sublingual hematoma.

Question 7

What is the most effective treatment for frostbite on the lower extremities?

Accepted Answer

Rewarming with immersion in warm water

Answer

Rewarming with friction and/or massage

Answer

Rewarming with blankets

Answer

Rewarming with encouragement of walking on warm surfaces

Question 8

A 45-year-old woman is admitted to the hospital after her automobile left the highway in a rainstorm and hit a tree. She had been wearing a seat belt. On radiographic examination, it is observed that she has suffered fractures of the ninth and tenth rib on her left side and that she has intraabdominal bleeding. Physical examination reveals hypovolemic shock and progressive hypotension. Which of the following organs is most likely injured to result in these clinical signs?

Accepted Answer

Spleen

Answer

Liver

Answer

Pancreas

Answer

Left kidney

Question 9

What does flail chest refer to?

Accepted Answer

Fracture of multiple ribs

Answer

Fracture of the sternum

Answer

Open pneumothorax

Answer

Tension pneumothorax

Question 10

During renal rupture, nephrectomy is NOT attempted until:

Accepted Answer

Contralateral renal function is ascertained

Answer

Fluid replacement is adequate

Answer

Antibiotics cover has been initiated

Answer

A renal angiogram has been performed

Trauma — MCQs

Trauma — MCQs

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