Trauma Practice Questions

Q: A 25-year-old man is brought to the emergency department by ambulance after falling 20 ft from a ladder. He was placed on a backboard for spinal stabilization. Intravenous access was obtained en route, and he received infusion of crystalloids. The patient is unconscious upon arrival. His blood pressure is 91/44 mm Hg, pulse is 129/min, and respirations are 8/min. Pulse oximetry is at 85%. Evaluation shows several superficial facial lacerations, a depressed temporal skull fracture, and a forearm fracture. There are no periorbital or periauricular hematomas, and there is no significant neck edema. Which of the following is the most appropriate next step in management of this patient?

Orotracheal intubation. ***Orotracheal intubation*** - This patient is **unconscious**, has a traumatic brain injury (depressed temporal skull fracture), and is experiencing **respiratory depression** (respirations 8/min, SpO2 85%). This indicates a need for **definitive airway management**. - **Orotracheal intubation** using an **RSI (rapid sequence intubation)** approach with **manual in-line stabilization** of the cervical spine is the preferred method for airway control in trauma patients with suspected cervical spine injury. *Nasotracheal intubation* - This method is **contraindicated** in patients with suspected **basilar skull fracture** or **midface trauma**, which is a concern given the depressed temporal skull fracture. - It also carries a higher risk of **epistaxis** and can be more difficult to perform in an emergency setting. *Needle cricothyroidotomy* - This is primarily used as a **rescue airway** when intubation is impossible or has failed (a "cannot ventilate, cannot intubate" scenario). - While it provides an airway, it is not the **definitive method of choice** when orotracheal intubation is feasible. *Laryngeal mask placement* - A laryngeal mask airway (LMA) is a **supraglottic airway device** that does not protect the airway from aspiration as effectively as an endotracheal tube. - It is generally not recommended for patients with **head trauma** or those at high risk of aspiration, and it is not a definitive airway solution for prolonged ventilation.

Q: You evaluate an 18 yrs old male who sustained a right sided cervical laceration during a gang fight. Which of the following is a relative rather than an absolute indication for neck exploration?

Pneumothorax. ***Pneumothorax*** - A pneumothorax, while concerning, can often be managed with a **chest tube** insertion without immediate surgical exploration, making it a relative indication. - Its presence suggests potential compromise to structures in the neck/chest but doesn't always mandate direct surgical wound exploration as a first step. *Dysphonia* - **Hoarseness or difficulty speaking** after a neck injury suggests potential direct laryngeal, tracheal, or recurrent laryngeal nerve injury, warranting exploration to assess and repair. - This symptom implies a direct compromise of the **airway or critical nerves**, making exploration more immediate. *Expanding hematoma* - An **expanding hematoma** indicates active, potentially life-threatening bleeding and/or mass effect, which can compromise the airway or blood supply to the brain. - This is an **absolute indication for immediate surgical exploration** to control hemorrhage and prevent airway obstruction. *Dysphagia* - **Difficulty swallowing** post-neck trauma suggests injury to the pharynx or esophagus. - Such injuries carry a significant risk of **mediastinitis** or sepsis if not promptly identified and repaired via surgical exploration.

Q: In a patient with head injury, eye opening is seen with painful stimulus, localizes the pain and there is inappropriate verbal response. What would be the score on Glasgow coma scale:

10. ***10*** - **Eye Opening (E)**: **2** (due to painful stimulus) - **Verbal Response (V)**: **3** (due to inappropriate verbal response) - **Motor Response (M)**: **5** (due to localizing pain) - The total GCS score is calculated by summing these individual scores: 2 + 3 + 5 = **10**. *9* - This score might arise from different combinations, for instance, if the motor response was only withdrawal from pain instead of localization. - Withdrawal from pain for motor response is rated as **4**, making total score 2+3+4 = 9 *8* - This score could result from even lower responses, such as eye opening to pain (2), incomprehensible sounds (2), and withdrawal from pain (4). - This might reflect more severe neurological impairment. *11* - A score of 11 would imply better responses in one or more categories. For example in eye opening, verbal or motor response respectively. - Example: Eye opening to pain (2) + Confused conversation (4) + Localizing pain (5) = 11.

Q: A driver wearing a seat belt applied brakes suddenly to avoid an accident. What is the most common structure injured in seat belt injury?

Mesentery. ***Mesentery*** - The **mesentery** is the most commonly injured structure in a seat belt injury due to the shearing forces exerted across the abdomen during sudden deceleration. - The seat belt creates a focal point of pressure, leading to avulsion or tear injuries of the mesentery and its contained vessels, often resulting in **hemorrhage** and **bowel ischemia**. - While the mesentery is a peritoneal fold (not a solid organ), it is frequently damaged alongside **hollow viscus injuries** (small bowel/colon) in seat belt syndrome. *Spleen* - While the spleen can be injured in blunt abdominal trauma, it is more commonly associated with direct impact to the **left upper quadrant** rather than the compressive forces of a seat belt across the midline abdomen. - Splenic injury would typically present with symptoms related to significant blood loss and **left upper quadrant pain**. *Liver* - The liver, situated in the **right upper quadrant**, can be injured in blunt abdominal trauma but is less frequently damaged than mesentery in classic seat belt injuries. - Liver injuries often result from direct impact or deceleration forces causing parenchymal tears or hematomas, typically presenting with **right upper quadrant pain**. *Abdominal aorta* - Traumatic injury to the abdominal aorta is a **rare but highly lethal** complication of severe deceleration trauma. - While possible, it is far less common than mesenteric injury in seat belt-related trauma and usually requires extreme force, leading to **severe internal bleeding** and shock.

Q: A 30-year-old woman involved in a car crash is brought into the emergency department. Her blood pressure is 90/60 mm Hg, pulse rate is 120 bpm, and respiration rate is 18 breaths per minute. On peritoneal lavage, she is noted to have free blood in the peritoneal cavity. At the time of exploratory laparotomy, a liver laceration is noted, and there is a 2.5-cm-diameter contusion to an area of small bowel. How should the small-bowel contusion be treated?

Resection of the bowel with single-layer anastomosis. ***Resection of the bowel with single-layer anastomosis*** - A **2.5-cm contusion** of small bowel represents significant trauma with risk of **transmural injury and delayed perforation** - The standard approach is **resection of the involved segment** with **primary anastomosis** - Small bowel has **excellent blood supply** and heals well even in trauma settings - **Primary anastomosis** is safe in small bowel injuries unless there is massive peritoneal contamination, multiple injuries requiring damage control, or the patient is in extremis requiring abbreviated laparotomy - This patient, though hypotensive, is stable enough for formal laparotomy and definitive repair *Resection of the bowel and ileostomy* - **Ileostomy** is reserved for more severe scenarios: extensive bowel destruction, massive contamination, colon injuries in unstable patients, or damage control situations - For a **localized small bowel contusion**, creating an ileostomy is unnecessarily morbid - Small bowel anastomoses have high success rates even in emergency settings *Transillumination evaluation of hematoma with meticulous hemostasis* - This conservative approach might be considered for **very minor serosal contusions** (<1 cm) in stable patients - A **2.5-cm contusion** is too large to observe safely due to high risk of **delayed perforation** (can occur 24-72 hours post-injury) - Transillumination helps assess bowel viability but doesn't eliminate perforation risk from significant contusions *Inversion of the area of contusion with a row of fine nonabsorbable mattress sutures* - **Inverting sutures** are an outdated technique that can cause **stricture formation** and don't address potential transmural injury - This approach doesn't remove potentially devitalized tissue and creates a weak point prone to perforation - Modern trauma surgery principles favor resection over repair attempts for significant contusions

Q: In burn management, which of the following is least useful?

Blood. ***Blood*** - **Blood transfusions** are generally not indicated in the initial resuscitation phase of burn management, as the primary fluid loss is plasma, not whole blood. - They may be considered later for significant **anemia** or ongoing hemorrhage, but not as part of the initial fluid resuscitation. - Blood is the **least useful** among the given options for burn fluid management. *Dextran* - **Dextran** is a colloid that can be used for fluid resuscitation in burn patients. - However, it carries a risk of **anaphylaxis**, renal failure, and can interfere with coagulation, making it less favorable than crystalloids for initial fluid replacement. - Modern burn protocols rarely use dextran due to these complications. *Normal saline* - **Normal saline (0.9% NaCl)** is a crystalloid solution commonly used for fluid resuscitation, including in burn patients. - While effective, it can lead to **hyperchloremic acidosis** if used in very large volumes because its chloride content is higher than plasma. - It is acceptable but not the preferred crystalloid for burn resuscitation. *Ringer's lactate* - **Ringer's lactate** is considered the **preferred crystalloid** for initial fluid resuscitation in burn patients. - Its **electrolyte composition** is closer to that of plasma, reducing the risk of hyperchloremic acidosis compared to normal saline. - Used in the **Parkland formula** (4 mL/kg/%TBSA) for calculating burn resuscitation fluid requirements.

Q: Type of injury in which there is brief temporary physiological paralysis of function without organic structural damage is:

Concussion.. ***Concussion*** - A **concussion** is defined as a brief, temporary **physiological paralysis of function**, specifically describing a type of **mild traumatic brain injury**. - It involves no **organic structural damage** observable on standard imaging, differentiating it from more severe injuries. *Laceration* - A **laceration** is a **tear or cut in the tissue**, indicating a clear disruption of anatomical structure. - This involves **visible structural damage**, contradicting the definition of temporary physiological paralysis without such damage. *Contusion* - A **contusion** is a **bruise**, which involves **damage to blood vessels** and tissues, leading to bleeding under the skin or within organs. - While it may cause temporary functional impairment due to swelling and pain, it signifies **detectable organic damage** (e.g., hematoma). *None of the options* - This option is incorrect because **concussion** accurately describes the scenario of temporary physiological paralysis without organic structural damage.

Q: A patient is in shock with gross comminuted fracture. The first step in management is to give

Ringer's Lactate solution intravenously. ***Ringer's Lactate solution intravenously*** - In cases of **hypovolemic shock**, the immediate priority is to restore circulating volume with an **isotonic crystalloid solution** like **Ringer's Lactate**. - This helps to stabilize hemodynamics and perfuse vital organs, while other measures are prepared. *Blood transfusion* - While blood loss is a concern in gross comminuted fractures, **blood transfusions** are generally reserved for more severe, confirmed blood loss and are often given after initial crystalloid resuscitation. - Type-specific or cross-matched blood may take time to prepare and administer. *Plasma expanders* - **Plasma expanders** (e.g., colloids) are alternatives but are generally not the first-line choice over crystalloids for initial resuscitation in trauma, due to their higher cost and potential side effects, with no clear survival benefit. - They also do not address the acute need for volume replacement as effectively as initial rapid infusion of crystalloids. *Normal saline intravenously* - **Normal saline** is an isotonic crystalloid and could be used; however, **Ringer's Lactate** is often preferred in large volumes for trauma and shock patients because its balanced electrolyte composition closer to plasma may help to prevent **hyperchloremic acidosis**. - While not as detrimental as in very large volumes, normal saline can contribute to metabolic acidosis when given in excessive amounts.

Q: Which of the following injuries is the most serious?

Open pneumothorax (sucking chest wound). ***Open pneumothorax (sucking chest wound)*** - An **open pneumothorax** allows air to enter and exit the pleural space directly through a chest wall defect, leading to rapid lung collapse and severe respiratory distress. - This condition can quickly progress to a **tension pneumothorax** and compromise both ventilation and circulation, making it immediately life-threatening. *Flail chest (multiple rib fractures with paradoxical movement)* - **Flail chest** involves a segment of the thoracic cage that separates independently from the rest of the chest wall, leading to **paradoxical chest wall movement**. - While serious and often causing significant pain and respiratory compromise, it is generally less acutely life-threatening than an open pneumothorax. *Diaphragmatic injury (rupture of the diaphragm)* - A **diaphragmatic injury** can lead to herniation of abdominal contents into the chest cavity, causing respiratory distress and potential organ strangulation. - While serious and requiring surgical repair, it is often not an immediate threat to life compared to direct impairment of gas exchange seen in an open pneumothorax. *Single rib fracture (isolated rib injury)* - A **single rib fracture** is generally the least serious of the options and can cause pain, but typically does not lead to significant respiratory compromise unless associated with other complications. - Management primarily involves pain control and monitoring for potential secondary injuries like a simple pneumothorax or hemothorax.

Question 1

A 25-year-old man is brought to the emergency department by ambulance after falling 20 ft from a ladder. He was placed on a backboard for spinal stabilization. Intravenous access was obtained en route, and he received infusion of crystalloids. The patient is unconscious upon arrival. His blood pressure is 91/44 mm Hg, pulse is 129/min, and respirations are 8/min. Pulse oximetry is at 85%. Evaluation shows several superficial facial lacerations, a depressed temporal skull fracture, and a forearm fracture. There are no periorbital or periauricular hematomas, and there is no significant neck edema. Which of the following is the most appropriate next step in management of this patient?

Accepted Answer

Orotracheal intubation

Answer

Nasotracheal intubation

Answer

Needle cricothyroidotomy

Answer

Laryngeal mask placement

Question 2

You evaluate an 18 yrs old male who sustained a right sided cervical laceration during a gang fight. Which of the following is a relative rather than an absolute indication for neck exploration?

Accepted Answer

Pneumothorax

Answer

Dysphonia

Answer

Expanding hematoma

Answer

Dysphagia

Question 3

In a patient with head injury, eye opening is seen with painful stimulus, localizes the pain and there is inappropriate verbal response. What would be the score on Glasgow coma scale:

Accepted Answer

10

Answer

9

Answer

8

Answer

11

Question 4

A driver wearing a seat belt applied brakes suddenly to avoid an accident. What is the most common structure injured in seat belt injury?

Accepted Answer

Mesentery

Answer

Spleen

Answer

Liver

Answer

Abdominal aorta

Question 5

All of the following are true regarding flail chest, EXCEPT:

Accepted Answer

Emergency thoracotomy should be required

Answer

Fracture of at least three consecutive ribs in two places

Answer

Mechanical ventilation and endotracheal intubation are not required in all cases

Answer

Paradoxical breathing may be less apparent in conscious patients due to chest wall splinting

Question 6

A 30-year-old woman involved in a car crash is brought into the emergency department. Her blood pressure is 90/60 mm Hg, pulse rate is 120 bpm, and respiration rate is 18 breaths per minute. On peritoneal lavage, she is noted to have free blood in the peritoneal cavity. At the time of exploratory laparotomy, a liver laceration is noted, and there is a 2.5-cm-diameter contusion to an area of small bowel. How should the small-bowel contusion be treated?

Accepted Answer

Resection of the bowel with single-layer anastomosis

Answer

Resection of the bowel and ileostomy

Answer

Inversion of the area of contusion with a row of fine nonabsorbable mattress sutures

Answer

Transillumination evaluation of hematoma with meticulous hemostasis

Question 7

In burn management, which of the following is least useful?

Accepted Answer

Blood

Answer

Dextran

Answer

Normal saline

Answer

Ringer's lactate

Question 8

Type of injury in which there is brief temporary physiological paralysis of function without organic structural damage is:

Accepted Answer

Concussion.

Answer

Laceration.

Answer

Contusion.

Answer

None of the options

Question 9

A patient is in shock with gross comminuted fracture. The first step in management is to give

Accepted Answer

Ringer's Lactate solution intravenously

Answer

Blood transfusion

Answer

Plasma expanders

Answer

Normal saline intravenously

Question 10

Which of the following injuries is the most serious?

Accepted Answer

Open pneumothorax (sucking chest wound)

Answer

Flail chest (multiple rib fractures with paradoxical movement)

Answer

Diaphragmatic injury (rupture of the diaphragm)

Answer

Single rib fracture (isolated rib injury)

Trauma — MCQs

Trauma — MCQs

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