Trauma Practice Questions

Q: A person had an accident and came to casualty with contusion on left precordium. There was decrease in breath sounds on left side, trachea deviated to right side and normal heart sounds. Which of the following is the first line of management?

Needle thoracocentesis. ***Needle thoracocentesis*** - The constellation of **decreased breath sounds** on the left, **tracheal deviation** to the right, and a history of trauma indicates a **tension pneumothorax**. - **Needle decompression** (thoracocentesis) is the immediate, life-saving intervention for tension pneumothorax to relieve pressure and restore cardiorespiratory function. *Chest tube thoracostomy* - While a **chest tube** (tube thoracostomy) is the definitive treatment for pneumothorax, it is not the *first-line* **emergency management** for a **tension pneumothorax** where immediate decompression is critical. - The delay in setting up and inserting a chest tube can be fatal in a **tension pneumothorax**. *Pericardiocentesis* - **Pericardiocentesis** is indicated for **cardiac tamponade**, which would typically present with muffled heart sounds, hypotension, and distended neck veins, none of which are noted here. - The presence of **tracheal deviation** and **decreased breath sounds** specifically points away from isolated cardiac tamponade. *Open surgery* - **Open surgery (thoracotomy)** is a major surgical procedure reserved for cases like massive hemorrhage or major airway injury, and not the initial rapid management for a tension pneumothorax. - Performing open surgery directly for a tension pneumothorax would be too slow and inappropriate as an initial intervention.

Q: A 19-year-old man is brought into the emergency department with a gunshot wound that occurred 4 hours before admission. At exploratory laparotomy, an injury is noted in the transverse colon with extensive tissue destruction. There is a large amount of fecal contamination. Management of this injury should include which of the following?

Resection with proximal colostomy and distal mucous fistula. ***Resection with proximal colostomy and distal mucous fistula*** - Extensive **tissue destruction** and significant **fecal contamination** in a gunshot wound to the colon necessitate diversion to prevent peritonitis and sepsis. - A **proximal colostomy** diverts the fecal stream, and a **distal mucous fistula** allows drainage of the distal segment, preventing a closed-loop obstruction and reducing the risk of anastomotic leak if a primary repair were attempted under septic conditions. *Resection of the wound with primary anastomosis and proximal cecostomy* - **Primary anastomosis** in the setting of extensive tissue destruction and heavy fecal contamination carries a high risk of **anastomotic leak** and peritonitis. - A **cecostomy** is generally insufficient for complete diversion of the fecal stream when dealing with injuries to the transverse colon or beyond. *Debridement and closure of wound with a proximal colostomy* - **Debridement and primary closure** are inadequate for extensive tissue destruction caused by a gunshot wound, as devitalized tissue will likely lead to breakdown and leak. - While a **proximal colostomy** provides diversion, inadequate management of the injury itself is prone to failure and complications. *Resection of the injured colon with primary anastomosis and proximal colostomy* - Although **resection** addresses the damaged tissue, performing a **primary anastomosis** in the presence of extensive **fecal contamination** significantly increases the risk of **anastomotic leak**. - A **proximal colostomy** would provide diversion, but the retained anastomosis remains a high-risk factor in this contaminated field.

Q: Commonest cause of death in penetrating injury of chest -

Cardiac and great vessel injury. ***Cardiac and great vessel injury*** - **Cardiac and great vessel injuries** are the most common cause of death in penetrating chest trauma, accounting for the majority of immediate fatalities. - Injuries to the **heart** (ventricles, atria), **aorta**, **pulmonary artery**, and **vena cava** lead to rapid **exsanguination** and **cardiac tamponade**. - Most patients with these injuries die at the scene or within minutes of arrival to the hospital due to massive hemorrhage and hemodynamic collapse. - Emergency **resuscitative thoracotomy** may be required but has limited success in severe cardiac/great vessel trauma. *Pulmonary laceration* - While **pulmonary lacerations** are common in penetrating chest injuries, they are often manageable with tube thoracostomy. - Most pulmonary injuries stop bleeding spontaneously due to the low-pressure pulmonary circulation. - Massive hemorrhage from pulmonary injuries is less common than from cardiac or great vessel injuries. *Oesophageal rupture* - **Oesophageal rupture** is relatively rare in penetrating chest trauma and typically presents with mediastinitis rather than immediate death. - Death from oesophageal rupture usually occurs later due to **sepsis** and multi-organ failure, not immediate exsanguination. *Tracheobronchial injury* - **Tracheobronchial injuries** are uncommon in penetrating chest trauma and often present with **tension pneumothorax** or persistent air leak. - While life-threatening, these injuries allow more time for intervention compared to cardiac/great vessel injuries.

Q: Hemostasis in scalp wound is best achieved by -

Direct pressure over the wound. ***Direct pressure over the wound*** - Initial and most effective method for immediate **hemostasis** in scalp wounds due to the rich vascular supply and the ability to compress vessels against the underlying bone. - Applying **firm, sustained pressure** directly to the bleeding site helps to tamponade the vessels and promote clot formation. *Catching and crushing the bleeders by hemostats* - While hemostats can be used for individual vessels, it is often impractical and time-consuming for the numerous small vessels in a scalp wound and can cause **tissue damage**. - This method is typically reserved for **identified, larger arterial bleeders** once initial control has been achieved. *Coagulation of bleeders* - **Electrocautery** can be effective for smaller bleeders but risks **thermal injury** to surrounding tissues of the scalp, which has a relatively thin overlying skin. - It is often used after direct pressure has controlled the bulk of the bleeding and individual vessels need precise control. *Eversion of galea aponeurotica* - **Eversion of the galea** is a technique used during wound closure to ensure proper anatomical apposition, but it does not directly achieve hemostasis. - This step is for facilitating wound closure and preventing dead space rather than immediate bleeding control.

Q: Battle's sign is:

Ecchymosis in the mastoid region. **Ecchymosis in the mastoid region** - **Battle's sign** refers to **retroauricular ecchymosis**, appearing as bruising over the mastoid process, typically seen hours to days after a **basilar skull fracture**. - It is caused by the extravasation of blood from the fracture site into the tissues overlying the mastoid bone, often indicative of a fracture extending into the **posterior cranial fossa**. *Sub-lingual ecchymosis* - While any ecchymosis indicates bleeding, **sub-lingual ecchymosis** is not specifically referred to as Battle's sign and is not a typical indicator of a basilar skull fracture. - It could be seen in various other conditions but lacks the diagnostic specificity of mastoid ecchymosis for head trauma. *Sub-conjunctival ecchymosis* - This involves bleeding under the conjunctiva of the eye, often referred to as a **sub-conjunctival hemorrhage**. - While ocular manifestations can occur with head trauma (e.g., **raccoon eyes**), **sub-conjunctival ecchymosis** alone is not Battle's sign. *Palatal ecchymosis* - **Palatal ecchymosis** refers to bruising on the roof of the mouth. - This is not a recognized sign of a basilar skull fracture and is not known as Battle's sign.

Q: Superficial partial thickness burn is caused due to involvement of:

Papillary dermis. ***Papillary dermis*** - **Superficial partial thickness burns** involve the epidermis and the superficial portion of the **dermis**, specifically the **papillary dermis**. - This type of burn typically presents with **blisters**, severe pain, and a moist, red appearance, and generally heals without scarring within 2-3 weeks. *Dermis* - This option is too broad; while the dermis is involved, superficial partial thickness burns only affect a specific layer of it, not the entire dermis. - Deeper burns, such as **deep partial thickness** or **full thickness burns**, involve more significant portions of the dermis. *Reticular dermis* - Involvement of the **reticular dermis** indicates a **deep partial thickness burn**, which is more severe than a superficial partial thickness burn. - These burns often appear pale or waxy, have reduced sensation, and are associated with a higher risk of scarring. *Epidermis* - Involvement of only the epidermis characterizes a **superficial burn** (first-degree burn), which presents as redness and pain without blistering. - Superficial burns do not involve the dermis and heal quickly without complications.

Q: Which is not true regarding compartment syndrome?

Intracompartmental pressure studies are required. ***Intracompartmental pressure studies are required*** - While **intracompartmental pressure studies** can confirm the diagnosis, the cardinal symptoms of compartment syndrome, such as severe pain disproportionate to injury, pain on passive stretch, and tense swelling, often make the diagnosis clinically. - The decision to perform a **fasciotomy** is primarily based on clinical findings and the severity of symptoms, with pressure measurements serving as supportive evidence, especially in equivocal cases or in uncooperative patients. *Common in soft-tissue crush injury* - **Crush injuries** frequently lead to muscle swelling and hemorrhage within a confined fascial compartment, significantly increasing the risk of compartment syndrome. - The extensive tissue damage and subsequent inflammatory response contribute to a rapid rise in **intracompartmental pressure**. *Pain on passive stretch of the muscles is characteristic* - **Severe pain with passive stretching** of the muscles within the affected compartment is a highly sensitive and often the earliest reliable sign of compartment syndrome. - This pain arises from **ischemia** and pressure on nerve endings as the muscle is stretched. *Common in a closed fracture* - **Closed fractures** are a very common cause of compartment syndrome, particularly in the tibia and forearm, due to bleeding and swelling within the rigid fascial compartment. - The intact skin prevents external decompression, causing **pressure buildup internally** that can compromise blood flow to muscles and nerves.

Q: Most common complication of skull injury is:

Hematoma.. ***Hematoma*** - **Hematomas** (epidural, subdural, intracerebral) are a very common and often immediate complication of skull injuries due to the trauma to blood vessels within or around the brain. - They can lead to increased **intracranial pressure** and brain damage if not promptly managed. *CSF rhinorrhea* - **CSF rhinorrhea** indicates a dural tear and leakage of cerebrospinal fluid through the nose, which is a significant but less universally common complication than hematomas. - While it can occur, not all skull injuries result in a **dural tear** leading to CSF leakage. *Meningitis* - **Meningitis** is an infection of the meninges, which is a serious but relatively less common and *delayed* complication of skull injuries, usually occurring after a breach of the dura (e.g., from CSF leakage or open skull fracture). - It is not an immediate or directly mechanical complication like bleeding. *All of the options* - While all listed conditions can be complications of skull injury, **hematoma** is the most *common* and often immediate sequela. - **CSF rhinorrhea** and **meningitis** are important but occur less frequently than hematomas.

Q: A patient with abdominal injury presents to the emergency department with signs of peritonitis and shock. Airway and breathing were secured and IV fluids were started with 2 large bore cannulas. The next line of management should be

Exploratory Laparotomy under general anesthesia. ***Exploratory Laparotomy under general anesthesia*** - The presence of **peritonitis** and **shock** following abdominal injury indicates a **life-threatening intra-abdominal injury** requiring immediate surgical intervention. - An **exploratory laparotomy** allows for direct visualization, control of hemorrhage, repair of organ damage, and addressing the source of peritonitis. *Laparoscopy* - While minimally invasive, laparoscopy is often **contraindicated in hemodynamically unstable patients** or those with diffuse peritonitis due to the risk of exacerbating shock and limited access. - It is also generally **more time-consuming** than a laparotomy in acute trauma settings, delaying definitive treatment. *Insertion of abdominal drain followed by laparotomy* - **Insertion of an abdominal drain** in the context of peritonitis and shock is insufficient and inappropriate as a primary measure. - A drain cannot address active bleeding, repair visceral perforation, or adequately decontaminate the peritoneal cavity, thus **delaying definitive surgical treatment**. *FAST* - **Focused Assessment with Sonography for Trauma (FAST)** is a diagnostic tool used to detect free fluid (blood) in the abdomen or pericardium. - While useful for initial assessment, a **positive FAST scan in an unstable patient** with peritonitis necessitates immediate surgical intervention, not further diagnostic delay.

Q: Lucid interval is classically seen in-

Extradural hematoma. ***Extradural hematoma*** - A **lucid interval** is a hallmark finding in **extradural (epidural) hematoma**, where a period of consciousness follows an initial loss of consciousness after head injury, before neurological deterioration. - This occurs because the initial impact causes temporary brain dysfunction, followed by a period where the patient appears normal while the **arterial bleed** (often from the middle meningeal artery) slowly expands, eventually compressing the brain. *Acute subdural hematoma* - While a decrease in the level of consciousness is expected, a **lucid interval** is less common in acute subdural hematoma due to the often immediate and continuous compression from a **venous bleed**. - Symptoms typically progress without a clear period of normalcy, though fluctuations can occur. *Chronic subdural hematoma* - A **lucid interval** is not characteristic of chronic subdural hematoma, which usually presents with subtle or progressive neurological symptoms over weeks to months as the venous bleed slowly accumulates. - Symptoms are often insidious and can include headache, confusion, or weakness without an initial acute injury followed by a period of lucidity. *Intraventricular hemorrhage* - **Intraventricular hemorrhage** involves bleeding directly into the brain's ventricular system and typically presents with sudden onset of severe headache, nausea, altered consciousness, and signs of increased intracranial pressure. - A **lucid interval** is not associated with this type of hemorrhage due to the immediate and significant impact on brain function.

Question 1

A person had an accident and came to casualty with contusion on left precordium. There was decrease in breath sounds on left side, trachea deviated to right side and normal heart sounds. Which of the following is the first line of management?

Accepted Answer

Needle thoracocentesis

Answer

Chest tube thoracostomy

Answer

Pericardiocentesis

Answer

Open surgery

Question 2

A 19-year-old man is brought into the emergency department with a gunshot wound that occurred 4 hours before admission. At exploratory laparotomy, an injury is noted in the transverse colon with extensive tissue destruction. There is a large amount of fecal contamination. Management of this injury should include which of the following?

Accepted Answer

Resection with proximal colostomy and distal mucous fistula

Answer

Resection of the wound with primary anastomosis and proximal cecostomy

Answer

Debridement and closure of wound with a proximal colostomy

Answer

Resection of the injured colon with primary anastomosis and proximal colostomy

Question 3

Commonest cause of death in penetrating injury of chest -

Accepted Answer

Cardiac and great vessel injury

Answer

Oesophageal rupture

Answer

Pulmonary laceration

Answer

Tracheobronchial injury

Question 4

Hemostasis in scalp wound is best achieved by -

Accepted Answer

Direct pressure over the wound

Answer

Catching and crushing the bleeders by hemostats

Answer

Coagulation of bleeders

Answer

Eversion of galea aponeurotica

Question 5

Battle's sign is:

Accepted Answer

Ecchymosis in the mastoid region

Answer

Sub-lingual ecchymosis

Answer

Sub-conjunctival ecchymosis

Answer

Palatal ecchymosis

Question 6

Superficial partial thickness burn is caused due to involvement of:

Accepted Answer

Papillary dermis

Answer

Dermis

Answer

Reticular dermis

Answer

Epidermis

Question 7

Which is not true regarding compartment syndrome?

Accepted Answer

Intracompartmental pressure studies are required

Answer

Common in soft-tissue crush injury

Answer

Common in a closed fracture

Answer

Pain on passive stretch of the muscles is characteristic

Question 8

Most common complication of skull injury is:

Accepted Answer

Hematoma.

Answer

CSF rhinorrhea.

Answer

Meningitis.

Answer

All of the options.

Question 9

A patient with abdominal injury presents to the emergency department with signs of peritonitis and shock. Airway and breathing were secured and IV fluids were started with 2 large bore cannulas. The next line of management should be

Accepted Answer

Exploratory Laparotomy under general anesthesia

Answer

Laparoscopy

Answer

Insertion of abdominal drain followed by laparotomy

Answer

FAST

Question 10

Lucid interval is classically seen in-

Accepted Answer

Extradural hematoma

Answer

Acute subdural hematoma

Answer

Chronic subdural hematoma

Answer

Intraventricular hemorrhage

Trauma — MCQs

Trauma — MCQs

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