Trauma — MCQs
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In the management of excessive burns, which of the following is least useful?
A young motorist suffered injuries in a major road traffic accident. He was diagnosed to have a fracture of the left femur and left humerus. He was also having fractures of multiple ribs anteriorly on both sides. In the examination, the blood pressure was 80/60 mm Hg and heart rate was 140/minute. The patient was agitated, restless, and tachypneic. Jugular veins were distended. Air entry was adequate in both lung fields. Heart sounds were barely audible. Femoral pulses were weakly palpable but distally no pulsation could be felt. On a priority basis, what is the immediate intervention?
A burn wound extending into the superficial epidermis without involving the dermis would present with all of the following EXCEPT?
Which type of intubation is preferred in cases of bilateral mandibular fractures?
A 30-year-old restrained driver was involved in a motor-vehicle crash. He is hemodynamically stable and has a large seat belt sign on the abdomen. His abdomen is tender to palpation. What is the primary concern in this patient?
Which of the following is transfused in a patient who has severe burn injuries?
In which of the following conditions is surgery not useful?
CSF rhinorrhea can be seen in which type of fracture?
Nine days following splenectomy, a 13-year-old patient presents with fever and leukocytosis. The chest x-ray shows free air under the diaphragm. What is the most likely diagnosis?
A hemodynamically unstable patient sustains a fracture of the left femoral shaft following a road traffic accident. The patient also exhibits guarding and rigidity in the abdomen. What is the next step in management?
Trauma Indian Medical PG Practice Questions and MCQs
Question 51: In the management of excessive burns, which of the following is least useful?
- A. Blood transfusion (Correct Answer)
- B. Dextran
- C. Ringer lactate solution
- D. Nasogastric intubation
Explanation: In the management of acute burns, the primary physiological challenge is **hypovolemic shock** caused by increased capillary permeability and plasma loss, rather than red cell loss. ### **Why Blood Transfusion is the Least Useful (Correct Option)** In the early (resuscitative) phase of burns, there is a significant loss of plasma into the interstitial space, leading to **hemoconcentration** (elevated hematocrit). Administering a blood transfusion at this stage would further increase blood viscosity, potentially worsening microcirculatory stasis and increasing the risk of thromboembolic complications. Blood transfusion is generally reserved for the later stages if the patient develops anemia due to sepsis or repeated surgical debridements. ### **Analysis of Other Options** * **Ringer Lactate (RL):** This is the **fluid of choice** for burn resuscitation (Parkland Formula). It is an isotonic crystalloid that helps restore intravascular volume and correct metabolic acidosis. * **Dextran:** This is a colloid used as a plasma expander. While crystalloids are preferred, colloids can be used in specific protocols (like the Muir and Barclay formula) or after the first 24 hours to maintain oncotic pressure. * **Nasogastric (NG) Intubation:** Essential in major burns (>20% BSA) to prevent gastric dilatation and aspiration due to **paralytic ileus** (Curling’s ulcer prophylaxis). ### **High-Yield Clinical Pearls for NEET-PG** * **Parkland Formula:** $4 \text{ ml} \times \text{Body Weight (kg)} \times \text{TBSA \%}$. Give half in the first 8 hours. * **Fluid of Choice:** Ringer Lactate is preferred over Normal Saline to avoid hyperchloremic acidosis. * **Monitoring:** The most sensitive indicator of adequate fluid resuscitation is **Urinary Output** (Target: $0.5\text{--}1 \text{ ml/kg/hr}$ in adults). * **Hematocrit:** Expect it to be high initially; a falling hematocrit without bleeding usually indicates successful hemodilution via resuscitation.
Question 52: A young motorist suffered injuries in a major road traffic accident. He was diagnosed to have a fracture of the left femur and left humerus. He was also having fractures of multiple ribs anteriorly on both sides. In the examination, the blood pressure was 80/60 mm Hg and heart rate was 140/minute. The patient was agitated, restless, and tachypneic. Jugular veins were distended. Air entry was adequate in both lung fields. Heart sounds were barely audible. Femoral pulses were weakly palpable but distally no pulsation could be felt. On a priority basis, what is the immediate intervention?
- A. Rapid blood transfusion.
- B. Urgent pericardial tap. (Correct Answer)
- C. Intercostal tube drainage on both sides.
- D. Fixation of left femur and repair of femoral artery.
Explanation: ### **Explanation** The patient presents with the classic **Beck’s Triad**, which is diagnostic of **Cardiac Tamponade**: 1. **Hypotension** (BP 80/60 mmHg) with tachycardia. 2. **Distended Jugular Veins** (indicating increased central venous pressure). 3. **Muffled/Distant Heart Sounds** (barely audible). The clinical picture is further supported by the mechanism of injury (blunt chest trauma from rib fractures) and the presence of **adequate air entry** bilaterally, which effectively rules out a tension pneumothorax (the other major cause of obstructive shock with distended neck veins). In an emergency setting, the immediate life-saving intervention for cardiac tamponade is an **Urgent Pericardial Tap (Pericardiocentesis)** to decompress the pericardial sac and restore cardiac output. #### **Analysis of Incorrect Options:** * **A. Rapid blood transfusion:** While the patient has femur/humerus fractures, the distended neck veins indicate obstructive shock, not simple hypovolemic shock. Fluids/blood won't resolve the cardiac compression. * **C. Intercostal tube drainage:** This is the treatment for tension pneumothorax. Since air entry is "adequate" in both lung fields, this is not the priority. * **D. Fixation of femur/artery repair:** These are secondary priorities. In trauma management (ATLS guidelines), "Circulation with hemorrhage control" (including tamponade) must be addressed before definitive orthopedic or vascular surgery. #### **Clinical Pearls for NEET-PG:** * **Pulsus Paradoxus:** A drop in systolic BP >10 mmHg during inspiration; a key sign of tamponade. * **Kussmaul’s Sign:** Paradoxical rise in JVP on inspiration (more common in constrictive pericarditis but can be seen in tamponade). * **FAST Exam:** In modern trauma protocols, a **Focused Assessment with Sonography for Trauma (FAST)** is the gold standard for the initial diagnosis of pericardial fluid. * **Definitive Treatment:** While pericardiocentesis is the immediate emergency step, the definitive treatment for traumatic tamponade is often a **subxiphoid pericardial window** or **thoracotomy**.
Question 53: A burn wound extending into the superficial epidermis without involving the dermis would present with all of the following EXCEPT?
- A. Healing of the wound spontaneously without scar formation
- B. Anaesthesia at the site of burn (Correct Answer)
- C. Blister formation
- D. Painful
Explanation: ### Explanation The question describes a **Superficial (First-degree) or Superficial Partial-thickness (Second-degree)** burn. In these injuries, the nerve endings located in the dermis remain intact and functional. **1. Why "Anaesthesia at the site of burn" is the correct answer:** Anaesthesia (loss of sensation) occurs only in **Full-thickness (Third-degree) burns**, where the entire dermis, including the sensory nerve endings and receptors, is completely destroyed. Since the wound described involves only the epidermis (and potentially the superficial dermis), the nerve endings are exposed and irritated rather than destroyed, leading to significant pain rather than numbness. **2. Analysis of Incorrect Options:** * **A. Healing without scar formation:** Superficial burns involve only the epidermis or the papillary dermis. Because the regenerative capacity of the basal layer or skin appendages is preserved, these wounds heal by epithelialization within 7–14 days without scarring. * **C. Blister formation:** Blisters are the hallmark of **Partial-thickness (Second-degree) burns**. They result from the separation of the epidermis from the dermis and the accumulation of inflammatory fluid in the potential space. * **D. Painful:** As the sensory nerves are intact and exposed to air and inflammatory mediators, these burns are characteristically very painful. **3. High-Yield Clinical Pearls for NEET-PG:** * **Depth Assessment:** The most reliable clinical sign of a **Full-thickness burn** is the absence of pain (anaesthesia) and the absence of capillary refill. * **Rule of Nines:** Used for TBSA (Total Body Surface Area) calculation; remember that **First-degree burns are NOT included** in the TBSA calculation for fluid resuscitation. * **Jackson’s Thermal Zones:** The "Zone of Coagulation" is the central area of irreversible tissue death, while the "Zone of Stasis" is the surrounding area where perfusion can be restored with proper resuscitation. * **Healing Time:** Superficial partial-thickness burns heal in <3 weeks; Deep partial-thickness burns take >3 weeks and often require grafting to prevent hypertrophic scarring.
Question 54: Which type of intubation is preferred in cases of bilateral mandibular fractures?
- A. Orotracheal intubation (Correct Answer)
- B. Naso tracheal intubation
- C. Cricothyrotomy
- D. Submental intubation
Explanation: In trauma management, securing the airway is the first priority (the 'A' of ABCDE). For **bilateral mandibular fractures**, the preferred method for securing a definitive airway is **Orotracheal intubation**. ### Why Orotracheal Intubation is Correct? In bilateral mandibular fractures (especially "flail mandible"), the structural support for the tongue is lost, leading to posterior displacement and upper airway obstruction. Orotracheal intubation is the **fastest, most direct, and standard method** to secure the airway. Despite the fracture, the oral cavity usually provides sufficient space for direct laryngoscopy, and it avoids the complications associated with nasal or surgical routes in an acute setting. ### Why Other Options are Incorrect: * **Nasotracheal Intubation:** This is generally avoided in facial trauma if there is any suspicion of a concomitant **base of skull fracture** (common in high-impact mandibular trauma) due to the risk of accidental intracranial tube placement. It is also more time-consuming and prone to causing epistaxis. * **Cricothyrotomy:** This is a surgical airway reserved for "cannot intubate, cannot ventilate" scenarios. It is not the *first* choice if orotracheal intubation is feasible. * **Submental Intubation:** This is a specialized technique used primarily in elective maxillofacial surgeries where both dental occlusion (precluding oral tubes) and nasal access (precluding nasal tubes) are required. It is not the preferred method for emergency airway stabilization in trauma. ### High-Yield Clinical Pearls for NEET-PG: * **Gold Standard:** Orotracheal intubation (with manual in-line stabilization if a C-spine injury is suspected) is the primary definitive airway in trauma. * **Flail Mandible:** Bilateral parasymphyseal fractures can lead to "tongue fall back," causing acute respiratory distress. * **Contraindication:** Nasal intubation is strictly contraindicated in patients with mid-face fractures (Le Fort II/III) or CSF rhinorrhea.
Question 55: A 30-year-old restrained driver was involved in a motor-vehicle crash. He is hemodynamically stable and has a large seat belt sign on the abdomen. His abdomen is tender to palpation. What is the primary concern in this patient?
- A. Liver and spleen injury
- B. Transection of the head of the pancreas
- C. Renal pedicle avulsion
- D. Hollow-viscus injuries (Correct Answer)
Explanation: **Explanation:** The presence of a **"Seat Belt Sign"** (ecchymosis across the lower abdomen in the distribution of a lap belt) is a classic clinical indicator of deceleration injury. In a hemodynamically stable patient with abdominal tenderness and a seat belt sign, the primary concern is **Hollow-Viscus Injury (HVI)**, specifically the small bowel, and associated mesenteric tears. **Why Hollow-Viscus Injury is correct:** During a motor vehicle crash, the lap belt acts as a fulcrum. The sudden deceleration causes a rapid increase in intraluminal pressure within the bowel loops (the "closed-loop" phenomenon) and compression of the bowel against the vertebral column. This frequently leads to perforations or mesenteric devascularization. While solid organ injuries are common in blunt trauma, the specific association with the seat belt sign strongly points toward HVI. **Analysis of Incorrect Options:** * **A. Liver and spleen injury:** These are the most common organs injured in blunt trauma overall. However, they usually present with signs of internal hemorrhage and hemodynamic instability (tachycardia/hypotension), which are absent in this stable patient. * **B. Transection of the head of the pancreas:** While pancreatic injuries can occur due to compression against the spine, they are less frequent than bowel injuries in the context of a seat belt sign. * **C. Renal pedicle avulsion:** This is a severe vascular injury typically resulting from massive deceleration. It would lead to rapid hemodynamic collapse and is not specifically associated with the seat belt sign. **High-Yield Clinical Pearls for NEET-PG:** * **Chance Fracture:** Always look for a distraction fracture of the lumbar spine (L1-L3) in patients with a seat belt sign; this triad (Seat belt sign + HVI + Chance fracture) is highly characteristic. * **Diagnostic Challenge:** HVI is notoriously difficult to diagnose on initial CT scans. Serial abdominal examinations are mandatory. * **Management:** If a patient with a seat belt sign develops increasing tenderness or signs of peritonitis, urgent laparotomy is indicated regardless of initial imaging.
Question 56: Which of the following is transfused in a patient who has severe burn injuries?
- A. Blood
- B. Plasma (Correct Answer)
- C. Platelets
- D. Erythrocytes
Explanation: ### Explanation In severe burn injuries, the primary pathophysiological event is a massive increase in capillary permeability (systemic capillary leak syndrome). This leads to the rapid loss of protein-rich **plasma** from the intravascular compartment into the interstitial space, resulting in profound hypovolemia and "burn shock." **Why Plasma is the Correct Answer:** The fluid lost in the first 24–48 hours of a burn is predominantly plasma, not whole blood. Transfusing plasma (or plasma expanders/crystalloids like Ringer’s Lactate) helps restore oncotic pressure and intravascular volume. While modern resuscitation protocols (like the Parkland Formula) prioritize crystalloids initially, plasma remains the physiological component lost that needs replacement to maintain circulatory stability. **Why Other Options are Incorrect:** * **A & D (Blood/Erythrocytes):** In the acute phase of a burn, there is actually **hemoconcentration** (elevated Hematocrit) because plasma is lost while red blood cells remain in the vessels. Transfusing blood or RBCs early on can increase blood viscosity and worsen microcirculatory stasis. * **C (Platelets):** Platelet deficiency is not a primary feature of early burn shock. Platelets are only indicated if there is evidence of disseminated intravascular coagulation (DIC) or massive transfusion requirements later in management. **High-Yield Clinical Pearls for NEET-PG:** * **Fluid of Choice:** Crystalloid (Ringer’s Lactate) is the gold standard for initial resuscitation. * **Parkland Formula:** $4 \text{ ml} \times \text{Body Weight (kg)} \times \% \text{ Total Body Surface Area (TBSA) burned}$. * **Baxter’s Formula:** Same as Parkland, but uses $3.75 \text{–} 4 \text{ ml}$. * **Indicator of Adequate Resuscitation:** Urine output ($0.5 \text{–} 1 \text{ ml/kg/hr}$ in adults; $1 \text{ ml/kg/hr}$ in children). * **Evaporative Loss:** Post-burn, patients lose significant water through the damaged skin barrier, but the initial shift is plasma-driven.
Question 57: In which of the following conditions is surgery not useful?
- A. Cerebral edema (Correct Answer)
- B. Depressed fracture
- C. Extradural hemorrhage
- D. Subdural hemorrhage
Explanation: ### Explanation The management of head injuries is a high-yield topic in NEET-PG, focusing on the distinction between **surgical (evacuatable)** and **medical (diffuse)** pathologies. **Why Cerebral Edema is the Correct Answer:** Cerebral edema is a diffuse physiological response to injury characterized by an increase in brain volume due to fluid accumulation. Since it is a global parenchymal process rather than a focal mass lesion, it cannot be "removed" surgically. The primary management is **medical**, utilizing osmotic diuretics (Mannitol or Hypertonic Saline), head elevation, and hyperventilation to reduce intracranial pressure (ICP). Surgery (like decompressive craniectomy) is only a last-resort measure to create space, but it does not treat the edema itself. **Analysis of Incorrect Options:** * **Depressed Fracture:** Surgery is indicated if the depression is greater than the thickness of the skull, if there is an underlying dural tear, or if it is a compound fracture (to debride and prevent infection). * **Extradural Hemorrhage (EDH):** This is a neurosurgical emergency. Since the blood is trapped between the skull and dura, urgent **burr-hole evacuation or craniotomy** is life-saving to prevent uncal herniation. * **Subdural Hemorrhage (SDH):** Acute SDH with a midline shift >5mm or clot thickness >10mm requires surgical evacuation via craniotomy to relieve mass effect. **Clinical Pearls for NEET-PG:** * **EDH:** Classic "Lucid Interval"; biconvex/lens-shaped on CT; usually involves the **Middle Meningeal Artery**. * **SDH:** Crescent-shaped on CT; involves tearing of **bridging veins**. * **Cushing’s Triad (Sign of high ICP):** Hypertension, Bradycardia, and Irregular Respiration. * **First-line medical management for raised ICP:** Mannitol (0.25–1 g/kg IV).
Question 58: CSF rhinorrhea can be seen in which type of fracture?
- A. Lefort 2 fracture
- B. Lefort 3 fracture
- C. Nasoethmoidal fracture
- D. All of the above (Correct Answer)
Explanation: **Explanation:** CSF rhinorrhea occurs when there is a breach in the **dura mater** and a fracture of the **cribriform plate** of the ethmoid bone or the floor of the anterior cranial fossa. This allows cerebrospinal fluid to leak from the subarachnoid space into the nasal cavity. * **Lefort II (Pyramidal) and Lefort III (Craniofacial Disjunction):** Both of these fracture lines involve the **ethmoid bone** and the nasofrontal suture area. In Lefort III, the entire facial skeleton is separated from the skull base, frequently involving the cribriform plate. In Lefort II, the fracture line passes through the bridge of the nose and the ethmoid air cells, often leading to dural tears. * **Nasoethmoidal (NOE) Fractures:** These involve the central midface and specifically the ethmoid bone. Because the ethmoid bone forms the roof of the nasal cavity and the floor of the anterior cranial fossa, these fractures are highly associated with CSF leaks. **Why "All of the above" is correct:** Since all three fracture patterns involve the ethmoid complex and the anatomical junction between the face and the anterior skull base, they are all potential causes of CSF rhinorrhea. **Clinical Pearls for NEET-PG:** 1. **Target/Halo Sign:** If CSF is mixed with blood, dropping it on a gauze piece creates a central red spot (blood) surrounded by a clear ring (CSF). 2. **Biochemical Marker:** **Beta-2 Transferrin** is the most specific gold-standard test to confirm CSF leakage. 3. **Management:** Most cases resolve with conservative management (head elevation, avoidance of straining). If persistent, surgical repair is required. 4. **Contraindication:** Nasogastric (NG) tubes are strictly contraindicated in these fractures to avoid accidental intracranial insertion; use an orogastric tube instead.
Question 59: Nine days following splenectomy, a 13-year-old patient presents with fever and leukocytosis. The chest x-ray shows free air under the diaphragm. What is the most likely diagnosis?
- A. Left lower lobe pneumonia
- B. Postsplenectomy sepsis
- C. Gastric wall ulcer
- D. Left colon perforation (Correct Answer)
Explanation: **Explanation:** The correct diagnosis is **Left colon perforation**. During a splenectomy, the surgeon must mobilize the splenic flexure of the colon and divide the splenocolic ligament. If the colon is inadvertently injured or its blood supply is compromised during this maneuver, a delayed perforation can occur. The presence of **free air under the diaphragm** (pneumoperitoneum) 9 days post-surgery is a pathognomonic sign of a hollow viscus perforation. **Analysis of Options:** * **Left lower lobe pneumonia (A):** While it causes fever and leukocytosis, it would present with pulmonary infiltrates or effusion on X-ray, not free air under the diaphragm. * **Postsplenectomy sepsis (B):** Also known as OPSI (Overwhelming Post-Splenectomy Infection), this is a fulminant systemic infection (usually *S. pneumoniae*). While it presents with fever and high mortality, it does not cause pneumoperitoneum. * **Gastric wall ulcer (C):** While the short gastric arteries are ligated during splenectomy (potentially causing gastric wall ischemia), injury to the splenic flexure is a more common surgical complication leading to delayed perforation in this clinical context. **Clinical Pearls for NEET-PG:** * **Most common organ injured during splenectomy:** Pancreatic tail (leading to fistula) and the Splenic flexure of the colon. * **Pneumoperitoneum:** Always indicates a perforated hollow viscus (stomach, duodenum, or colon) unless proven otherwise in a post-operative setting where air should have normally resorbed (usually by day 5-7). * **OPSI Prevention:** Patients should receive vaccinations against *Streptococcus pneumoniae*, *Haemophilus influenzae* type b, and *Neisseria meningitidis* (ideally 2 weeks before elective surgery or 2 weeks after emergency surgery).
Question 60: A hemodynamically unstable patient sustains a fracture of the left femoral shaft following a road traffic accident. The patient also exhibits guarding and rigidity in the abdomen. What is the next step in management?
- A. Open reduction and fixation of femur
- B. CECT abdomen
- C. Stabilize the fracture and monitor the patient, then perform eFAST (Correct Answer)
- D. Stabilize the fracture only
Explanation: ### Explanation The management of a trauma patient follows the **ATLS (Advanced Trauma Life Support)** protocols, prioritizing life-threatening injuries over limb-threatening ones. **1. Why Option C is Correct:** In a **hemodynamically unstable** patient with abdominal signs (guarding/rigidity) and a long bone fracture, the priority is resuscitation and identifying the source of internal bleeding. A femoral shaft fracture can cause significant blood loss (up to 1.5L), contributing to instability. The immediate steps are: * **Stabilization:** Splinting the femur (e.g., Thomas splint) reduces further hemorrhage and pain. * **eFAST (Extended Focused Assessment with Sonography for Trauma):** This is the **investigation of choice** for hemodynamically unstable patients to identify hemoperitoneum or hemopericardium. Guarding and rigidity strongly suggest intra-abdominal visceral injury. **2. Why Other Options are Incorrect:** * **Option A:** Definitive orthopedic surgery is never the first step in an unstable patient. This follows the principle of "Damage Control Surgery" where physiological stability precedes anatomical alignment. * **Option B:** While CECT is the gold standard for abdominal trauma, it is **contraindicated in hemodynamically unstable patients** because the patient must be moved to the radiology suite, risking cardiac arrest away from resuscitative equipment. * **Option D:** Stabilizing the fracture alone ignores the potential life-threatening intra-abdominal bleed indicated by the clinical signs of guarding and rigidity. **Clinical Pearls for NEET-PG:** * **Unstable + Blunt Trauma Abdomen:** Initial investigation is **eFAST** or **DPL** (Diagnostic Peritoneal Lavage). * **Stable + Blunt Trauma Abdomen:** Investigation of choice is **CECT Abdomen**. * **Femur Fracture Blood Loss:** Approximately **1000–1500 ml**. * **The "Lethal Triad" in Trauma:** Acidosis, Coagulopathy, and Hypothermia. Management aims to avoid this through rapid stabilization and hemorrhage control.
Practice by Chapter
Initial Assessment of Trauma Patient
Practice Questions
Advanced Trauma Life Support (ATLS) Principles
Practice Questions
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
Practice Questions
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