Trauma Practice Questions

Q: The most important clinical finding in a case of head injury is -

Conscious level determined on Glasgow coma scale. ***Conscious level determined on Glasgow coma scale*** - The **Glasgow Coma Scale (GCS)** provides an objective, standardized assessment of neurological function, crucial for monitoring trends and predicting outcomes in head injury. - A deteriorating **GCS score** is the most sensitive indicator of worsening intracranial pathology and impending herniation. *Focal neurological deficit* - While significant, a **focal neurological deficit** indicates localized brain damage but does not always reflect the overall severity or the dynamic changes in intracranial pressure as comprehensively as the GCS. - Its presence is important for pinpointing the area of injury but less crucial for assessing global brain function and real-time deterioration. *Pupillary dilatation* - **Pupillary dilatation**, particularly if unilateral and unreactive, is a late sign of transtentorial herniation due to increased intracranial pressure. - It signifies a critical event but is not the "most important" clinical finding for continuous monitoring, as it appears after significant brain compromise has already occurred. *Fracture skull* - A **skull fracture** indicates trauma severity but does not directly correlate with the degree of brain injury. - Patients can have severe brain injury without a fracture, and a fracture can be present without significant brain parenchyma damage.

Q: A person after a pelvic fracture, could not pass urine. On examination bladder is not palpable. What is the probable diagnosis?

Extraperitoneal rupture of bladder. ***Extraperitoneal rupture of bladder*** - This typically occurs with **pelvic fractures**, especially pubic rami fractures, as the bony fragments can lacerate the bladder wall outside the peritoneum. - The inability to pass urine and a **non-palpable bladder** suggest that urine has escaped into the surrounding tissues, but not into the peritoneal cavity, and is not distending the bladder. *Intraperitoneal rupture of bladder* - Usually results from a **direct blow to a full bladder**, rather than a pelvic fracture, causing urine to spill into the peritoneal cavity. - While there would be an inability to pass urine, the bladder would likely be **distended and palpable** initially, or there would be signs of peritonitis. *Rectourethral injury* - This involves a tear between the rectum and the urethra, often associated with severe pelvic trauma. - While it causes an inability to void, the primary concern would be **fecal leakage into the urethra** or urinary leakage into the rectum, not necessarily a non-palpable bladder due to rupture into surrounding tissues. *Posterior urethra rupture with retention of urine* - A rupture of the posterior urethra, common with pelvic fractures, would indeed cause **retention of urine** and an inability to void. - However, in this scenario, the bladder would be **distended and palpable** above the symphysis pubis due to the retained urine, which contradicts the "non-palpable bladder" finding.

Q: Type of shock seen in burn cases:

Hypovolemic. ***Hypovolemic*** - Extensive burns lead to significant **fluid loss** from the damaged capillary beds and surface of the wound. - This loss of plasma and extravascular fluid reduces **intravascular volume**, leading to hypovolemic shock. *Neurogenic* - Neurogenic shock results from **spinal cord injury** causing loss of sympathetic tone and widespread vasodilation. - It is not directly caused by the tissue damage and fluid loss associated with burns. *Cardiogenic* - Cardiogenic shock occurs due to the **heart's inability to pump enough blood**, often from myocardial infarction or severe heart failure. - While burns can indirectly affect cardiac function, the primary shock mechanism is not cardiac pump failure itself. *None of the options* - This option is incorrect because **hypovolemic shock** is a well-established and common type of shock observed in burn cases.

Q: What is to be addressed first in case of polytrauma -

Airway. ***Airway*** - Maintaining a **patent airway** is the absolute first priority in polytrauma management according to the **ATLS (Advanced Trauma Life Support)** protocol. - Failure to secure an airway can lead to **hypoxia** and **brain damage** within minutes, regardless of other injuries. *Circulation* - While critical, addressing **circulation** (C in ABCDE) comes after establishing a secure airway and adequate breathing (A and B). - Uncontrolled hemorrhage would be the focus of circulation management, but only after guaranteeing proper oxygenation. *Neurology* - Neurological assessment (D in ABCDE for Disability) follows the primary survey of airway, breathing, and circulation. - Initial neurological evaluation focuses on **level of consciousness** using the **GCS (Glasgow Coma Scale)**. *Blood Pressure* - **Blood pressure** is an indicator of circulatory status but is not the first thing to be addressed. - It falls under the "C" for circulation in the ATLS protocol, which is secondary to airway and breathing.

Q: In adults, circulatory collapse occurs after a minimum of what percentage burns of total body surface area: NIMHANS 08; TN 11

20%. ***20%*** - In adults, **circulatory collapse** (hypovolemic shock) in burn patients typically occurs when burns involve **20% or more** of the total body surface area (TBSA). - This is the established threshold in burn classification where burns are considered **major** and require formal fluid resuscitation protocols. - The **Parkland formula** (4 mL × kg × %TBSA) for fluid resuscitation is typically applied for burns **≥20% TBSA** because this level of injury causes significant **capillary permeability** and plasma extravasation leading to hypovolemic shock. - Burns ≥20% TBSA have high risk of **burn shock** if not adequately resuscitated. *15%* - While 15% TBSA burns cause significant fluid shifts and require close monitoring with IV fluid administration, this is generally **below the threshold** for overt circulatory collapse in adults. - Burns of 10-20% TBSA are classified as **moderate burns** and typically do not progress to frank hypovolemic shock with appropriate management. - The critical threshold for **circulatory collapse** is considered to be **20% TBSA**. *10%* - A 10% TBSA burn in an adult causes fluid shifts but is generally well-tolerated and is **below the threshold** for circulatory collapse. - Burns 10-20% TBSA are classified as **moderate** and may require some IV fluids but typically don't cause hemodynamic instability. - **Minor burns** (<10% in adults) are often managed with oral hydration alone. *5%* - A 5% TBSA burn would **not lead to circulatory collapse** in an adult, as compensatory mechanisms easily manage this level of fluid loss. - This is considered a **minor burn** requiring only local wound care and oral hydration. - Fluid shifts are minimal and insufficient to cause **hemodynamic instability** in healthy adults.

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: 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.

Question 1

The most important clinical finding in a case of head injury is -

Accepted Answer

Conscious level determined on Glasgow coma scale

Answer

Focal neurological deficit

Answer

Pupillary dilatation

Answer

Fracture skull

Question 2

A person after a pelvic fracture, could not pass urine. On examination bladder is not palpable. What is the probable diagnosis?

Accepted Answer

Extraperitoneal rupture of bladder

Answer

Intraperitoneal rupture of bladder

Answer

Rectourethral injury

Answer

Posterior urethra rupture with retention of urine

Question 3

Type of shock seen in burn cases:

Accepted Answer

Hypovolemic

Answer

Neurogenic

Answer

Cardiogenic

Answer

None of the options

Question 4

What is to be addressed first in case of polytrauma -

Accepted Answer

Airway

Answer

Circulation

Answer

Neurology

Answer

Blood Pressure

Question 5

In adults, circulatory collapse occurs after a minimum of what percentage burns of total body surface area: NIMHANS 08; TN 11

Accepted Answer

20%

Answer

5%

Answer

15%

Answer

10%

Question 6

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 7

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 8

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 9

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 10

Best diagnostic aid in blunt trauma abdomen is -

Accepted Answer

Ultrasound

Answer

Peritoneal lavage

Answer

4 quadrant aspiration

Answer

CT scan

Trauma — MCQs

Trauma — MCQs

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