Trauma Practice Questions

Q: Which IV fluid should not be used in a patient with head injury?

5% Dextrose. In neurotrauma management, the primary goal is to maintain cerebral perfusion pressure and prevent secondary brain injury caused by **cerebral edema**. ### Why 5% Dextrose is Contraindicated 5% Dextrose is an **isostonic-in-the-bag** but **hypotonic-in-the-body** solution. Once infused, the glucose is rapidly metabolized by the liver, leaving behind "free water." This free water moves from the intravascular space into the brain cells (intracellular space) via osmosis, significantly worsening **cerebral edema** and increasing intracranial pressure (ICP). Furthermore, hyperglycemia in the setting of acute brain injury can exacerbate neuronal damage through lactic acidosis. ### Analysis of Other Options * **Normal Saline (0.9% NaCl):** This is an **isotonic** crystalloid and the fluid of choice in head injuries. It stays within the extracellular compartment, maintaining blood pressure without causing brain cell swelling. * **Dextrose Normal Saline (DNS):** While it contains dextrose, the presence of 0.9% NaCl makes it hypertonic/isotonic enough to prevent the massive fluid shift seen with pure 5% Dextrose. However, it is still generally avoided unless the patient is hypoglycemic. ### NEET-PG High-Yield Pearls * **Fluid of Choice in Head Injury:** Normal Saline (0.9% NaCl) or Ringer's Lactate (though some prefer NS as RL is slightly hypotonic). * **Hypertonic Saline (3%):** Used specifically to reduce ICP in cases of cerebral edema or herniation. * **Avoid Hypotonic Fluids:** Never use 0.45% NS or 5% Dextrose in neuro-surgical patients. * **Target:** Maintain **Euvolemia** and avoid hypotension (SBP >100-110 mmHg) to ensure adequate Cerebral Perfusion Pressure (CPP).

Q: What is true regarding a second-degree deep burn?

Dry white color. **Explanation:** Burns are classified based on the depth of tissue involvement. A **second-degree deep partial-thickness burn** extends into the deeper layers of the dermis (reticular dermis), damaging hair follicles and sweat glands. **Why "Dry white color" is correct:** In deep second-degree burns, the damage to the dermal vasculature is significant. The destruction of the superficial capillary plexus leads to a lack of perfusion, resulting in a **waxy white or mottled appearance**. Unlike superficial burns, these are often **dry** because the sweat glands and sebaceous units are compromised. **Analysis of Incorrect Options:** * **A & B (Blanches on pressure / Erythema):** These are hallmarks of **First-degree** or **Superficial Second-degree** burns. In deep burns, the capillary refill is absent because the dermal vessels are thrombosed. * **D (Painless):** While deep second-degree burns have decreased sensation (hypoalgesia) due to damage to nerve endings, they are typically **painful to deep pressure**. A completely **painless** (anesthetic) wound is characteristic of a **Third-degree (Full-thickness)** burn. **NEET-PG High-Yield Pearls:** * **Superficial 2nd Degree:** Characterized by **blisters**, extreme pain, and brisk capillary refill. * **Deep 2nd Degree:** Characterized by a **cheesy white** appearance and takes >3 weeks to heal, often requiring skin grafting to prevent hypertrophic scarring. * **Jackson’s Burn Zones:** The **Zone of Stasis** is the critical area surrounding the central necrosis that can either recover or progress to deeper injury depending on resuscitation. * **Gold Standard for Depth:** Laser Doppler Imaging (LDI) is the most accurate tool to assess burn depth clinically.

Q: Under which step of the ABCDE approach for trauma care is cervical spine protection implemented?

A. **Explanation:** In trauma management, the **ATLS (Advanced Trauma Life Support)** protocol follows a strict hierarchical sequence (ABCDE) to address life-threatening injuries in order of priority. **Why Option A is Correct:** The first step, **A (Airway with Cervical Spine Protection)**, mandates that while ensuring a patent airway, the cervical spine must be protected. The medical rationale is that any blunt trauma above the clavicle or high-energy mechanism is assumed to have a cervical spine injury until proven otherwise. Excessive movement during airway maneuvers (like head-tilt/chin-lift) can convert a stable fracture into an unstable one, leading to permanent quadriplegia or respiratory arrest. Therefore, **Manual Inline Stabilization (MILS)** or a rigid cervical collar is mandatory during this phase. **Why Other Options are Incorrect:** * **B (Breathing):** Focuses on gas exchange and lung expansion (e.g., tension pneumothorax, flail chest). By this stage, the spine should already be secured. * **C (Circulation):** Focuses on hemorrhage control and fluid resuscitation. * **D (Disability):** Involves a rapid neurological assessment (GCS and pupil reaction). While it assesses spinal cord function, the *protection* of the spine must occur at Step A. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard for Airway:** Endotracheal Intubation. * **Airway Maneuver in Trauma:** Always use the **Jaw Thrust** (avoids neck extension) instead of the Head-tilt/Chin-lift. * **Clearing the C-Spine:** In conscious patients, the **NEXUS criteria** or **Canadian C-Spine Rules** are used to clinically rule out the need for imaging. * **Definitive Airway:** Required if GCS ≤ 8.

Q: In cases of burn, which is the fluid of choice in the first 24 hours?

Ringer Lactate. **Explanation:** The management of burn shock focuses on replacing the massive fluid loss caused by increased capillary permeability. **Ringer’s Lactate (RL)** is the fluid of choice during the first 24 hours because it is an isotonic crystalloid that most closely mimics the electrolyte composition of human plasma. **Why Ringer’s Lactate is the Correct Choice:** 1. **Balanced Electrolytes:** It contains sodium, potassium, and calcium in physiological concentrations. 2. **Acid-Base Balance:** RL contains **sodium lactate**, which is metabolized by the liver into bicarbonate. This helps buffer the metabolic acidosis commonly seen in burn patients due to tissue hypoperfusion. 3. **Reduced Risk of Hyperchloremia:** Unlike Normal Saline, RL has a lower chloride concentration, preventing hyperchloremic metabolic acidosis. **Why Other Options are Incorrect:** * **Normal Saline (0.9% NaCl):** While isotonic, its high chloride content (154 mEq/L) can lead to hyperchloremic acidosis and may exacerbate renal vasoconstriction. * **5% Dextrose:** This is a hypotonic solution once glucose is metabolized. It does not stay in the intravascular space and can lead to cerebral edema and hyponatremia. * **Blood:** Acute burn shock is characterized by loss of plasma and electrolytes, not primarily red blood cells. Blood is only indicated if there is a concomitant traumatic hemorrhage. **High-Yield Clinical Pearls for NEET-PG:** * **Parkland Formula:** The most common resuscitation guide: **4 mL × Body Weight (kg) × % TBSA (Total Body Surface Area)**. Give half in the first 8 hours and the remaining half over the next 16 hours. * **Modified Brooke Formula:** Uses **2 mL/kg/% TBSA** of RL. * **Monitoring:** The best indicator of adequate fluid resuscitation is **Urinary Output** (Target: 0.5–1.0 mL/kg/hr in adults; 1.0 mL/kg/hr in children). * **Rule of Nines:** Used to quickly estimate the % TBSA in adults.

Q: What is the most common cause of extradural/subdural hemorrhage in children?

Skull fracture. **Explanation:** In the pediatric population, **trauma** is the leading cause of intracranial hemorrhage. Specifically, **skull fractures** are the most common cause of both extradural (epidural) and subdural hemorrhages. * **Extradural Hemorrhage (EDH):** This usually occurs due to an arterial bleed (most commonly the **middle meningeal artery**) following a skull fracture that lacerates the vessel. In children, the dura is less firmly attached to the skull than in adults, but a forceful impact causing a fracture remains the primary trigger. * **Subdural Hemorrhage (SDH):** While SDH is caused by the tearing of **bridging veins**, these injuries are frequently associated with high-impact trauma and concomitant skull fractures, or in infants, via non-accidental trauma (Shaken Baby Syndrome). **Analysis of Incorrect Options:** * **A. Arteriovenous Malformation (AVM):** While AVMs are a common cause of *intraparenchymal* or *subarachnoid* hemorrhage in children, they are rarely the primary cause of extradural or subdural bleeds. * **C. Aneurysm:** Cerebral aneurysms are rare in children compared to adults and typically present as *subarachnoid* hemorrhage (SAH). * **D. Atherosclerosis:** This is a disease of the elderly and is virtually non-existent as a cause of hemorrhage in the pediatric age group. **Clinical Pearls for NEET-PG:** * **EDH Shape:** Biconvex/Lens-shaped (does not cross sutures). * **SDH Shape:** Crescent-shaped (can cross sutures). * **Lucid Interval:** Classically associated with EDH. * **Non-Accidental Trauma (NAT):** If a child presents with SDH and retinal hemorrhages without a clear history of major trauma, suspect child abuse.

Q: CSF rhinorrhoea is commonest following a fracture to which anatomical structure?

Cribriform plate. **Explanation:** **CSF Rhinorrhoea** occurs when there is a breach in the dura mater, arachnoid mater, and the bony floor of the anterior cranial fossa, creating a communication between the subarachnoid space and the nasal cavity. **Why Cribriform Plate is Correct:** The **cribriform plate of the ethmoid bone** is the most common site for CSF rhinorrhoea. Anatomically, it is extremely thin and fragile. Furthermore, the dura mater is tightly adherent to the bone in this region, making it highly susceptible to dural tears even with minor linear fractures of the anterior cranial fossa. **Analysis of Incorrect Options:** * **Temporal bone:** Fractures here (especially petrous part) more commonly lead to **CSF Otorrhoea**. While CSF can reach the nose via the Eustachian tube (paradoxical rhinorrhoea), it is less common than direct leakage via the ethmoid. * **Nasal bones:** These are extracranial structures. Fractures of the nasal bones cause epistaxis and deformity but do not involve the dural layers unless the underlying ethmoid bone is also fractured. * **Temporo-sphenoid region:** While sphenoid sinus fractures can cause rhinorrhoea, they are statistically less frequent than ethmoid/cribriform injuries. **Clinical Pearls for NEET-PG:** 1. **Diagnosis:** The most specific biochemical test is **Beta-2 Transferrin** (highly sensitive and specific for CSF). 2. **Target Sign/Halo Sign:** On a paper or linen, CSF forms a clear outer ring around a central red spot of blood. 3. **Management:** Most cases (80%) resolve with conservative management (bed rest, head elevation, avoiding straining). If persistent, endoscopic endonasal repair is the gold standard. 4. **Imaging:** **High-Resolution CT (HRCT)** of the paranasal sinuses is the investigation of choice to locate the bony defect.

Question 1

Which IV fluid should not be used in a patient with head injury?

Accepted Answer

5% Dextrose

Answer

Normal saline

Answer

Dextrose normal saline

Answer

All of the above

Question 2

A patient with burns dies within 24 hours. What is the most probable cause?

Accepted Answer

Physical burn injury to the airways above the larynx

Answer

Circulatory shock

Answer

Physical burn injury to the airways below the larynx

Answer

Circumferential burn

Question 3

What is true regarding a second-degree deep burn?

Accepted Answer

Dry white color

Answer

Blanches on pressure

Answer

Erythema

Answer

Painless

Question 4

Under which step of the ABCDE approach for trauma care is cervical spine protection implemented?

Accepted Answer

A

Answer

B

Answer

C

Answer

D

Question 5

In cases of burn, which is the fluid of choice in the first 24 hours?

Accepted Answer

Ringer Lactate

Answer

Normal saline

Answer

5% Dextrose

Answer

Blood

Question 6

A 50-year-old female has a second-degree deep burn involving 45% of total body surface area (TBSA). Regarding her management, which of the following statements is/are true?

Accepted Answer

Half of the calculated fluid should be given in the initial 8 hours.

Answer

Administer rapid normal saline infusion.

Answer

9 liters of Ringer's lactate should be given in the first 24 hours.

Answer

Urine output should be maintained at 25-30 ml/hr.

Question 7

Which is the most important factor in the management of shock?

Accepted Answer

Deficiency of effective circulation

Answer

Blood pressure

Answer

Cardiac output

Answer

Central venous pressure (CVP) to 8 cm of water

Question 8

What is true about diaphragmatic injury?

Accepted Answer

Diagnostic laparoscopy is advised.

Answer

Chest X-ray is useful.

Answer

Conservative management is done in most cases.

Answer

Late complication is herniation of abdominal contents.

Question 9

What is the most common cause of extradural/subdural hemorrhage in children?

Accepted Answer

Skull fracture

Answer

Arteriovenous malformation

Answer

Aneurysm

Answer

Atherosclerosis

Question 10

CSF rhinorrhoea is commonest following a fracture to which anatomical structure?

Accepted Answer

Cribriform plate

Answer

Temporal bone

Answer

Nasal bones

Answer

Temporo-sphenoid region

Trauma — MCQs

Trauma — MCQs

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