Trauma Practice Questions

Q: Arrange the following according to good outcome a - zone of stasis b - zone of coagulation c - zone of hyperemia

c > a > b. **Context:** This question refers to Jackson's burn wound model, which describes three concentric zones in a burn injury. ***c > a > b*** (Correct Answer) - The **zone of hyperemia (c)** has the **best prognosis** for recovery because tissue damage is minimal, involving primarily vasodilation and increased blood flow. This zone typically recovers completely within 7-10 days. - The **zone of stasis (a)** has an **intermediate prognosis**; tissue here is potentially salvageable but at risk of progression to necrosis within 24-48 hours if not properly managed (adequate fluid resuscitation, prevention of infection, avoiding vasoconstrictors). - The **zone of coagulation (b)** has the **worst prognosis**, as cellular damage is irreversible with immediate coagulative necrosis. This tissue will eventually slough off and requires debridement. *a > b > c* - Incorrectly suggests the **zone of stasis** has better outcome than **zone of hyperemia**, which contradicts the pathophysiology of burn injuries. - The **zone of coagulation** cannot have better outcome than **zone of hyperemia** as it represents dead tissue. *a > c > b* - Incorrectly places **zone of stasis** as having the best outcome when it has only intermediate prognosis. - The **zone of hyperemia** should be first as it has the highest probability of complete recovery without intervention. *a = c > b* - Incorrectly equates the prognosis of **zone of stasis** and **zone of hyperemia**, despite clear differences in severity and reversibility of tissue damage. - The **zone of hyperemia** has unequivocally better prognosis than the **zone of stasis**.

Q: Deep skin burns are treated with:

Split thickness graft. ***Split thickness graft*** - A **split-thickness skin graft (STSG)** involves transferring the epidermis and a portion of the dermis from a donor site to the burned area. - This type of graft is commonly used for deep partial-thickness or full-thickness burns because it provides good coverage with minimal donor site morbidity and has a high take rate. *Amniotic membrane* - **Amniotic membrane** is primarily used as a biological dressing for superficial burns or chronic wounds, promoting healing and reducing pain. - It does not provide permanent skin coverage for deep burns, which require viable skin for closure. *Full thickness graft* - A **full-thickness skin graft (FTSG)** includes the entire epidermis and dermis, resulting in better cosmetic and functional outcomes. - However, FTSGs are typically used for smaller, deeper defects or areas requiring maximum durability, rather than extensive deep burns, and their take rate is lower compared to STSGs. *Synthetic skin derivatives* - **Synthetic skin derivatives** (e.g., Integra, Biobrane) can be used as temporary dressings or matrices to facilitate wound healing in deep burns, but they typically require subsequent grafting. - They do not provide permanent, living tissue for definitive closure of large, deep burn wounds.

Q: Necrosis of entire skin thickness and variable thickness of underlying subcutaneous tissue is:

3rd degree frostbite. ***3rd degree frostbite*** - This degree of frostbite is characterized by **necrosis of the full thickness of the skin** and involvement of variable depths of the **subcutaneous tissue**. - Clinically, it presents with **hemorrhagic blisters**, often turning into **black eschars** over time, indicating permanent tissue damage. *2nd degree frostbite* - This involves damage to the **epidermis and dermis** but typically spares the subcutaneous tissue. - It is characterized by the formation of **clear or milky blisters** that are painful and often surrounded by edema and erythema. *4th degree frostbite* - This is the most severe form, involving **all layers of the skin, subcutaneous tissue, muscle, bone, and tendons**. - The affected area appears **mottled, deep purple, or black** and eventually becomes dry, mummified, and requires amputation. *1st degree frostbite* - This is the mildest form, affecting only the **epidermal layer** of the skin. - It presents with **numbness, erythema, and mild edema**, but no blistering or tissue loss.

Q: In a bus accident, which patient is given highest priority for immediate transfer to the hospital?

Airway obstruction. ***Airway obstruction*** - In emergency triage, **airway obstruction** is the most immediate life threat, as a patient cannot survive for long without oxygen. - Addressing the airway is paramount in the **ABCDE approach** (Airway, Breathing, Circulation, Disability, Exposure) to trauma patients, as it directly impacts oxygenation and ventilation. *Severe haemorrhage with leg fracture* - While severe hemorrhage is a life-threatening condition requiring urgent attention, **airway obstruction** takes immediate precedence as it leads to rapid oxygen deprivation. - A **leg fracture** itself is not immediately life-threatening, though associated severe hemorrhage can cause hypovolemic shock. *Head injury* - A **head injury** can be very serious and may lead to intraparenchymal bleeding or brain swelling, but its immediate life-threatening potential is often secondary to potential airway compromise, breathing difficulties, or circulatory failure. - Patients with significant head injuries may eventually require advanced neurosurgical care, but initial stabilization always prioritizes **airway and breathing**. *Circulatory shock* - **Circulatory shock** means inadequate tissue perfusion, which is a critical condition. However, effective circulation cannot be maintained without adequate **oxygenation and ventilation**, which are directly dependent on a patent airway and effective breathing. - While managing shock (e.g., fluid resuscitation for hypovolemic shock) is crucial, it always follows the establishment of a **secure airway** and adequate breathing in the prioritization hierarchy.

Q: Best diagnostic aid in blunt trauma abdomen is -

Ultrasound. ***Ultrasound (FAST)*** - **Focused Assessment with Sonography for Trauma (FAST)** is considered the **best initial diagnostic aid** in blunt abdominal trauma due to its **speed, availability, and versatility**. - It is **rapid, non-invasive, repeatable**, and can be performed **at the bedside** during resuscitation without moving the patient. - Highly sensitive for detecting **free intraperitoneal fluid** (blood) and **pericardial effusion**, which are critical in hemodynamically unstable patients. - Can be performed by **emergency physicians and surgeons** with minimal training, making it universally applicable in trauma settings. - **ATLS protocol** recommends FAST as the primary screening tool in the trauma bay. *CT scan* - **CT scan** provides the **most detailed anatomical information** and is the gold standard for evaluating **solid organ injuries** and **retroperitoneal hemorrhage** in **hemodynamically stable** patients. - However, it requires **patient transport**, involves **radiation exposure**, is **time-consuming**, and is **not suitable for unstable patients**. - Reserved for stable patients where detailed injury characterization is needed for non-operative management decisions. *Peritoneal lavage* - **Diagnostic peritoneal lavage (DPL)** was historically used but is **highly invasive** with a high rate of **non-therapeutic laparotomies**. - Largely **replaced by FAST ultrasound** due to better specificity and non-invasive nature. - Still occasionally used when FAST and CT are unavailable or inconclusive. *4 quadrant aspiration* - **Four-quadrant aspiration** (diagnostic paracentesis) has **poor sensitivity** for detecting intra-abdominal injuries. - **Rarely used** in modern trauma care due to **limited diagnostic yield** and risk of **iatrogenic injury**. - Superseded by more reliable modalities like FAST and CT.

Q: According to ATLS classification of hemorrhagic shock, a patient with decreased blood pressure, decreased urine output and decreased circulatory volume of 30-40% is managed by?

crystalloids+blood transfusion. ***Correct: crystalloids+blood transfusion*** - A 30-40% blood volume loss, indicated by **decreased blood pressure** and **decreased urine output**, corresponds to ATLS **Class III hemorrhagic shock**. - Management for Class III shock requires both **intravenous crystalloids** to restore circulatory volume and **blood transfusion** to replace lost red blood cells and improve oxygen-carrying capacity. - The initial approach follows the **3:1 crystalloid replacement rule**, followed by or concurrent with **packed red blood cells** to address ongoing hemorrhage and maintain oxygen delivery. *Incorrect: blood transfusion alone* - While blood transfusion is crucial for Class III hemorrhagic shock, administering it **alone** without initial crystalloid resuscitation may not adequately address the immediate need for **intravascular volume expansion**. - **Crystalloids** are typically administered first or concurrently to rapidly restore circulating volume and support perfusion before packed red blood cells can be prepared and transfused. *Incorrect: crystalloids infusion* - **Crystalloids alone** would be insufficient for Class III hemorrhage as the patient has experienced significant **red blood cell loss** (30-40% circulating volume) which requires direct replacement to improve oxygen delivery. - While initial crystalloid resuscitation is vital, continuing with crystalloids alone will lead to **dilutional coagulopathy** and failure to correct oxygen-carrying capacity. *Incorrect: plasma therapy* - **Plasma therapy** (e.g., fresh frozen plasma) is primarily used for the correction of **coagulopathy** in actively bleeding patients or those with anticipated massive transfusion. - Although it may be part of a massive transfusion protocol for severe hemorrhage, it is not the primary or sole initial treatment strategy for volume resuscitation and red blood cell replacement in Class III shock.

Q: True about burns -

Hyperglycemia is seen in early burns. ***Hyperglycemia is seen in early burns*** - **Hyperglycemia** is a common metabolic response in the early phase of severe burns due to a **stress-induced increase in counter-regulatory hormones** (e.g., cortisol, catecholamines, glucagon). - This leads to increased **gluconeogenesis** and **glycogenolysis**, alongside **insulin resistance**, contributing to elevated blood glucose levels. *3rd degree burns are painful* - **Third-degree burns** are typically **not painful** at the center of the burn because the nerve endings in the skin have been completely destroyed. - Pain may be present in areas surrounding the burn that are less severely damaged (e.g., second-degree burn areas). *Chemical powder burns should be kept dry* - **Chemical powder burns** should typically be **brushed off dry** before irrigation, as adding water immediately can activate some chemical agents or exacerbate the burn. - After brushing off, **copious irrigation with water** is usually the next step to dilute and remove the remaining chemical. *Child with burns should have damp dressing* - While proper wound care is crucial, **damp dressings** are generally avoided for initial management of burns, especially in children, due to the risk of **hypothermia** and potential for infection if not sterile. - Initial management often involves covering the burn with a **clean, dry dressing** or sterile sheets to protect the wound and prevent further contamination.

Q: For resuscitation in burn shock, the following fluid is advised

Crystalloids & Colloids. ***Crystalloids & Colloids*** - **Crystalloids** (e.g., Ringer's lactate) are the primary fluid for **burn resuscitation** to restore intravascular volume due to increased capillary permeability. - **Colloids** (e.g., albumin) may be added after the initial fluid shift stabilizes (typically after 12-24 hours) to maintain oncotic pressure and prevent excessive edema. *Packed cell volume* - **Packed red blood cells** are generally not indicated for routine early burn resuscitation, as the primary fluid loss is plasma, not red blood cells. - They are reserved for significant **hemorrhage** or severe anemia that develops later in the burn course. *Whole blood volume* - **Whole blood** is rarely used in burn shock resuscitation because it contains both red blood cells and plasma, which are not lost in equal proportions during the acute phase. - The focus is on replacing the lost **plasma volume** and electrolytes. *Plasma* - While plasma is the fluid lost in burn injuries, direct **plasma transfusion** is usually not the first-line treatment for volume resuscitation. - **Crystalloids** are preferred initially due to their availability, lower cost, and ability to expand intravascular volume effectively in the acute phase.

Q: Which of the following is the most important initial step in managing a patient with extensive burns?

Secure the airway and assess for inhalation injury. ***Secure the airway and assess for inhalation injury*** - **Airway management** is the most critical initial step in all trauma patients, including burns, following the **ABCDE protocol**. - In extensive burns, especially those involving **face/neck**, rapid airway swelling can occur due to **thermal injury** and inflammation, requiring early assessment for **inhalation injury signs** (singed nasal hairs, carbonaceous sputum, hoarse voice). *Begin immediate fluid resuscitation with crystalloids* - Critical for preventing **burn shock** in extensive burns and should begin promptly after airway assessment. - Uses formulas like **Parkland formula** for calculation and is part of **circulation management** in ABCDE protocol. *Perform immediate escharotomy for circumferential burns* - Important intervention for **circumferential full-thickness burns** causing **compartment syndrome**. - Should be performed when indicated, but only after **airway and breathing** are secured, as not all extensive burn patients have circumferential burns requiring immediate escharotomy. *Administer prophylactic antibiotics* - **NOT recommended** in initial burn management as it can promote **antibiotic resistance** and mask early infection signs. - Antibiotics should be reserved for treating **documented infections**.

Question 1

An 18 year old boy while riding a motorbike without a helmet sustained a road traffic accident. He is brought to casualty and imaging studies done. He is diagnosed with left frontal skull fracture and cortical contusion. He has had no seizures and his GCS is 10. Antiepileptic drug therapy in this patient

Accepted Answer

Indicated to reduce incidence of early onset post traumatic seizures

Answer

Is contraindicated due to risk of rash

Answer

Is likely to cause increased cerebral edema

Answer

Indicated to reduce incidence of late onset post traumatic seizures

Question 2

Arrange the following according to good outcome
a - zone of stasis
 b - zone of coagulation
 c - zone of hyperemia

Accepted Answer

c > a > b

Answer

a > b > c

Answer

a > c > b

Answer

a = c > b

Question 3

Deep skin burns are treated with:

Accepted Answer

Split thickness graft

Answer

Amniotic membrane

Answer

Full thickness graft

Answer

Synthetic skin derivatives

Question 4

Necrosis of entire skin thickness and variable thickness of underlying subcutaneous tissue is:

Accepted Answer

3rd degree frostbite

Answer

2nd degree frostbite

Answer

4th degree frostbite

Answer

1st degree frostbite

Question 5

In a bus accident, which patient is given highest priority for immediate transfer to the hospital?

Accepted Answer

Airway obstruction

Answer

Severe haemorrhage with leg fracture

Answer

Head injury

Answer

Circulatory shock

Question 6

Best diagnostic aid in blunt trauma abdomen is -

Accepted Answer

Ultrasound

Answer

Peritoneal lavage

Answer

4 quadrant aspiration

Answer

CT scan

Question 7

According to ATLS classification of hemorrhagic shock, a patient with decreased blood pressure, decreased urine output and decreased circulatory volume of 30-40% is managed by?

Accepted Answer

crystalloids+blood transfusion

Answer

blood transfusion alone

Answer

crystalloids infusion

Answer

plasma therapy

Question 8

True about burns -

Accepted Answer

Hyperglycemia is seen in early burns

Answer

3rd degree burns are painful

Answer

Chemical powder burns should be kept dry

Answer

Child with burns should have damp dressing

Question 9

For resuscitation in burn shock, the following fluid is advised

Accepted Answer

Crystalloids & Colloids

Answer

Packed cell volume

Answer

Whole blood volume

Answer

Plasma

Question 10

Which of the following is the most important initial step in managing a patient with extensive burns?

Accepted Answer

Secure the airway and assess for inhalation injury

Answer

Begin immediate fluid resuscitation with crystalloids

Answer

Administer prophylactic antibiotics

Answer

Perform immediate escharotomy for circumferential burns

Trauma — MCQs

Trauma — MCQs

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