Trauma — MCQs
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A 30-year-old man is brought to the emergency department following a high-speed car accident. He was the driver, and the windshield of the car was broken. On examination, he is alert, awake, oriented, and in no respiratory distress. He is unable to move any of his four extremities; however, his extremities are warm and pink. His vital signs on admission are HR 54 bpm and BP 70/40 mm Hg. What is the diagnosis?
What is true about abdominal compartment syndrome?
A client presents to the emergency department after sustaining a head injury in a motor vehicle accident. The client is alert and oriented. Which of the following nursing interventions should be performed first?
In a polytrauma patient, what does priapism signify?
The first step in the management of head injury is:
Hypovolemic shock is seen in all conditions except?
A 48-year-old male had a road traffic accident and was brought to the emergency. All of the following are done as part of a primary survey except?
A patient with traumatic paraplegia due to injury of the thoracic cord at T3 level is observed to have a blood pressure of 210/120 mmHg. What is the initial management?
Which of the following is not typically seen in splenic trauma?
A patient presents with chest trauma and tachypnea (respiratory rate >40 breaths/min). Physical examination reveals hypertension (blood pressure = 90/60 mmHg) and a hyperresonant note on the involved side. What is the next appropriate management step?
Trauma Indian Medical PG Practice Questions and MCQs
Question 521: A 30-year-old man is brought to the emergency department following a high-speed car accident. He was the driver, and the windshield of the car was broken. On examination, he is alert, awake, oriented, and in no respiratory distress. He is unable to move any of his four extremities; however, his extremities are warm and pink. His vital signs on admission are HR 54 bpm and BP 70/40 mm Hg. What is the diagnosis?
- A. Hemorrhagic shock
- B. Cardiogenic shock
- C. Neurogenic shock (Correct Answer)
- D. Septic shock
Explanation: **Explanation:** The clinical presentation of **quadriplegia** (inability to move all four extremities) following a high-speed trauma strongly suggests a **cervical spinal cord injury**. In this context, the combination of **hypotension** (BP 70/40) and **bradycardia** (HR 54) is the classic hallmark of **Neurogenic Shock**. **Underlying Concept:** Neurogenic shock occurs due to the loss of sympathetic vasomotor tone and unopposed vagal activity following a high spinal cord injury (usually above T6). This leads to: 1. **Massive Vasodilation:** Resulting in hypotension and warm, pink extremities (unlike the cold, clammy skin seen in other shocks). 2. **Loss of Cardiac Accelerator Fibers:** Resulting in bradycardia instead of the compensatory tachycardia typically seen in trauma. **Why other options are incorrect:** * **Hemorrhagic Shock:** The most common shock in trauma, but it presents with **tachycardia** and cold, pale extremities due to peripheral vasoconstriction. * **Cardiogenic Shock:** Usually follows blunt cardiac injury or MI; it typically presents with tachycardia and signs of heart failure (e.g., raised JVP). * **Septic Shock:** A form of distributive shock like neurogenic shock, but it is unlikely in the immediate acute setting of a trauma and is usually accompanied by fever and a source of infection. **High-Yield Pearls for NEET-PG:** * **Neurogenic vs. Spinal Shock:** Neurogenic shock is a **hemodynamic** phenomenon (hypotension + bradycardia); Spinal shock is a **neurologic** phenomenon (loss of reflexes and flaccid paralysis). * **Management:** Initial treatment involves aggressive fluid resuscitation followed by vasopressors (e.g., Norepinephrine or Phenylephrine) if fluids fail. Atropine may be used for symptomatic bradycardia. * **Rule of Thumb:** In a trauma patient, always rule out hemorrhage first, but if the patient is **hypotensive and bradycardic**, think Neurogenic Shock.
Question 522: What is true about abdominal compartment syndrome?
- A. Cardiac output is decreased. (Correct Answer)
- B. Urine output is increased.
- C. Pulmonary capillary wedge pressure is decreased.
- D. Venous return is increased.
Explanation: **Abdominal Compartment Syndrome (ACS)** is defined as sustained intra-abdominal pressure (IAP) >20 mmHg associated with new organ dysfunction. It occurs due to decreased abdominal wall compliance, increased intraluminal contents, or capillary leak (e.g., massive fluid resuscitation). ### **Explanation of Options** * **A. Cardiac output is decreased (Correct):** Increased IAP causes direct compression of the **Inferior Vena Cava (IVC)** and the portal vein, significantly reducing venous return (preload). Additionally, the elevated diaphragm increases intrathoracic pressure, which increases afterload on the heart. The combination of reduced preload and increased afterload leads to a significant drop in cardiac output. * **B. Urine output is increased (Incorrect):** Renal dysfunction is one of the earliest signs of ACS. Increased IAP causes direct compression of the renal parenchyma and renal veins, leading to decreased renal blood flow and glomerular filtration rate (GFR), resulting in **oliguria**. * **C. Pulmonary capillary wedge pressure is decreased (Incorrect):** Due to the upward displacement of the diaphragm, intrathoracic pressure increases. This pressure is transmitted to the heart, causing a **falsely elevated** PCWP and Central Venous Pressure (CVP), even though the actual intravascular volume may be low. * **D. Venous return is increased (Incorrect):** As mentioned, compression of the IVC and iliac veins leads to **decreased** venous return. ### **High-Yield Clinical Pearls for NEET-PG** * **Gold Standard Diagnosis:** Indirect measurement of IAP via a **bladder catheter (Foley’s)** using a pressure transducer. * **Respiratory Impact:** Decreased lung compliance, increased peak airway pressures, and hypercapnia (Type II respiratory failure). * **Abdominal Perfusion Pressure (APP):** Calculated as MAP minus IAP. A target APP of **>60 mmHg** is associated with improved survival. * **Definitive Treatment:** Surgical decompression (decompressive laparotomy) with a temporary abdominal closure (e.g., Bogota bag).
Question 523: A client presents to the emergency department after sustaining a head injury in a motor vehicle accident. The client is alert and oriented. Which of the following nursing interventions should be performed first?
- A. Assess full range of motion to determine the extent of injuries.
- B. Obtain an immediate chest x-ray.
- C. Immobilize the client's head and neck. (Correct Answer)
- D. Open the airway using the head-tilt-chin-lift maneuver.
Explanation: In trauma management, the primary goal is to prevent secondary injury. This question tests the application of the **ATLS (Advanced Trauma Life Support)** protocol. ### **Why Option C is Correct** In any patient with a head injury or significant blunt trauma above the clavicle, a **cervical spine (C-spine) injury** must be presumed until proven otherwise. Even if the patient is alert and oriented, sudden movement can convert a stable vertebral fracture into a permanent spinal cord injury (quadriplegia). Therefore, **immobilization of the head and neck** using a rigid cervical collar and lateral supports is the mandatory first step during the primary survey. ### **Why Other Options are Incorrect** * **Option A:** Assessing range of motion is strictly contraindicated in trauma until the spine has been radiologically and clinically cleared. Moving the neck could cause catastrophic cord compression. * **Option B:** While a chest X-ray is part of the "adjuncts" to the primary survey, it follows the stabilization of the airway and C-spine. * **Option D:** In a suspected spinal injury, the **head-tilt-chin-lift is contraindicated** as it hyperextends the neck. The preferred method to open the airway is the **Jaw-Thrust maneuver**. ### **NEET-PG High-Yield Pearls** * **Nexus Criteria/Canadian C-Spine Rules:** Used to clinically determine if a patient needs cervical imaging. * **Airway Management:** If a trauma patient requires intubation, **Manual In-Line Stabilization (MILS)** must be maintained by an assistant. * **Golden Hour:** The first hour after trauma where prompt intervention (starting with C-spine protection) significantly reduces mortality. * **Clearing the Spine:** A spine is only "cleared" when the patient is conscious, has no midline tenderness, no distracting injuries, no focal deficits, and (if necessary) negative imaging.
Question 524: In a polytrauma patient, what does priapism signify?
- A. Penile injury
- B. Spinal cord injury (Correct Answer)
- C. Significant head injury
- D. Pelvic injury
Explanation: **Explanation:** In the context of polytrauma, **priapism** (a persistent, involuntary erection) is a classic clinical sign of a **complete spinal cord injury**, typically occurring at or above the level of the thoracic spine. **Why Spinal Cord Injury is Correct:** Priapism in trauma is "neurogenic" in origin. It occurs due to the loss of sympathetic nervous system outflow (which normally maintains penile detumescence) and the subsequent unopposed parasympathetic activity originating from the sacral plexus (S2-S4). This leads to vasodilation of the corpora cavernosa and engorgement. It is often associated with **spinal shock** and is a poor prognostic sign indicating a complete rather than incomplete cord lesion. **Analysis of Incorrect Options:** * **A. Penile injury:** While direct trauma to the penis can cause high-flow priapism (due to arterial laceration), it is rare in polytrauma and usually presents with localized hematoma or deformity rather than isolated involuntary erection. * **C. Significant head injury:** Isolated head injuries typically present with altered consciousness or focal neurological deficits; they do not cause priapism unless there is a concomitant spinal injury. * **D. Pelvic injury:** While pelvic fractures can cause urethral or bladder injuries, they do not typically result in priapism unless there is associated nerve root damage. **High-Yield Clinical Pearls for NEET-PG:** * **Neurogenic Shock Triad:** Hypotension, Bradycardia, and Peripheral Vasodilation (warm extremities). * **Bulbocavernosus Reflex:** The absence of this reflex indicates **Spinal Shock**. Its return marks the end of spinal shock. * **Level of Injury:** Priapism is most commonly seen in cervical or high thoracic cord injuries. * **Management:** In trauma, neurogenic priapism is usually self-limiting as the acute phase of spinal shock evolves, but it serves as a critical "red flag" for immediate spinal immobilization and imaging.
Question 525: The first step in the management of head injury is:
- A. Secure airway (Correct Answer)
- B. IV mannitol
- C. IV dexamethasone
- D. Blood transfusion
Explanation: **Explanation:** The management of head injury follows the universal principles of trauma resuscitation, prioritizing the **ABCDE (Airway, Breathing, Circulation, Disability, Exposure)** protocol. **1. Why "Secure Airway" is correct:** In any trauma patient, securing the airway is the absolute first priority. In head injuries, patients often have a depressed level of consciousness (GCS ≤ 8), which leads to the loss of protective airway reflexes and potential obstruction by the tongue or secretions. Furthermore, maintaining an airway ensures adequate oxygenation and prevents **hypercarbia**. Hypercarbia causes cerebral vasodilation, increasing intracranial pressure (ICP) and worsening secondary brain injury. **2. Why the other options are incorrect:** * **IV Mannitol:** This is an osmotic diuretic used to reduce ICP. While important, it is part of the "Disability" or definitive management phase and is only administered once the patient is hemodynamically stable and the airway is secure. * **IV Dexamethasone:** Steroids have **no role** in the management of acute traumatic brain injury. Large-scale studies (CRASH trial) proved they do not improve outcomes and may increase mortality. They are primarily used for peritumoral edema. * **Blood Transfusion:** This falls under "Circulation." While vital for treating hemorrhagic shock, it follows "Airway" and "Breathing" in the priority sequence. **Clinical Pearls for NEET-PG:** * **The Golden Hour:** The first hour after trauma where prompt intervention significantly improves survival. * **GCS ≤ 8:** The classic indication for endotracheal intubation ("Less than 8, intubate"). * **Secondary Brain Injury:** The primary goal of early management is to prevent secondary insults caused by hypoxia and hypotension. * **Cushing’s Triad:** Hypertension, bradycardia, and irregular respiration (a late sign of increased ICP).
Question 526: Hypovolemic shock is seen in all conditions except?
- A. Hemorrhage
- B. Starvation (Correct Answer)
- C. Vomiting
- D. Diarrhea
Explanation: **Explanation:** Hypovolemic shock occurs when there is a critical reduction in intravascular volume, leading to decreased cardiac output and inadequate tissue perfusion. **Why Starvation is the correct answer:** In **Starvation**, the body primarily loses adipose tissue and muscle mass to meet energy requirements. While there is a gradual loss of total body water, the body’s homeostatic mechanisms (such as ADH and the Renin-Angiotensin-Aldosterone System) effectively maintain intravascular volume and blood pressure for a prolonged period. Therefore, starvation does not typically result in acute hypovolemic shock unless accompanied by severe dehydration or terminal organ failure. **Why the other options are incorrect:** * **Hemorrhage:** This is the most common cause of hypovolemic shock. It involves the direct loss of whole blood, leading to an immediate drop in preload and stroke volume. * **Vomiting and Diarrhea:** These are "non-hemorrhagic" causes of hypovolemic shock. They result in significant loss of water and electrolytes (sodium, potassium, chloride). If the fluid loss exceeds intake, it leads to severe extracellular fluid (ECF) depletion and subsequent circulatory collapse. **Clinical Pearls for NEET-PG:** * **Classification:** Hypovolemic shock is classified into 4 stages based on blood loss. **Class III** (1500–2000 mL loss) is the earliest stage where a drop in **systolic blood pressure** is typically observed. * **Earliest Sign:** Tachycardia is often the earliest clinical sign of hypovolemic shock. * **Management:** The priority is "Stop the bleed" and volume replacement. In trauma, the current gold standard is **Balanced Resuscitation** (using blood products in a 1:1:1 ratio) rather than excessive crystalloids to avoid the "Lethal Triad" (Acidosis, Coagulopathy, and Hypothermia).
Question 527: A 48-year-old male had a road traffic accident and was brought to the emergency. All of the following are done as part of a primary survey except?
- A. CT abdomen for bleeder identification (Correct Answer)
- B. Airway checking
- C. BP recording
- D. Cervical spine stabilization
Explanation: **Explanation:** The primary survey in trauma follows the **ABCDE** protocol, designed to identify and treat life-threatening conditions in a specific order of priority. **Why Option A is the correct answer:** A **CT abdomen** is considered part of the **Secondary Survey** (or an adjunct to it) once the patient is hemodynamically stable. It is a time-consuming procedure that requires transporting the patient away from the resuscitation area, which is contraindicated during the initial primary survey. In the primary survey, internal bleeding is screened using **FAST (Focused Assessment with Sonography for Trauma)** or **DPL (Diagnostic Peritoneal Lavage)**, as these can be performed bedside without interrupting resuscitation. **Analysis of incorrect options (Components of Primary Survey):** * **B. Airway checking:** This is the 'A' (Airway) of the primary survey. Ensuring a patent airway is the first priority. * **D. Cervical spine stabilization:** This is performed simultaneously with airway management. Any trauma patient is assumed to have a cervical spine injury until proven otherwise. * **C. BP recording:** This falls under 'C' (Circulation). Assessing blood pressure, pulse, and skin perfusion is vital to identify and manage shock. **NEET-PG High-Yield Pearls:** * **Sequence:** Airway & C-spine → Breathing → Circulation & Hemorrhage control → Disability (GCS) → Exposure. * **Golden Hour:** The first 60 minutes after injury where prompt intervention maximizes survival. * **Hemodynamic Stability:** If a patient is unstable with suspected abdominal trauma, the next step is **FAST**, not CT. If FAST is positive and the patient is unstable, they go straight to **Laparotomy**. * **CT Scan:** Often called the "Non-invasive Autopsy," it is the gold standard for stable blunt trauma patients but is never performed during the primary survey.
Question 528: A patient with traumatic paraplegia due to injury of the thoracic cord at T3 level is observed to have a blood pressure of 210/120 mmHg. What is the initial management?
- A. Subcutaneous low molecular weight heparin
- B. Steroids
- C. Nifedipine (Correct Answer)
- D. Normal saline/Dextrose
Explanation: **Explanation:** The patient is presenting with **Autonomic Dysreflexia (AD)**, a life-threatening medical emergency occurring in patients with spinal cord injuries at or above the **T6 level**. **1. Why Nifedipine is Correct:** Autonomic Dysreflexia is triggered by noxious stimuli (e.g., distended bladder, fecal impaction) below the level of the lesion. This causes a massive, uninhibited sympathetic discharge leading to severe hypertension, bradycardia (reflexive), and pounding headaches. The **initial management** involves sitting the patient upright (to induce orthostatic pressure drop) and identifying/removing the trigger. If blood pressure remains dangerously high (as in this case, 210/120 mmHg), rapid-acting antihypertensives are indicated. **Nifedipine (immediate-release)** or Nitroglycerin paste are the preferred agents to prevent intracranial hemorrhage or seizures. **2. Why Other Options are Incorrect:** * **A. LMWH:** Used for DVT prophylaxis in spinal cord injuries, but it does not address the acute hypertensive crisis. * **B. Steroids:** High-dose methylprednisolone was previously used for acute spinal cord injury to reduce edema, but it is no longer the standard of care due to complications and has no role in managing acute hypertension. * **D. Normal Saline/Dextrose:** Fluid resuscitation is contraindicated here as it could further worsen the hypertension and volume load. **High-Yield Clinical Pearls for NEET-PG:** * **Level of Lesion:** AD typically occurs in injuries at **T6 or above** (above the splanchnic outflow). * **Classic Triad:** Hypertension, Bradycardia, and Flushing/Sweating *above* the level of injury. * **Most Common Trigger:** Bladder distension (check the Foley catheter first!). * **Management Priority:** 1. Sit the patient up → 2. Loosen tight clothing → 3. Empty bladder/bowel → 4. Pharmacotherapy (Nifedipine) if BP >150 mmHg systolic.
Question 529: Which of the following is not typically seen in splenic trauma?
- A. Splenic rupture often requires splenectomy.
- B. Post-splenectomy infections are common.
- C. Late-onset septic shock is a common complication. (Correct Answer)
- D. Many cases of splenic trauma can be managed conservatively.
Explanation: **Explanation:** The spleen is the most commonly injured organ in blunt abdominal trauma. Understanding its management and the risks associated with its removal is high-yield for NEET-PG. **Why Option C is the Correct Answer (The "Not" Statement):** While **Overwhelming Post-Splenectomy Infection (OPSI)** is a dreaded complication, it is **not common**. The lifetime risk of OPSI is approximately 1–2%, with the highest risk occurring within the first two years post-surgery. While it presents as a fulminant septic shock with high mortality (up to 50-80%), its low incidence makes the statement "common complication" clinically inaccurate. **Analysis of Other Options:** * **Option A:** Historically, splenic rupture often required splenectomy to prevent life-threatening hemorrhage. While trends are shifting, splenectomy remains the standard for Grade IV/V injuries or hemodynamically unstable patients. * **Option B:** Post-splenectomy, patients are at a lifelong increased risk of infections, particularly from encapsulated organisms (*S. pneumoniae, H. influenzae, N. meningitidis*), due to the loss of the spleen’s filtering and IgM-producing functions. * **Option D:** Currently, **Non-Operative Management (NOM)** is the treatment of choice for hemodynamically stable patients (Grades I–III), with success rates exceeding 80% in specialized centers. **Clinical Pearls for NEET-PG:** * **Kehr’s Sign:** Referred pain to the left shoulder due to diaphragmatic irritation (classic sign of splenic rupture). * **Ballance’s Sign:** Fixed dullness in the left flank and shifting dullness in the right flank. * **Vaccination Protocol:** Post-splenectomy patients must receive vaccinations against *Pneumococcus, Meningococcus,* and *H. influenzae* (ideally 14 days before elective surgery or 14 days after emergency surgery). * **Opsonization:** The spleen is the primary site for clearing poorly opsonized bacteria.
Question 530: A patient presents with chest trauma and tachypnea (respiratory rate >40 breaths/min). Physical examination reveals hypertension (blood pressure = 90/60 mmHg) and a hyperresonant note on the involved side. What is the next appropriate management step?
- A. Intubation
- B. Chest X-ray (CXR)
- C. Intravenous fluids (IVF)
- D. Wide bore needle insertion on the 2nd intercostal space (ICS) (Correct Answer)
Explanation: ### **Explanation** The clinical presentation of chest trauma, respiratory distress (tachypnea), hypotension (90/60 mmHg), and a hyperresonant percussion note is a classic triad for **Tension Pneumothorax**. **1. Why Option D is Correct:** Tension pneumothorax is a **life-threatening clinical diagnosis**. The "one-way valve" effect allows air to enter the pleural space but not escape, leading to increased intrapleural pressure. This causes a mediastinal shift, compressing the superior/inferior vena cava and decreasing venous return, which results in obstructive shock (hypotension). The immediate management is **needle decompression** to convert the tension pneumothorax into a simple pneumothorax. While the ATLS 10th edition now suggests the 5th ICS (mid-axillary line) for adults, the **2nd ICS in the mid-clavicular line** remains a standard, high-yield answer in many exams. **2. Why Other Options are Incorrect:** * **Option A (Intubation):** Positive pressure ventilation can worsen a tension pneumothorax by forcing more air into the pleural space, potentially leading to rapid cardiac arrest. Decompression must occur first. * **Option B (CXR):** You must **never wait for a CXR** if a tension pneumothorax is suspected clinically. The delay for imaging can be fatal. * **Option C (IV Fluids):** While the patient is hypotensive, the shock is obstructive, not hypovolemic. Fluids will not resolve the underlying pathology of mediastinal compression. **3. Clinical Pearls for NEET-PG:** * **Diagnosis:** Clinical (Distended neck veins + Hyperresonance + Hypotension + Tracheal shift to the opposite side). * **Definitive Treatment:** Insertion of an Intercostal Drain (Chest tube) in the 5th ICS (Monaldi’s point). * **Key Distinction:** In a **Massive Hemothorax**, the percussion note is **dull**, whereas in a **Tension Pneumothorax**, it is **hyperresonant**.
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Initial Assessment of Trauma Patient
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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
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