Trauma Practice Questions

Q: Consider the following findings with reference to a diagnostic peritoneal lavage (DPL) in a case of abdominal trauma : 1. 10 ml of gross blood on aspiration 2. W.B.C. count more than 500/cu mm 3. Amylase level more than 175 IU/dL 4. R.B.C. count more than 100,000/cu mm The criteria for a positive DPL are :

1, 2, 3 and 4. ***1, 2, 3 and 4*** - A **positive DPL** is indicated by any of these findings: gross blood on aspiration (≥10 mL), WBC count >500/mm³, amylase level >175 IU/dL, or RBC count >100,000/mm³. - All four criteria listed are standard indicators for a positive DPL, suggesting significant intra-abdominal injury requiring further intervention. *1 and 2 only* - While **gross blood aspiration** and an **elevated WBC count** are indeed criteria for a positive DPL, this option is incomplete as it omits other critical indicators. - A **high amylase level** and **RBC count >100,000/mm³** are also definitive signs of a positive DPL. *3 and 4 only* - Although an **elevated amylase level** and a **high RBC count** are valid criteria, this option is insufficient because it excludes the important findings of gross blood aspiration and an elevated WBC count. - A comprehensive assessment requires considering **all definitive indicators** for a positive DPL. *1, 2 and 3 only* - This option includes gross blood aspiration, elevated WBC count, and elevated amylase level, which are all positive indicators. - However, it incorrectly excludes an **RBC count >100,000/mm³**, which is a crucial and widely accepted criterion for a positive DPL.

Q: Consider the following conditions in blunt trauma of the chest : 1. Flail chest 2. Drainage of 1 litre of blood from the chest tube 3. Cardiac tamponade 4. Rupture of oesophagus Which of the above are the indications of emergency thoracotomy?

2, 3 and 4 only. ***Correct: 2, 3 and 4 only*** **Emergency thoracotomy indications in blunt chest trauma:** **Drainage of 1 litre of blood from chest tube (Massive Hemothorax):** - Definite indication for emergency thoracotomy - Standard criteria: >1500 mL initial drainage OR >200-300 mL/hr for 2-4 consecutive hours - 1 liter initially approaches the threshold and indicates ongoing hemorrhage requiring surgical control **Cardiac tamponade:** - Life-threatening condition requiring immediate intervention - Initial management may include pericardiocentesis, but if patient is in extremis or pericardiocentesis fails, emergency thoracotomy is indicated - In the setting of blunt trauma with hemodynamic instability, thoracotomy may be necessary for definitive repair **Rupture of oesophagus:** - Though rare in blunt trauma, when it occurs it requires surgical repair via thoracotomy - While not always an immediate "emergency" in the resuscitation bay, it does require urgent surgical intervention once diagnosed - Can lead to mediastinitis and requires thoracotomy for repair and debridement *Incorrect: Flail chest (Statement 1)* - **Flail chest is NOT an indication for emergency thoracotomy** - Management is primarily conservative: adequate analgesia, pulmonary toilet, and respiratory support - Surgical rib fixation (ORIF) may be considered in select cases but this is different from emergency thoracotomy for hemorrhage or cardiac injury - Flail chest does not require opening the chest cavity emergently; it's a chest wall injury managed supportively *Incorrect: 2 and 4 only* - Excludes cardiac tamponade, which is a critical indication for thoracotomy in unstable patients *Incorrect: 1, 2, 3 and 4* - Incorrectly includes flail chest, which is not an indication for emergency thoracotomy *Incorrect: 1, 2 and 3 only* - Incorrectly includes flail chest - Excludes esophageal rupture which does require surgical thoracotomy when diagnosed

Q: A 23-year-old male riding his motorcycle meets with a road accident. He is tachypnoeic with HR 110/min and BP 112/74 mmHg. On examination, he appears pale and has tenderness over the left side of chest with dullness to percussion. There is slight mediastinal shift to the opposite side. Abdominal examination is unremarkable. Most probably he is suffering from:

Haemothorax. **Haemothorax** - **Dullness to percussion** on the left side of the chest, combined with symptoms of **hypovolemia** (pale, HR 110/min, BP 112/74 mmHg), strongly suggests blood accumulation in the pleural space. - **Slight mediastinal shift** to the opposite side is consistent with a large volume of blood pushing the mediastinum, though it's typically more pronounced in tension pneumothorax. *Tension pneumothorax* - Characterized by **hyperresonance** to percussion, not dullness, as air accumulates in the pleural space. - Would present with marked **tracheal deviation**, **severe respiratory distress**, and often severe hypotension due to impaired cardiac output. *Subcutaneous emphysema* - Identified by **crepitus** (crackling sensation) on palpation due to air in the subcutaneous tissues. - While it can be associated with chest trauma, it does not explain the dullness to percussion or the systemic signs of blood loss. *Tracheal rupture* - Typically presents with **severe subcutaneous emphysema**, **dyspnea**, **hoarseness**, and possibly a **pneumomediastinum**. - Does not directly cause dullness to percussion in the pleural space or explain the significant signs of blood loss.

Q: Glasgow Coma Score Scale pertains to:

Level of consciousness. ***Level of consciousness*** - The **Glasgow Coma Scale (GCS)** is a neurological scale that aims to give a reliable and objective way of recording the conscious state of a person [1]. - It assesses a patient's motor, verbal, and eye-opening responses to determine their **level of consciousness** [1], [3]. *Chest injury* - The GCS is not designed to assess **chest injuries**; other trauma scores like the Injury Severity Score (ISS) are used for that purpose. - Chest injuries are evaluated through physical examination, imaging like **X-rays** and **CT scans**, and assessment of respiratory function. *Head injury only* - While GCS is crucial for assessing **head injuries**, its primary focus is on the patient's **overall level of consciousness**, which can be affected by various conditions beyond isolated head trauma [1], [2]. - Conditions like metabolic disturbances, drug overdose, and shock can also alter consciousness and are monitored using GCS [1], [4]. *Head and cervical injury* - The GCS evaluates the **level of consciousness**, which is a systemic response, not specific to a combined head and cervical injury. - While head injuries often coincide with cervical spine precautions, the GCS itself does not directly assess the presence or severity of a **cervical injury** [4].

Q: In a male patient of road traffic accident with blood at the tip of external meatus, the likely injury is:

Injury to urethra. ***Injury to urethra*** - **Blood at the tip of the external meatus** is a classic sign of urethral injury, often occurring in male patients following a **pelvic fracture** from a road traffic accident. - This symptom indicates a direct tear or disruption of the urethral continuity, allowing blood to exit through the penile meatus. *Injury to urinary bladder* - Bladder injuries typically present with **hematuria** (blood in the urine), but rarely with blood at the external meatus unless there is an associated urethral tear. - Patients might also experience **suprapubic pain**, difficulty voiding, or anuria. *Injury to kidney* - Kidney injuries often cause **gross hematuria** (visible blood in urine) but do not typically result in blood at the external meatus directly. - Other signs include flank pain, tenderness, and sometimes a palpable mass. *Injury to all of these* - While multiple injuries can occur in a severe road traffic accident, the specific presentation of **blood at the tip of the external meatus** is highly indicative of a urethral injury, making it the most likely isolated injury suggested by this particular symptom. - There is no direct evidence presented in the question to suggest simultaneous injury to the kidney and bladder leading to this specific sign.

Q: A 50 year old patient had a haematoma in his left gluteal region which was large, painful and causing some neural deficit. The next plan of management will be to:

Incise or aspirate the haematoma. ***Incise or aspirate the haematoma*** - A large, painful hematoma, especially one causing **neurological deficits**, requires intervention to relieve pressure and prevent further damage. - **Incision and drainage** or **aspiration** are appropriate surgical methods to remove the collected blood and alleviate symptoms. *Apply some superficial ointment for it to subside* - **Superficial ointments** are ineffective for large, deep hematomas, particularly when they are causing **neurological compression**. - This approach would not address the underlying pressure or the potential for **tissue damage** from the hematoma. *Get an CECT or MRI done* - While imaging like **CECT or MRI** can provide detailed information about the hematoma's size, location, and relationship to surrounding structures, it is a **diagnostic step, not the definitive management** for an already established, symptomatic hematoma. - Given the patient’s symptoms, especially **neurological deficits**, prompt intervention to relieve pressure is more critical than immediate advanced imaging. *Leave it alone* - Leaving a large, painful hematoma with **neural compromise** unattended can lead to **permanent nerve damage**, **compartment syndrome**, or other severe complications. - This approach is appropriate only for small, asymptomatic hematomas that are expected to resolve spontaneously without complications.

Q: Which one of the following regarding management of acute wounds is NOT true?

Clamps should be used to stop all bleeding vessels. ***Clamps should be used to stop all bleeding vessels*** - While **hemostasis** is crucial, using clamps on *all* bleeding vessels, especially small ones, is generally discouraged as it can cause **tissue damage** and may not be necessary for effective bleeding control in many acute wound settings. - The primary initial goal is to achieve **hemostasis** safely, often through direct pressure, elevation, and pressure dressings, before more invasive measures. *Wounds should be examined, taking into consideration site and structures damaged* - A thorough examination is fundamental to identify the **extent of the injury**, including potential damage to underlying structures like nerves, tendons, vessels, or joints. - This assessment guides the appropriate cleaning, debridement, and repair strategies to optimize **healing and function**. *Bleeding wounds should be elevated and a pressure pad applied* - **Elevation** helps reduce hydrostatic pressure, thereby decreasing blood flow to the injured area. - Applying **direct pressure** with a pressure pad is the most immediate and effective method for controlling venous and capillary bleeding, and often arterial bleeding as well. *The whole patient should be examined according to ATLS principles* - The **Advanced Trauma Life Support (ATLS)** principles prioritize a systematic approach to trauma care, starting with the primary survey (ABCDE) to identify and manage life-threatening injuries. - This ensures that hidden or more critical injuries are not missed amidst the focus on the visible wound, maintaining a **holistic view** of the patient's condition.

Q: Indications of computed tomography after head injury include all EXCEPT:

Mild head injury in a 50 year old man. ***Mild head injury in a 50-year-old man*** - This is not an absolute indication for CT scanning after head injury, especially if the patient is **neurologically intact** (GCS 15) and has no other high-risk features. - While age **> 65 years** is considered a risk factor in some guidelines (Canadian CT Head Rule), age 50 alone does not warrant CT in mild head injury (GCS 13-15) without additional warning signs. - CT would be indicated if this patient had **other risk factors** such as loss of consciousness, amnesia, vomiting, anticoagulation use, or dangerous mechanism of injury. *Open depressed fracture* - This is a **high-risk feature** indicating a severe head injury and potential for **intracranial injury** or infection, requiring immediate imaging. - CT is essential to assess the extent of **bone depression**, foreign bodies, and associated brain injury. *Glasgow Coma Scale 30 minutes* - **Post-traumatic amnesia (PTA)** lasting longer than 30 minutes is a recognized risk factor for **intracranial injury**, even in patients with otherwise normal GCS scores. - It indicates a more significant impact on brain function and warrants a CT scan to rule out **structural lesions** per NICE and Canadian CT Head Rules.

Q: Mainstay of an accurate diagnosis of pancreatic injury following blunt abdominal trauma is:

Computed Tomogram. ***Computed Tomogram*** - **CT scan** is the **imaging modality of choice** for evaluating solid organ injuries, including the pancreas, following blunt abdominal trauma due to its rapid acquisition and high resolution. - It effectively identifies signs of pancreatic injury such as **lacerations**, **hematoma**, **peripancreatic fluid**, and **transection of the pancreatic duct**. *USG abdomen* - **Ultrasound** has limited utility in diagnosing pancreatic injury due to the gland's **retroperitoneal location** and frequent overlying bowel gas obfuscating views. - While useful for rapid assessment of free fluid, it is **not sensitive enough** to reliably detect subtle pancreatic parenchymal damage. *MRI abdomen* - **MRI** provides excellent soft tissue contrast but is typically **time-consuming** and less accessible than CT in acute trauma settings, making it impractical for initial evaluation. - It may be used for **further characterization** of an injury, especially ductal involvement, if CT findings are equivocal or in stable patients. *Diagnostic peritoneal lavage* - **Diagnostic peritoneal lavage (DPL)** is primarily used to detect **hemoperitoneum** or rupture of hollow viscous organs, but it is **not specific for pancreatic injury**. - A positive DPL can indicate intra-abdominal injury but doesn't localize the source, and it has largely been replaced by focused assessment with sonography for trauma (FAST) and CT scans.

Question 1

A truck driver hit his chest against the steering wheel and sustained multiple rib fractures. His vitals are stable; however, the injured side of the chest shows paradoxical movement. The chest X-ray shows no evidence of haemothorax or pneumothorax but there is a large pulmonary contusion. The most appropriate treatment will be

Accepted Answer

Immediate operative stabilisation

Answer

Insertion of an intrathoracic drain

Answer

Stabilisation of fractured ribs with towel clips

Answer

Tracheostomy, mechanical ventilation and positive end-expiratory pressure ventilation

Question 2

Consider the following findings with reference to a diagnostic peritoneal lavage (DPL) in a case of abdominal trauma :

1. 10 ml of gross blood on aspiration
2. W.B.C. count more than 500/cu mm
3. Amylase level more than 175 IU/dL
4. R.B.C. count more than 100,000/cu mm The criteria for a positive DPL are :

Accepted Answer

1, 2, 3 and 4

Answer

1 and 2 only

Answer

3 and 4 only

Answer

1, 2 and 3 only

Question 3

Consider the following conditions in blunt trauma of the chest :
1. Flail chest
2. Drainage of 1 litre of blood from the chest tube
3. Cardiac tamponade
4. Rupture of oesophagus
Which of the above are the indications of emergency thoracotomy?

Accepted Answer

2, 3 and 4 only

Answer

2 and 4 only

Answer

1, 2, 3 and 4

Answer

1, 2 and 3 only

Question 4

A 23-year-old male riding his motorcycle meets with a road accident. He is tachypnoeic with HR 110/min and BP 112/74 mmHg. On examination, he appears pale and has tenderness over the left side of chest with dullness to percussion. There is slight mediastinal shift to the opposite side. Abdominal examination is unremarkable. Most probably he is suffering from:

Accepted Answer

Haemothorax

Answer

Tension pneumothorax

Answer

Subcutaneous emphysema

Answer

Tracheal rupture

Question 5

Glasgow Coma Score Scale pertains to:

Accepted Answer

Level of consciousness

Answer

Chest injury

Answer

Head injury only

Answer

Head and cervical injury

Question 6

In a male patient of road traffic accident with blood at the tip of external meatus, the likely injury is:

Accepted Answer

Injury to urethra

Answer

Injury to urinary bladder

Answer

Injury to kidney

Answer

Injury to all of these

Question 7

A 50 year old patient had a haematoma in his left gluteal region which was large, painful and causing some neural deficit. The next plan of management will be to:

Accepted Answer

Incise or aspirate the haematoma

Answer

Apply some superficial ointment for it to subside

Answer

Get a CECT or MRI done

Answer

Leave it alone

Question 8

Which one of the following regarding management of acute wounds is NOT true?

Accepted Answer

Clamps should be used to stop all bleeding vessels

Answer

Wounds should be examined, taking into consideration site and structures damaged

Answer

Bleeding wounds should be elevated and a pressure pad applied

Answer

The whole patient should be examined according to ATLS principles

Question 9

Indications of computed tomography after head injury include all EXCEPT:

Accepted Answer

Mild head injury in a 50 year old man

Answer

Open depressed fracture

Answer

Glasgow Coma Scale < 13 at any point

Answer

Amnesia > 30 minutes

Question 10

Mainstay of an accurate diagnosis of pancreatic injury following blunt abdominal trauma is:

Accepted Answer

Computed Tomogram

Answer

USG abdomen

Answer

MRI abdomen

Answer

Diagnostic peritoneal lavage

Trauma — MCQs

Trauma — MCQs

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