Trauma Practice Questions

Q: A patient presents with severe respiratory distress, hyperresonance and absent breath sounds on one side of the chest, distended neck veins, and tracheal shift away from the affected side. What is the best immediate management for this life-threatening condition?

Wide bore needle in 2nd ICS. ***Wide bore needle in 2nd ICS*** - This is the immediate, life-saving intervention for a **tension pneumothorax**, a clinical diagnosis based on the triad of respiratory distress, hemodynamic instability, and unilateral chest signs. - Needle decompression rapidly converts the **tension pneumothorax** into a simple pneumothorax by relieving intrapleural pressure, and is a temporizing measure followed by definitive chest tube insertion. *Bedside CXR in casualty followed by chest tube insertion* - Delaying treatment for a chest X-ray in a clinically evident and unstable **tension pneumothorax** is dangerous and can lead to cardiovascular collapse and death. - The diagnosis is **clinical**, and immediate decompression should precede any imaging. *Pericardiocentesis* - This procedure is indicated for **cardiac tamponade**, which presents with muffled heart sounds, not the unilateral hyperresonance and absent breath sounds seen in pneumothorax. - While both conditions can cause obstructive shock with distended neck veins, the pulmonary findings are key to differentiating them. *Pleurodesis with doxycycline* - Pleurodesis is a procedure to prevent the **recurrence** of a pneumothorax or pleural effusion, not a treatment for an acute, life-threatening event. - It is performed electively after the lung has been fully re-expanded with a chest tube.

Q: On examination, a person has distended neck veins, absent breath sounds, hyperresonance, and a shift of the trachea. What is the management?

Wide bore needle in 2nd ICS. ***Wide bore needle in 2nd ICS***- The constellation of absent breath sounds, **hyperresonance**, distended neck veins, and tracheal deviation indicates **tension pneumothorax**, which requires immediate definitive management before imaging can be done via a **needle decompression**.- This emergent procedure involves inserting a large-bore needle (e.g., 14-gauge) into the **second intercostal space (ICS)** in the midclavicular line to immediately relieve the pleural pressure and convert it to a simple pneumothorax.*Bedside CXR in casualty followed by chest tube insertion*- Obtaining a **CXR** is contraindicated as it significantly delays the urgent, life-saving decompression required for a clinically diagnosed **tension pneumothorax**.- While **chest tube insertion** is the definitive management, initial stabilization via needle decompression must precede this step in unstable patients with tension pneumothorax.*Pericardiocentesis*- This procedure is indicated for **cardiac tamponade**, which presents with features such as Beck's triad (hypotension, muffled heart sounds, elevated JVP), not the hyperresonance and absent breath sounds seen here.- Cardiac tamponade is a fluid accumulation issue impacting cardiac function, distinct from the life-threatening air accumulation and massive pressure shift seen in **tension pneumothorax**.*Pleurodesis with doxycycline*- **Pleurodesis** is an elective, definitive procedure used to prevent the recurrence of pleural effusions or pneumothorax by fusing the pleural layers, not an immediate emergency intervention.- This is typically reserved for stable patients with recurrent pneumothorax or chronic conditions like refractory **malignant pleural effusion**.

Q: A 45-year-old male patient was brought to the emergency department following a road traffic accident. O/E, he had multiple injuries all over his body and was found to be in class III hemorrhagic shock. The percentage of blood loss would be between:

30-40%. ***30-40%***- **Class III hemorrhagic shock** is defined by an estimated blood loss of **30-40%** (approximately 1500 to 2000 mL in an adult).- Clinically, patients in Class III shock present with **marked tachycardia** (>120 bpm), significant **hypotension**, and altered **mental status** (confusion).*5-15%*- This range corresponds to **Class I hemorrhagic shock**, which involves minimal blood loss (up to 750 mL).- Patients in **Class I** typically present with near-normal vital signs or mild **tachycardia** only, not the severe clinical picture described.*>40%*- This defines **Class IV hemorrhagic shock**, representing extremely severe and **life-threatening** blood loss (over 2000 mL).- Patients in **Class IV** present with profound **hypotension** and absent peripheral pulses; they are often unresponsive.*15-30%*- This range characterizes **Class II hemorrhagic shock**, which involves moderate blood loss (750 to 1500 mL).- Patients exhibit **tachycardia** (100–120 bpm) and decreased **pulse pressure**, but usually maintain adequate blood pressure and good mental status, unlike the patient described.

Q: A patient presents to the emergency department with confusion. On examination, he opens his eyes to pain, shows abnormal flexion to pain, and is disoriented in speech. What is his Glasgow Coma Scale (GCS) score?

9. ***9***- The Glasgow Coma Scale (GCS) total score is the sum of scores for Eye (E), Verbal (V), and Motor (M) responses (E+V+M). - **Eye Opening (E)** score is 2 for opening eyes only to **painful stimuli** (4=Spontaneous, 1=None). - **Verbal Response (V)** score is 4 for **disoriented in speech**, which is categorized as disoriented/confused conversation (5=Oriented, 3=Inappropriate Words). - **Motor Response (M)** score is 3 for showing **abnormal flexion** (Decorticate posturing) to pain (6=Obeys Commands, 1=None). Total GCS = 2 + 4 + 3 = **9**. *11* - A GCS of 11 is too high for this clinical presentation, as it implies a much better neurological status, typically requiring higher E, V, and M scores (e.g., E3/4, V4/5, M4/5). - This score conflicts with the patient's severe responses: E=2 (to pain) and M=3 (**abnormal flexion**), which together limit the maximum possible GCS to 11 (2+5+4). *12* - A GCS of 12 represents a moderate head injury, which is inconsistent with the patient demonstrating **abnormal flexion** (M=3), a sign often associated with severe injury or significant cerebral dysfunction. - Achieving a score of 12 would necessitate very strong cognitive responses (e.g., E4, V5, M3), which contradict the observed responses of E=2 and M=3. *10* - While close to the correct score, 10 would require a combination like E2, V5, M3, meaning the patient should be **oriented verbally** (V=5). - The patient is explicitly described as "**disoriented in speech**," which dictates a verbal score of V=4 or less, thus ruling out GCS 10.

Q: Identify the sign given in the image below:

Double target sign. ***Double target sign*** - The image displays the **double target sign**, also known as the **halo sign**, which is highly suggestive of a **basilar skull fracture**. - This sign appears when blood mixed with **cerebrospinal fluid (CSF)** is dropped onto an absorbent surface; the heavier red blood cells accumulate in the center, while the lighter CSF diffuses outward, forming a distinct ring. *Beta 2 transferrin sign* - This is not a visual sign but a highly specific laboratory test used to confirm a **CSF leak**. **Beta-2 transferrin** is a protein almost exclusively found in CSF. - The test involves analyzing fluid collected from the nose or ear (rhinorrhea or otorrhea) to detect the presence of this specific protein, confirming its origin is CSF. *Handkerchief sign* - The **handkerchief sign** (or reservoir sign) refers to the clinical observation of a patient with **CSF rhinorrhea** who constantly has to wipe their nose due to the continuous, watery discharge. - It describes a patient's action rather than the appearance of the fluid itself on a surface. *Tear drop sign* - The **tear drop sign** is a radiological finding seen on orbital imaging (X-ray or CT scan), not a clinical sign on a cloth. - It indicates an **orbital floor (blowout) fracture**, where orbital contents, such as fat and the inferior rectus muscle, herniate into the maxillary sinus, resembling a hanging teardrop.

Q: A 45-year-old man is found unconscious after a fall from a ladder. In the emergency department, his eyes do not open even in response to pain; he is making incomprehensible sounds, and he exhibits abnormal flexion in response to painful stimuli. What is his Glasgow Coma Scale (GCS) score?

6. ***Correct Answer: 6*** - The GCS score is calculated by summing Eye (E), Verbal (V), and Motor (M) responses - E=1 (no eye opening to pain) + V=2 (incomprehensible sounds) + M=3 (abnormal flexion/decorticate posturing) = **6** - A GCS ≤8 indicates **severe head injury** requiring definitive airway management *Incorrect: 5* - A score of 5 would require an even lower motor response: M=2 (abnormal extension/decerebrate posturing) or M=1 (no motor response) - The patient demonstrates M=3 (abnormal flexion), making the total score 6, not 5 *Incorrect: 7* - A score of 7 would require a higher verbal or motor component - For example: E=1 + V=3 (inappropriate words) + M=3 = 7, or E=1 + V=2 + M=4 (withdrawal from pain) = 7 - The patient's V=2 (incomprehensible sounds) and E=1 prevent reaching a total of 7 *Incorrect: 8* - A GCS of 8 requires significantly better responses, such as M=4 (withdraws from pain) or V=3 (inappropriate words) combined with M=4 - The patient's M=3 (abnormal flexion) and V=2 (incomprehensible sounds) are too low to reach 8

Q: A 26 year old female was brought to ER post fire incidence. Her face and lower limbs were spared. Based on the burn distribution shown, calculate the percentage of body surface area affected.

40-50%. ***40-50%*** - The **Rule of Nines** is used to estimate the Total Body Surface Area (TBSA) of burns in adults. According to this rule, the anterior trunk is 18%, each upper limb is 9%, and the posterior trunk is 18%. - In this patient, burns cover the entire anterior trunk (18%), both upper limbs (9% + 9% = 18%), and likely the upper posterior trunk (approx. 9%), totaling around **45%**, which falls in this range. This calculation is critical for fluid resuscitation. *5-10%* - This percentage represents a much smaller burn area, equivalent to approximately one full arm (9%) or the head (9%). - The visual evidence clearly shows extensive burns involving the entire torso and both arms, far exceeding this estimation. *20-30%* - This TBSA would typically represent burns covering the entire anterior trunk (18%) plus one arm (9%), totaling 27%. - This estimate is incorrect as it fails to account for the burns on the second upper limb and the likely involvement of the back. *10-15%* - A burn of this size would involve an area such as the anterior chest (9%) or one leg from the knee down. - This option significantly underestimates the burn severity, as the anterior trunk alone accounts for 18% of the TBSA.

Q: A fracture caused by falls landing on feet/buttocks (force transmitted through the spine), heavy blows to the top of the skull/vertex, twisting of the head on the spine, or blows to the occiput or chin. Which type of fracture is this?

Fissured Fracture (Linear Fracture). ***Fissured Fracture (Linear Fracture)*** - This type of fracture, also known as a **linear fracture**, results from forces that cause a simple, nondisplaced crack in the skull vault. - The mechanisms described—such as forces transmitted through the spine (falls on feet/buttocks) or blows to the vertex, chin, or occiput—are classic causes of **linear skull fractures** because the force is typically dispersed over a wide area, rather than focused enough to cause depression. *Depressed Fracture* - These fractures occur due to high-velocity **localized impact**, where the outer table of the skull is driven inward below the level of the inner table, posing a high risk of **dural tear** and underlying brain injury. - The mechanisms listed in the question involve generalized force transmission or twisting, which are inconsistent with the **inward comminution** required for a depressed fracture. *Gutter Fracture* - This term is specifically associated with **penetrating missile injuries**, like low-velocity bullet wounds, where bone fragments are typically driven inward, creating a characteristic groove or channel. - The mechanisms listed in the prompt are **blunt force** injuries or transmission of force, not penetrating trauma that creates a 'gutter.' *Diastatic Fracture (Sutural Fracture)* - This fracture involves the **separation of cranial sutures** due to a fracture line extending into them, primarily observed in infants and young children before the sutures are fully fused. - The forces described result in a break *through* the bone of the vault (a fissure) rather than primarily causing the **separation of existing, fused sutures** in an adult skull.

Q: A 3-year-old child presented with multiple burn injuries involving the entire head, neck & one upper limb. What is the percentage of burn?

25-30%. ***Correct Answer: 25-30%*** Using the **Modified Rule of Nines for Pediatric Burns** (for children aged 1-4 years): **Calculation:** - **Head & Neck:** ~18% (children have proportionally larger heads compared to adults) - **One Upper Limb:** ~9% - **Total TBSA (Total Body Surface Area):** 18% + 9% = **27%** This falls within the range of **25-30%**, making this the correct answer. **Why Other Options are Incorrect:** *Incorrect: 5-10%* - This significantly underestimates the burn area. Head and neck alone account for ~18% in young children. *Incorrect: 18-20%* - This would represent only the head and neck, failing to account for the upper limb involvement. *Incorrect: 40-44%* - This overestimates the burn area. Even if both upper limbs were involved (18%), the total would be ~36%, not 40-44%. **Clinical Pearl:** In pediatric burns, remember that children have different body surface area proportions than adults - the head is proportionally larger (18% vs 9% in adults), while the lower limbs are proportionally smaller. Always use age-appropriate burn assessment charts.

Q: Four patients were brought to the casualty after sustaining trauma. Which of the following is the correct match among the following?

Gaze palsy is - Midbrain lesion. ***Gaze palseis-Mid brain lesion***- **Vertical gaze palsies** are commonly associated with lesions affecting the **midbrain**, particularly the **pretectal area** and the rostral interstitial nucleus of the **medial longitudinal fasciculus (riMLF)**.- Trauma or increased intracranial pressure leading to compression in this region, such as in **Parinaud syndrome**, can result in impaired upward or downward gaze.*Extradural hemorrhage (EDH)- Pin point pupil*- An **EDH** typically causes rapid mass effect and subsequent **uncal herniation**, leading to compression of the **oculomotor nerve (CN III)** and resulting in a fixed, **dilated pupil** (mydriasis) ipsilateral to the lesion.- **Pinpoint pupils** are classically associated with damage to the descending sympathetic pathways in the **pons** (pontine hemorrhage) or opioid overdose.*Penetrating injury to eustachian tube- CSF otorrhea*- **CSF otorrhea** (leakage of CSF from the ear) occurs due to a tear in the dura mater and the **temporal bone**, specifically involving the **petrous segment** and tympanic membrane rupture.- Injury to the **Eustachian tube** primarily connects the middle ear to the nasopharynx; damage here would typically cause air leak or middle ear bleeding, not primary CSF leakage through the external auditory canal.*Penetrating injury to eye- Battle sign*- **Battle sign** is ecchymosis (bruising) over the **mastoid process** and is a hallmark clinical indicator of a **basilar skull fracture**, usually involving the middle cranial fossa (temporal bone).- Penetrating injuries to the eye are associated with localized ocular trauma (e.g., globe rupture, hyphema) but are not typically linked to this specific sign of underlying skull base injury.

Question 1

A patient presents with severe respiratory distress, hyperresonance and absent breath sounds on one side of the chest, distended neck veins, and tracheal shift away from the affected side. What is the best immediate management for this life-threatening condition?

Accepted Answer

Wide bore needle in 2nd ICS

Answer

Bedside CXR in casualty followed by chest tube insertion

Answer

Pleurodesis with doxycycline

Answer

Pericardiocentesis

Question 2

On examination, a person has distended neck veins, absent breath sounds, hyperresonance, and a shift of the trachea. What is the management?

Accepted Answer

Wide bore needle in 2nd ICS

Answer

Pericardiocentesis

Answer

Bedside CXR in casualty followed by chest tube insertion

Answer

Pleurodesis with doxycycline

Question 3

A 45-year-old male patient was brought to the emergency department following a road traffic accident. O/E, he had multiple injuries all over his body and was found to be in class III hemorrhagic shock. The percentage of blood loss would be between:

Accepted Answer

30-40%

Answer

>40%

Answer

5-15%

Answer

15-30%

Question 4

A patient presents to the emergency department with confusion. On examination, he opens his eyes to pain, shows abnormal flexion to pain, and is disoriented in speech. What is his Glasgow Coma Scale (GCS) score?

Accepted Answer

9

Answer

12

Answer

11

Answer

10

Question 5

Identify the sign given in the image below:

Accepted Answer

Double target sign

Answer

Handkerchief sign

Answer

Beta 2 transferrin sign

Answer

Tear drop sign

Question 6

A 45-year-old man is found unconscious after a fall from a ladder. In the emergency department, his eyes do not open even in response to pain; he is making incomprehensible sounds, and he exhibits abnormal flexion in response to painful stimuli. What is his Glasgow Coma Scale (GCS) score?

Accepted Answer

6

Answer

7

Answer

8

Answer

5

Question 7

A 26 year old female was brought to ER post fire incidence. Her face and lower limbs were spared. Based on the burn distribution shown, calculate the percentage of body surface area affected.

Accepted Answer

40-50%

Answer

20-30%

Answer

5-10%

Answer

10-15%

Question 8

A fracture caused by falls landing on feet/buttocks (force transmitted through the spine), heavy blows to the top of the skull/vertex, twisting of the head on the spine, or blows to the occiput or chin. Which type of fracture is this?

Accepted Answer

Fissured Fracture (Linear Fracture)

Answer

Diastatic Fracture (Sutural Fracture)

Answer

Depressed Fracture

Answer

Gutter Fracture

Question 9

A 3-year-old child presented with multiple burn injuries involving the entire head, neck & one upper limb. What is the percentage of burn?

Accepted Answer

25-30%

Answer

5-10%

Answer

40-44%

Answer

18-20%

Question 10

Four patients were brought to the casualty after sustaining trauma. Which of the following is the correct match among the following?

Accepted Answer

Gaze palsy is - Midbrain lesion

Answer

b.Penetrating injury to eustachian tube- CSF otorrhea

Answer

c.Penetrating injury to eye- Battle sign

Answer

a.Extradural hemorrhage (EDH)- Pin point pupil

Trauma — MCQs

Trauma — MCQs

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