Trauma Practice Questions

Q: According to ATLS classification of hemorrhagic shock, a patient with decreased blood pressure, decreased urine output and decreased circulatory volume of 30-40% is managed by?

crystalloids+blood transfusion. ***Correct: crystalloids+blood transfusion*** - A 30-40% blood volume loss, indicated by **decreased blood pressure** and **decreased urine output**, corresponds to ATLS **Class III hemorrhagic shock**. - Management for Class III shock requires both **intravenous crystalloids** to restore circulatory volume and **blood transfusion** to replace lost red blood cells and improve oxygen-carrying capacity. - The initial approach follows the **3:1 crystalloid replacement rule**, followed by or concurrent with **packed red blood cells** to address ongoing hemorrhage and maintain oxygen delivery. *Incorrect: blood transfusion alone* - While blood transfusion is crucial for Class III hemorrhagic shock, administering it **alone** without initial crystalloid resuscitation may not adequately address the immediate need for **intravascular volume expansion**. - **Crystalloids** are typically administered first or concurrently to rapidly restore circulating volume and support perfusion before packed red blood cells can be prepared and transfused. *Incorrect: crystalloids infusion* - **Crystalloids alone** would be insufficient for Class III hemorrhage as the patient has experienced significant **red blood cell loss** (30-40% circulating volume) which requires direct replacement to improve oxygen delivery. - While initial crystalloid resuscitation is vital, continuing with crystalloids alone will lead to **dilutional coagulopathy** and failure to correct oxygen-carrying capacity. *Incorrect: plasma therapy* - **Plasma therapy** (e.g., fresh frozen plasma) is primarily used for the correction of **coagulopathy** in actively bleeding patients or those with anticipated massive transfusion. - Although it may be part of a massive transfusion protocol for severe hemorrhage, it is not the primary or sole initial treatment strategy for volume resuscitation and red blood cell replacement in Class III shock.

Q: True about burns -

Hyperglycemia is seen in early burns. ***Hyperglycemia is seen in early burns*** - **Hyperglycemia** is a common metabolic response in the early phase of severe burns due to a **stress-induced increase in counter-regulatory hormones** (e.g., cortisol, catecholamines, glucagon). - This leads to increased **gluconeogenesis** and **glycogenolysis**, alongside **insulin resistance**, contributing to elevated blood glucose levels. *3rd degree burns are painful* - **Third-degree burns** are typically **not painful** at the center of the burn because the nerve endings in the skin have been completely destroyed. - Pain may be present in areas surrounding the burn that are less severely damaged (e.g., second-degree burn areas). *Chemical powder burns should be kept dry* - **Chemical powder burns** should typically be **brushed off dry** before irrigation, as adding water immediately can activate some chemical agents or exacerbate the burn. - After brushing off, **copious irrigation with water** is usually the next step to dilute and remove the remaining chemical. *Child with burns should have damp dressing* - While proper wound care is crucial, **damp dressings** are generally avoided for initial management of burns, especially in children, due to the risk of **hypothermia** and potential for infection if not sterile. - Initial management often involves covering the burn with a **clean, dry dressing** or sterile sheets to protect the wound and prevent further contamination.

Q: For resuscitation in burn shock, the following fluid is advised

Crystalloids & Colloids. ***Crystalloids & Colloids*** - **Crystalloids** (e.g., Ringer's lactate) are the primary fluid for **burn resuscitation** to restore intravascular volume due to increased capillary permeability. - **Colloids** (e.g., albumin) may be added after the initial fluid shift stabilizes (typically after 12-24 hours) to maintain oncotic pressure and prevent excessive edema. *Packed cell volume* - **Packed red blood cells** are generally not indicated for routine early burn resuscitation, as the primary fluid loss is plasma, not red blood cells. - They are reserved for significant **hemorrhage** or severe anemia that develops later in the burn course. *Whole blood volume* - **Whole blood** is rarely used in burn shock resuscitation because it contains both red blood cells and plasma, which are not lost in equal proportions during the acute phase. - The focus is on replacing the lost **plasma volume** and electrolytes. *Plasma* - While plasma is the fluid lost in burn injuries, direct **plasma transfusion** is usually not the first-line treatment for volume resuscitation. - **Crystalloids** are preferred initially due to their availability, lower cost, and ability to expand intravascular volume effectively in the acute phase.

Q: Which of the following is the most important initial step in managing a patient with extensive burns?

Secure the airway and assess for inhalation injury. ***Secure the airway and assess for inhalation injury*** - **Airway management** is the most critical initial step in all trauma patients, including burns, following the **ABCDE protocol**. - In extensive burns, especially those involving **face/neck**, rapid airway swelling can occur due to **thermal injury** and inflammation, requiring early assessment for **inhalation injury signs** (singed nasal hairs, carbonaceous sputum, hoarse voice). *Begin immediate fluid resuscitation with crystalloids* - Critical for preventing **burn shock** in extensive burns and should begin promptly after airway assessment. - Uses formulas like **Parkland formula** for calculation and is part of **circulation management** in ABCDE protocol. *Perform immediate escharotomy for circumferential burns* - Important intervention for **circumferential full-thickness burns** causing **compartment syndrome**. - Should be performed when indicated, but only after **airway and breathing** are secured, as not all extensive burn patients have circumferential burns requiring immediate escharotomy. *Administer prophylactic antibiotics* - **NOT recommended** in initial burn management as it can promote **antibiotic resistance** and mask early infection signs. - Antibiotics should be reserved for treating **documented infections**.

Q: Epidural hematoma is caused by

Middle meningeal artery. ***Middle meningeal artery*** - An **epidural hematoma** most commonly results from trauma causing rupture of the **middle meningeal artery**, which runs in a groove on the inner surface of the temporal bone. - Due to arterial pressure, blood rapidly accumulates in the **epidural space** (between the dura and the skull), leading to a characteristic **lenticular** or **biconvex** shape on imaging. *Posterior cerebellar artery* - The **posterior cerebellar artery** supplies the cerebellum and brainstem; its rupture would more likely cause a **subarachnoid hemorrhage** or an **intracerebral hemorrhage** in the posterior fossa. - It is not typically involved in the formation of an epidural hematoma, which is outside the brain parenchyma. *Vertebral artery* - The **vertebral arteries** form the basilar artery and supply the brainstem and cerebellum; rupture can lead to **subarachnoid hemorrhage** or **intracerebral hemorrhage**. - Like the posterior cerebellar artery, it is not anatomically associated with the epidural space in a way that would cause an epidural hematoma. *Anterior cerebral artery* - The **anterior cerebral artery** supplies the medial frontal and parietal lobes; an aneurysm rupture or trauma involving this artery would typically result in a **subarachnoid hemorrhage** or **intracerebral hemorrhage**. - Its location deep within the cranial cavity makes it an unlikely source for an epidural hematoma, which forms superficial to the dura.

Q: Most common cause of fracture of roof of orbit?

Blow on the forehead. ***Blow on the forehead*** - A direct impact to the forehead transmits force **posteriorly and inferiorly**, directly affecting the thin and fragile **roof of the orbit**. - The roof of the orbit, being part of the **frontal bone**, is susceptible to fracture from such anterior blunt trauma. *Blow on back of head* - A blow to the back of the head primarily impacts the **occipital bone** and associated structures. - The force from this type of impact is unlikely to directly fracture the orbital roof, which is located anteriorly, and would more likely result in **posterior fossa** or **base of skull** fractures. *Blow on the upper jaw* - An impact to the upper jaw typically results in fractures of the **maxilla** or **zygoma**, such as **Le Fort fractures**. - This type of trauma has a different vector of force that generally does not directly cause fractures of the orbital roof. *Blow on parietal bone* - A blow to the parietal bone typically leads to fractures of the **calvarium** in that region. - The force is distributed across the top or side of the skull and usually does not directly propagate to cause isolated fractures of the orbital roof.

Q: Abdominal compartment syndrome develops when intra-abdominal pressure is more than

20 mm of Hg. ***20 mm of Hg*** - **Abdominal compartment syndrome (ACS)** is diagnosed when sustained **intra-abdominal pressure (IAP)** is greater than 20 mmHg, with new organ dysfunction or failure. - This elevated pressure can compromise organ function due to reduced blood flow and increased pressure on surrounding structures. *14 mm of Hg* - While an IAP of 14 mmHg indicates **intra-abdominal hypertension (IAH)**, it does not typically meet the criteria for frank abdominal compartment syndrome. - IAH is graded, and 14 mmHg falls into a lower grade, which may or may not lead to organ dysfunction. *12 mm of Hg* - An IAP of 12 mmHg is considered the upper limit of **normal intra-abdominal pressure** or mild IAH (Grade I). - This pressure level is generally not associated with the severe organ dysfunction characteristic of abdominal compartment syndrome. *16 mm of Hg* - An IAP of 16 mmHg falls into the range of **Grade II intra-abdominal hypertension**. - While it warrants close monitoring and intervention, it is typically not sufficient to define abdominal compartment syndrome unless there is clear evidence of organ failure.

Q: A 22-year-old woman is found in a comatose condition, having lain for an unknown length of time on the tile floor of the courtyard. She is found in possession of cocaine. The patient is transported to the hospital while EMT personnel receive instructions for treatment of drug overdose. During the physical examination the patient's gluteal region shows signs of ischemia. After regaining consciousness, she exhibits paralysis of knee flexion and dorsal and plantar flexion and sensory loss in the limb. What is the most likely diagnosis?

Gluteal crush injury. ***Gluteal crush injury*** - Prolonged pressure on the gluteal region, especially in a comatose state on a hard surface, can lead to **muscle necrosis** and **compartment syndrome**, causing secondary nerve damage. - The symptoms, including **paralysis of knee flexion** (hamstrings, supplied by sciatic/tibial) and **dorsal/plantar flexion** (peroneal and tibial nerves), along with sensory loss in the limb, are consistent with sciatic nerve damage resulting from a crush injury in the gluteal region. *Tibial nerve loss* - While damage to the tibial nerve would cause **paralysis of plantar flexion** and sensory loss, it would not explain the **paralysis of dorsal flexion** (peroneal nerve) or knee flexion (hamstrings). - This option represents a partial injury pattern and does not fully encompass all the described neurological deficits. *Piriformis entrapment syndrome* - This syndrome primarily involves compression of the **sciatic nerve** by the piriformis muscle, causing gluteal pain and paresthesias, often exacerbated by activities. - It typically does not result in a global loss of motor function in the entire lower limb, especially in the context of a crush injury. *S1-2 nerve compression* - Compression at the S1-S2 level would primarily affect **plantar flexion** (S1-S2), **eversion** of the foot, and sensation along the posterior leg and sole of the foot. - It would not explain the **paralysis of knee flexion** (L5-S2, predominantly L5-S1) or **dorsal flexion** (L4-S1, predominantly L4-L5).

Q: Fluid of choice for resuscitation of a burn patient:

Ringer lactate. ***Ringer lactate*** - **Ringer's lactate**, a **balanced crystalloid solution**, is the fluid of choice for initial resuscitation in burn patients due to its electrolyte composition closely mimicking that of plasma. - It helps to restore **fluid volume** and **electrolyte balance** effectively, reducing the risks associated with large-volume resuscitation. *Dextrose 5%* - **Dextrose 5%** is primarily used for providing **free water** and is not suitable for initial volume resuscitation due to its hypotonicity and tendency to distribute into the intracellular space quickly. - Its use in large volumes for burn resuscitation can lead to **hyponatremia** and exacerbate **cerebral edema**. *Human albumin solution* - **Albumin solutions** are colloids and are generally not recommended for initial burn resuscitation as they do not significantly reduce mortality or fluid requirements in the first 24 hours and can be more expensive. - In the initial phases of burn injury, capillaries become leaky, and administered albumin can extravasate into the interstitial space, potentially worsening **edema**. *Hypertonic saline* - While hypertonic saline can reduce the total volume required for resuscitation, its use is complex and carries a higher risk of **hypernatremia** and **hyperchloremic acidosis**. - It is not the standard first-line fluid and typically reserved for specific situations or in centers with extensive experience and close monitoring capabilities.

Q: A man comes to the emergency department with stab injury to left flank. He has stable vitals. What would be the next step in management?

CECT. ***CECT*** - A **Contrast-Enhanced Computed Tomography (CECT)** scan is the preferred initial diagnostic step for a hemodynamically stable patient with a stab wound to the flank. - It effectively assesses the **depth of penetration** and identifies potential internal organ injuries in the abdomen or retroperitoneum, guiding further management. *Diagnostic peritoneal lavage* - **Diagnostic peritoneal lavage (DPL)** is less commonly used for stab wounds in hemodynamically stable patients due to its **invasiveness** and lower specificity compared to CT scans. - While it can detect peritoneal penetration or significant hemorrhage, it often leads to **unnecessary laparotomies** and is not as precise in identifying specific organ injuries. *Laparotomy* - **Laparotomy** (surgical exploration) is indicated for **hemodynamically unstable** patients or those with definitive signs of peritonitis or evisceration. - Since the patient has **stable vitals**, immediate laparotomy is not the next step, as diagnostic imaging is needed first. *Laparoscopy* - **Laparoscopy** is a minimally invasive surgical procedure that can be used diagnostically or therapeutically in stable patients. - However, in the initial assessment of a flank stab wound, a **CECT scan** is typically performed first to get a comprehensive view of potential organ damage before considering a more invasive procedure like laparoscopy.

Question 1

According to ATLS classification of hemorrhagic shock, a patient with decreased blood pressure, decreased urine output and decreased circulatory volume of 30-40% is managed by?

Accepted Answer

crystalloids+blood transfusion

Answer

blood transfusion alone

Answer

crystalloids infusion

Answer

plasma therapy

Question 2

True about burns -

Accepted Answer

Hyperglycemia is seen in early burns

Answer

3rd degree burns are painful

Answer

Chemical powder burns should be kept dry

Answer

Child with burns should have damp dressing

Question 3

For resuscitation in burn shock, the following fluid is advised

Accepted Answer

Crystalloids & Colloids

Answer

Packed cell volume

Answer

Whole blood volume

Answer

Plasma

Question 4

Which of the following is the most important initial step in managing a patient with extensive burns?

Accepted Answer

Secure the airway and assess for inhalation injury

Answer

Begin immediate fluid resuscitation with crystalloids

Answer

Administer prophylactic antibiotics

Answer

Perform immediate escharotomy for circumferential burns

Question 5

Epidural hematoma is caused by

Accepted Answer

Middle meningeal artery

Answer

Posterior cerebellar artery

Answer

Vertebral artery

Answer

Anterior cerebral artery

Question 6

Most common cause of fracture of roof of orbit?

Accepted Answer

Blow on the forehead

Answer

Blow on back of head

Answer

Blow on the upper jaw

Answer

Blow on parietal bone

Question 7

Abdominal compartment syndrome develops when intra-abdominal pressure is more than

Accepted Answer

20 mm of Hg

Answer

14 mm of Hg

Answer

12 mm of Hg

Answer

16 mm of Hg

Question 8

A 22-year-old woman is found in a comatose condition, having lain for an unknown length of time on the tile floor of the courtyard. She is found in possession of cocaine. The patient is transported to the hospital while EMT personnel receive instructions for treatment of drug overdose. During the physical examination the patient's gluteal region shows signs of ischemia. After regaining consciousness, she exhibits paralysis of knee flexion and dorsal and plantar flexion and sensory loss in the limb. What is the most likely diagnosis?

Accepted Answer

Gluteal crush injury

Answer

Tibial nerve loss

Answer

Piriformis entrapment syndrome

Answer

S1-2 nerve compression

Question 9

Fluid of choice for resuscitation of a burn patient:

Accepted Answer

Ringer lactate

Answer

Dextrose 5%

Answer

Human albumin solution

Answer

Hypertonic saline

Question 10

A man comes to the emergency department with stab injury to left flank. He has stable vitals. What would be the next step in management?

Accepted Answer

CECT

Answer

Diagnostic peritoneal lavage

Answer

Laparotomy

Answer

Laparoscopy

Trauma — MCQs

Trauma — MCQs

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