Trauma — MCQs
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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
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 :
A man falls astride a penetrating object. He develops retention of urine, perineal hematoma and bleeding from urinary meatus. The nature of injury would be
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?
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:
In a male patient of road traffic accident with blood at the tip of external meatus, the likely injury is:
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:
Which one of the following regarding management of acute wounds is NOT true?
Mainstay of an accurate diagnosis of pancreatic injury following blunt abdominal trauma is:
Untidy wounds are characterised by which of the following? 1. Crushed or avulsed tissues 2. Contaminated wound 3. Devitalised tissue 4. No loss of tissue
Trauma Indian Medical PG Practice Questions and MCQs
Question 771: 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
- A. Insertion of an intrathoracic drain
- B. Stabilisation of fractured ribs with towel clips
- C. Immediate operative stabilisation (Correct Answer)
- D. Tracheostomy, mechanical ventilation and positive end-expiratory pressure ventilation
Explanation: ***Immediate operative stabilisation*** - The patient has **flail chest** (paradoxical chest wall movement with multiple rib fractures) with a **large pulmonary contusion**, indicating significant chest wall instability and underlying lung injury. - **Modern evidence-based management** favors **early surgical fixation (ORIF - Open Reduction Internal Fixation)** of flail chest, particularly when associated with large pulmonary contusions, as it: - **Restores chest wall stability** mechanically, eliminating paradoxical movement - **Reduces ventilator dependence** and ICU stay compared to conservative management - **Improves pulmonary function** and reduces pulmonary complications - **Decreases need for mechanical ventilation** and associated complications - Current **AAST (American Association for Surgery of Trauma) and EAST (Eastern Association for Surgery of Trauma) guidelines** support surgical stabilization for flail chest with significant chest wall instability. - Given stable vitals, the patient can undergo operative stabilization safely, providing definitive treatment. *Tracheostomy, mechanical ventilation and positive end-expiratory pressure ventilation* - This represents **outdated management** from the 1970s-1980s when mechanical ventilation was considered "internal pneumatic stabilization." - **Modern practice avoids routine prophylactic intubation** in stable patients with flail chest due to: - Increased risk of ventilator-associated pneumonia (VAP) - Prolonged ICU stays and morbidity - Better outcomes with conservative management or surgical fixation - Mechanical ventilation is reserved for patients developing **respiratory failure**, not as first-line treatment in stable patients. - **Tracheostomy** is particularly inappropriate as initial management. *Insertion of an intrathoracic drain* - This is indicated for **pneumothorax or hemothorax**, both of which are **explicitly absent** on the chest X-ray. - Does not address the fundamental problem of chest wall instability and flail segment. *Stabilisation of fractured ribs with towel clips* - **Obsolete technique** involving external fixation with high infection risk and poor efficacy. - Has been abandoned in modern trauma care in favor of internal fixation when surgical stabilization is indicated.
Question 772: 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 :
- A. 1 and 2 only
- B. 3 and 4 only
- C. 1, 2 and 3 only
- D. 1, 2, 3 and 4 (Correct Answer)
Explanation: ***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.
Question 773: A man falls astride a penetrating object. He develops retention of urine, perineal hematoma and bleeding from urinary meatus. The nature of injury would be
- A. intraperitoneal rupture of bladder
- B. rupture of bulbar urethra (Correct Answer)
- C. rupture of membranous urethra
- D. extraperitoneal rupture of bladder
Explanation: ***Rupture of bulbar urethra*** - An injury from falling astride a penetrating object, causing symptoms like **retention of urine**, **perineal hematoma**, and **bleeding from the urinary meatus**, is highly indicative of a **bulbar urethral rupture**. - The **bulbar urethra** is particularly vulnerable to crush injuries against the **pubic symphysis** in astride falls, leading to extravasation of urine and blood into the perineum. *Intraperitoneal rupture of bladder* - This typically occurs from a **direct blow to the lower abdomen** when the bladder is full, resulting in release of urine into the **peritoneal cavity**. - Symptoms would include generalized **abdominal pain**, **rebound tenderness**, and **peritonitis-like signs**, rather than localized perineal hematoma. *Rupture of membranous urethra* - A rupture of the **membranous urethra** is typically associated with **pelvic fractures** and is usually **above the urogenital diaphragm**. - While it can cause hematoma, the extravasation of urine and blood would more commonly track into the **retropubic space** and potentially the anterior abdominal wall, not primarily the perineum. *Extraperitoneal rupture of bladder* - This often results from **pelvic fractures** and is characterized by urine leaking into the **prevesical space**. - Symptoms include **suprapubic pain** and tenderness, but a perineal hematoma and meatal bleeding are less typical in isolation for this type of injury.
Question 774: 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?
- A. 2 and 4 only
- B. 1, 2, 3 and 4
- C. 2, 3 and 4 only (Correct Answer)
- D. 1, 2 and 3 only
Explanation: ***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
Question 775: 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:
- A. Tension pneumothorax
- B. Subcutaneous emphysema
- C. Haemothorax (Correct Answer)
- D. Tracheal rupture
Explanation: **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.
Question 776: In a male patient of road traffic accident with blood at the tip of external meatus, the likely injury is:
- A. Injury to urinary bladder
- B. Injury to kidney
- C. Injury to urethra (Correct Answer)
- D. Injury to all of these
Explanation: ***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.
Question 777: 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:
- A. Apply some superficial ointment for it to subside
- B. Incise or aspirate the haematoma (Correct Answer)
- C. Get a CECT or MRI done
- D. Leave it alone
Explanation: ***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.
Question 778: Which one of the following regarding management of acute wounds is NOT true?
- A. Wounds should be examined, taking into consideration site and structures damaged
- B. Bleeding wounds should be elevated and a pressure pad applied
- C. The whole patient should be examined according to ATLS principles
- D. Clamps should be used to stop all bleeding vessels (Correct Answer)
Explanation: ***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.
Question 779: Mainstay of an accurate diagnosis of pancreatic injury following blunt abdominal trauma is:
- A. USG abdomen
- B. MRI abdomen
- C. Computed Tomogram (Correct Answer)
- D. Diagnostic peritoneal lavage
Explanation: ***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 780: Untidy wounds are characterised by which of the following? 1. Crushed or avulsed tissues 2. Contaminated wound 3. Devitalised tissue 4. No loss of tissue
- A. 1, 2, 3 and 4
- B. 1, 2 and 4
- C. 1, 2 and 3 (Correct Answer)
- D. 2, 3 and 4
Explanation: ***1, 2 and 3*** - **Untidy wounds**, often resulting from high-energy trauma, are defined by the presence of **crushed or avulsed tissues**, **contamination**, and **devitalized tissue**. - These characteristics make the wound more complex to manage and prone to complications like infection. *1, 2, 3 and 4* - This option incorrectly includes "no loss of tissue" (option 4) as a characteristic of untidy wounds. **Untidy wounds** frequently involve **tissue loss**, making this statement contradictory to their definition. - The presence of **crushed or avulsed tissues** inherently suggests some degree of tissue damage or loss. *1, 2 and 4* - This option incorrectly states that "no loss of tissue" is a characteristic of untidy wounds. In reality, **untidy wounds** are often associated with significant **tissue destruction and loss**. - **Crushed and avulsed tissues** are direct indicators of tissue damage and potential loss. *2, 3 and 4* - This option incorrectly omits "crushed or avulsed tissues" (option 1), which is a cardinal feature of untidy wounds. It also incorrectly includes "no loss of tissue" (option 4). - While **contamination** and **devitalized tissue** are hallmarks of untidy wounds, the absence of crushed/avulsed tissue and the idea of no tissue loss are inaccurate.
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Initial Assessment of Trauma Patient
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Advanced Trauma Life Support (ATLS) Principles
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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
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