Trauma Practice Questions

Q: A 50 kg woman is brought to the emergency department with severe burns. It is estimated that partial thickness and full thickness burns (second and third degree) cover 60% of the total body surface area (TBSA). What is the rate of fluid resuscitation to be given in the first 8 hours?

750 ml/hr. ***750 ml/hr*** - The Parkland formula is used for fluid resuscitation in burn patients: **4 mL x kg x %TBSA burn**. For this patient: 4 mL x 50 kg x 60% = **12,000 mL** over 24 hours. - Half of this total fluid (6,000 mL) is given in the **first 8 hours**: 6,000 mL / 8 hours = **750 mL/hr**. *1000 ml/hr* - This rate would deliver 8,000 mL in the first 8 hours, which is **over-resuscitation** for this patient according to the Parkland formula. - Excessive fluid administration can lead to complications such as **compartment syndrome** and **pulmonary edema**. *500 ml/hr* - This rate would deliver 4,000 mL in the first 8 hours, which is **under-resuscitation** for this patient according to the Parkland formula. - Inadequate fluid resuscitation can lead to **burn shock**, **renal failure**, and increased mortality. *1250 ml/hr* - This rate would deliver 10,000 mL in the first 8 hours, which represents significant **over-resuscitation** and is not indicated. - Such a high rate is well beyond the calculated needs and could result in severe fluid overload and its associated complications.

Q: For the immediately life-threatening injuries of the chest "Flail chest", select the proper intervention (SELECT 1 INTERVENTION)

Endotracheal intubation. ***Endotracheal intubation*** - **Endotracheal intubation** with **positive pressure ventilation** is the definitive intervention for flail chest to stabilize the chest wall and ensure adequate ventilation. - This prevents paradoxical chest wall movement and improves oxygenation, addressing the life-threatening impact on respiratory mechanics. *Tube thoracostomy* - **Tube thoracostomy** is primarily indicated for **pneumothorax** or **hemothorax**, which may co-exist with flail chest but is not the direct treatment for the flail segment itself. - While necessary for associated conditions, it does not stabilize the flail segment to improve ventilation. *Subxiphoid window* - A **subxiphoid window** is a diagnostic procedure performed to detect **pericardial effusion** or **cardiac tamponade**, not a primary intervention for flail chest. - It does not address the mechanical instability or respiratory compromise caused by a flail chest. *Cricothyroidotomy* - **Cricothyroidotomy** is an emergency procedure for securing an airway when **oral or nasal intubation is not possible** due to obstruction or trauma to the upper airway. - It is an airway intervention but does not specifically address the chest wall instability or paradoxical movement seen in flail chest.

Q: In blunt trauma abdomen, maximum injury to the small bowel occurs at:

Proximal jejunum. ***Proximal jejunum*** - The **proximal jejunum** is particularly vulnerable to blunt abdominal trauma due to its relatively fixed position at the **ligament of Treitz** and its proximity to the impact forces. - The rapid change in momentum during deceleration can cause tearing or shearing injuries at this point of relative immobility. *Ileocecal junction* - While the ileocecal junction is another relatively fixed point, it is less commonly injured in blunt abdominal trauma compared to the proximal jejunum. - Its anatomical position often shields it from the direct impact and shearing forces that typically affect the more superior small bowel. *Mid ileum* - The **mid ileum** is generally more mobile within the abdominal cavity, making it less susceptible to the shearing forces that affect fixed segments. - Injuries to this region are usually associated with more severe, widespread trauma or direct crushing mechanisms, rather than a specific point of maximum vulnerability. *Proximal ileum* - Similar to the mid ileum, the **proximal ileum** also has considerable mobility, reducing its risk of injury from acceleration-deceleration forces. - The more common sites of injury in the small bowel are those with relative fixation points, such as the jejunum near the ligament of Treitz.

Q: A patient presented with bleeding from thigh and broken 5th rib on right side. What should be done first:

Control bleeding. ***Control bleeding*** - In trauma cases, **hemorrhage control** is the immediate priority to prevent exsanguination and hypovolemic shock, which can be rapidly fatal. - The **ABCDE approach** in trauma management (Airway, Breathing, Circulation, Disability, Exposure) dictates that controlling life-threatening bleeding falls under "Circulation" and often takes precedence over other injuries once the airway is secured. *Strapping of chest* - While a fractured rib can cause pain and impair breathing, **chest strapping** is generally not recommended as it restricts chest wall movement, potentially leading to **atelectasis** and **pneumonia**. - Furthermore, it does not address the immediate life threat of uncontrolled bleeding from the thigh. *Internal fixation of rib* - **Internal fixation** of a broken rib is an advanced and elective surgical procedure, typically performed significantly later for specific indications such as flail chest or non-union. - It is not an emergent intervention and would be performed only after the patient is stable and all life-threatening conditions, including active bleeding, have been addressed. *Wait & watch* - A "wait and watch" approach is inappropriate for a patient with active bleeding and a fractured rib, as it delays critical interventions and can lead to **deterioration** of the patient's condition. - Immediate assessment and intervention are required to manage both the bleeding and the potential respiratory compromise from the rib fracture.

Q: A 30-year-old female with a history of burns involving abdomen, both limbs, and back presented after 8 hours. Which of the following is the formula for calculation of fluid infusion:

4 mL/kg × % TBSA over 24 hours. ***4 mL/kg × % TBSA over 24 hours*** - This is the **Parkland formula**, the gold standard for burn resuscitation in adults. - The total fluid requirement is **4 mL/kg × % TBSA**, with **half given in the first 8 hours** from the time of burn and **half in the remaining 16 hours**. - Since this patient presented after 8 hours, the resuscitation timeline needs adjustment, but the formula itself remains the standard Parkland calculation. - This provides adequate **fluid resuscitation** while minimizing risks of under-resuscitation or fluid overload. *3 mL/kg × % TBSA* - This formula provides **insufficient fluid volume** for adequate burn resuscitation in adults. - Using only 3 mL/kg would lead to **under-resuscitation**, risking hypovolemic shock and inadequate tissue perfusion. - This is significantly below the evidence-based Parkland formula requirement. *5 mL/kg × % TBSA* - This fluid resuscitation rate is **excessive** and significantly higher than the standard Parkland formula. - Using this amount increases the risk of **fluid overload, pulmonary edema**, and **abdominal compartment syndrome**. - Over-resuscitation can be as harmful as under-resuscitation in burn patients. *2 mL/kg × % TBSA* - This formula provides **grossly inadequate fluid resuscitation** for major burns in adults. - This represents only **half of the Parkland formula** requirement and would result in severe under-resuscitation. - Using this reduced volume could lead to **hypovolemic shock, renal failure**, and increased mortality.

Q: In the primary survey, which of the following is not included?

CECT to look for bleeding. ***CECT to look for bleeding*** - A **CECT scan** is a detailed imaging study that is performed during the **secondary survey**, not during the primary survey. - The primary survey focuses on the immediate **ABCDE assessment** (Airway, Breathing, Circulation, Disability, Exposure) to identify and treat immediately life-threatening conditions. - While identifying bleeding is critical, detailed imaging like CECT is done only after initial stabilization is achieved in the primary survey. *ABC* - **Airway, Breathing, and Circulation (ABC)** are the fundamental first three components of the primary survey. - These represent the immediate priorities for life support in trauma management according to ATLS guidelines. - Ensuring a patent airway, adequate breathing, and circulatory stability are critical first steps. *Exposure of the whole body* - **Exposure** (the "E" in ABCDE) is an essential part of the primary survey. - Complete exposure allows full assessment for injuries and prevents missing critical external wounds. - This step also involves maintaining **thermoregulation** to prevent hypothermia. *Recording BP* - **Recording blood pressure** is a crucial part of assessing circulation (the "C") during the primary survey. - It helps quickly evaluate hemodynamic status and identify potential signs of shock or internal bleeding. - Vital signs monitoring is integral to the initial trauma assessment.

Q: For open pneumothorax which of the following is management of choice?

ICD with underwater seal. ***ICD with underwater seal*** - An **intercostal drain (ICD)** with an **underwater seal** is the definitive management for an open pneumothorax once the initial wound has been covered. - This system allows air to escape the pleural space but prevents its re-entry, helping the lung to re-expand. *Wait and watch.* - This approach is suitable for very small, **stable spontaneous pneumothoraces** when the patient is asymptomatic, which is not the case for an open pneumothorax. - In an open pneumothorax, air continuously enters the pleural space, leading to **tension pneumothorax** and rapid deterioration if not addressed promptly. *Thoracostomy and close the rent* - **Thoracostomy** (creation of a surgical opening into the chest) might be part of the overall management, but simply closing the rent without addressing the underlying pneumothorax, often with a drain, is incomplete. - The immediate priority for an open pneumothorax is to convert it into a **closed pneumothorax** and then drain the air. *IPPV* - **Intermittent positive pressure ventilation (IPPV)** with a high enough pressure can worsen an open pneumothorax by forcing more air into the pleural space if the wound is not sealed. - While mechanical ventilation might be needed for respiratory failure, it's not the primary or sole management for the open pneumothorax itself and can be dangerous without proper sealing and drainage.

Q: First treatment of flail chest is

O2 administration and analgesia. ***O2 administration and analgesia*** - The immediate priority in flail chest is to ensure adequate **oxygenation** and manage pain to allow for effective ventilation and prevent respiratory compromise. - **Analgesia** helps reduce pain during breathing, improving tidal volume and reducing the risk of atelectasis and pneumonia. *Mechanical ventilation* - While mechanical ventilation may be necessary in cases of severe respiratory distress or failure, it is not the **first-line treatment** for all flail chest patients. - Its use is indicated if initial supportive measures like oxygen and analgesia fail, or if there's evidence of **respiratory acidosis** or persistent hypoxemia. *Intrapleural analgesia* - This is a form of advanced pain management and is typically not the initial step in treating flail chest. - While effective for pain control, it requires specific expertise and equipment, making it a **secondary intervention** after basic analgesia and oxygen. *Surgical stabilization* - Surgical stabilization of the fractured ribs is considered when there is significant chest wall deformity, persistent respiratory failure despite other treatments, or in cases of non-union. - It is an **elective procedure** and not the immediate first treatment for flail chest.

Q: Which among the following is the best method to assess adequacy of fluid resuscitation in a polytrauma patient:

Urine output. ***Urine output*** - **Urine output** is a direct and real-time reflection of **renal perfusion**, which is highly sensitive to changes in circulating blood volume and cardiac output in trauma patients. - Maintaining a urine output of **0.5-1 mL/kg/hr** is generally accepted as a key indicator of adequate fluid resuscitation and organ perfusion in polytrauma. *CVP* - **Central Venous Pressure (CVP)** can be influenced by multiple factors beyond fluid status, such as **intrathoracic pressure**, **venous tone**, and **right ventricular function**, making it an unreliable sole indicator. - While it offers some insight into preload, CVP measurements alone do not provide a direct and dynamic assessment of **end-organ perfusion** in trauma. *Pulse rate* - **Pulse rate** is a non-specific indicator that can be affected by pain, anxiety, medications, and other systemic responses beyond fluid status in polytrauma. - While **tachycardia** often suggests hypovolemia, a normal pulse rate does not guarantee adequate fluid resuscitation, especially in patients with compensatory mechanisms. *BP* - **Blood pressure (BP)** is a relatively late indicator of hypovolemia in trauma, as compensatory mechanisms can maintain BP near normal despite significant blood loss. - Relying solely on BP can lead to delayed recognition of **inadequate resuscitation** and potential end-organ damage.

Q: Which one of the following is a secondary brain injury?

Intracerebral haematoma with raised intracranial pressure. ***Intracerebral haematoma with raised intracranial pressure*** - **Intracerebral haematoma** is a potentially treatable, secondary injury directly contributing to **raised intracranial pressure (ICP)**, leading to further brain damage if not managed. - **Secondary brain injuries** occur minutes to days after the initial impact, resulting from a cascade of events like ischaemia, oedema, and intracranial hypertension. *Diffuse axonal injury* - **Diffuse axonal injury (DAI)** is a **primary brain injury** caused by shearing forces at the moment of impact. - It is a direct consequence of the initial trauma, not a subsequent physiological process. *Cortical lacerations* - **Cortical lacerations** are **primary injuries**, representing a direct tearing or cutting of brain tissue due to the initial traumatic force. - These are immediately present at the time of injury and are not a consequence of subsequent physiological changes. *Brainstem and hemispheric contusions* - **Contusions** are localised areas of bruising on the brain, characteristic of a **primary brain injury**, occurring directly from the impact. - While contusions can evolve and contribute to secondary injury mechanisms like oedema, the contusion itself is a direct result of the initial trauma.

Question 1

A 50 kg woman is brought to the emergency department with severe burns. It is estimated that partial thickness and full thickness burns (second and third degree) cover 60% of the total body surface area (TBSA). What is the rate of fluid resuscitation to be given in the first 8 hours?

Accepted Answer

750 ml/hr

Answer

1000 ml/hr

Answer

500 ml/hr

Answer

1250 ml/hr

Question 2

For the immediately life-threatening injuries of the chest "Flail chest", select the proper intervention (SELECT 1 INTERVENTION)

Accepted Answer

Endotracheal intubation

Answer

Tube thoracostomy

Answer

Subxiphoid window

Answer

Cricothyroidotomy

Question 3

In blunt trauma abdomen, maximum injury to the small bowel occurs at:

Accepted Answer

Proximal jejunum

Answer

Ileocecal junction

Answer

Proximal ileum

Answer

Mid ileum

Question 4

A patient presented with bleeding from thigh and broken 5th rib on right side. What should be done first:

Accepted Answer

Control bleeding

Answer

Strapping of chest

Answer

Internal fixation of rib

Answer

Wait & watch

Question 5

A 30-year-old female with a history of burns involving abdomen, both limbs, and back presented after 8 hours. Which of the following is the formula for calculation of fluid infusion:

Accepted Answer

4 mL/kg × % TBSA over 24 hours

Answer

3 mL/kg × % TBSA

Answer

5 mL/kg × % TBSA

Answer

2 mL/kg × % TBSA

Question 6

In the primary survey, which of the following is not included?

Accepted Answer

CECT to look for bleeding

Answer

ABC

Answer

Exposure of the whole body

Answer

Recording BP

Question 7

For open pneumothorax which of the following is management of choice?

Accepted Answer

ICD with underwater seal

Answer

IPPV

Answer

Wait and watch

Answer

Thoracostomy and close the rent

Question 8

First treatment of flail chest is

Accepted Answer

O2 administration and analgesia

Answer

Mechanical ventilation

Answer

Intrapleural analgesia

Answer

Surgical stabilization

Question 9

Which among the following is the best method to assess adequacy of fluid resuscitation in a polytrauma patient:

Accepted Answer

Urine output

Answer

CVP

Answer

Pulse rate

Answer

BP

Question 10

Which one of the following is a secondary brain injury?

Accepted Answer

Intracerebral haematoma with raised intracranial pressure

Answer

Diffuse axonal injury

Answer

Cortical lacerations

Answer

Brainstem and hemispheric contusions

Trauma — MCQs

Trauma — MCQs

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