Trauma — MCQs

Trauma Indian Medical PG Practice Questions and MCQs

Question 81: Flail chest means fracture of:

A. Two ribs on the same side
B. Two ribs on opposite sides
C. Four ribs on two sides (Correct Answer)
D. All ribs

Explanation: ### Explanation **Concept and Definition** Flail chest is a clinical diagnosis defined by the fracture of **two or more adjacent ribs** in **two or more places** along their length. This creates a "flail segment"—a portion of the chest wall that is no longer in bony continuity with the rest of the thoracic cage. This segment moves **paradoxically**: it sucks inward during inspiration (due to negative intrathoracic pressure) and bulges outward during expiration. **Why Option C is Correct** Option C ("Four ribs on two sides") is the most accurate description among the choices because it fulfills the criteria of multiple fractures per rib. If four ribs are fractured at two different sites (sides) each, it creates a large, unstable segment that results in the classic clinical presentation of flail chest. **Analysis of Incorrect Options** * **Option A & B:** A single fracture in two ribs (whether on the same or opposite sides) does not create a free-floating segment. The chest wall remains stable. * **Option D:** While fracturing all ribs would certainly cause instability, it is not the minimum definition required for the diagnosis. **Clinical Pearls for NEET-PG** * **Primary Pathology:** The main cause of respiratory failure in flail chest is not the paradoxical movement itself, but the underlying **Pulmonary Contusion**. * **Management:** The mainstay of treatment is **adequate analgesia** (often epidural) and aggressive pulmonary toilet. Mechanical ventilation is reserved for patients with respiratory failure, not for "internal splinting" of the fractures. * **Associated Findings:** Always look for associated injuries like hemothorax or pneumothorax. * **Radiology:** Flail chest is a **clinical diagnosis**, though X-rays or CT scans are used to confirm the number and location of fractures.

Question 82: Which IV fluid should not be used in a patient with head injury?

A. 5% Dextrose (Correct Answer)
B. Normal saline
C. Dextrose normal saline
D. All of the above

Explanation: In neurotrauma management, the primary goal is to maintain cerebral perfusion pressure and prevent secondary brain injury caused by **cerebral edema**. ### Why 5% Dextrose is Contraindicated 5% Dextrose is an **isostonic-in-the-bag** but **hypotonic-in-the-body** solution. Once infused, the glucose is rapidly metabolized by the liver, leaving behind "free water." This free water moves from the intravascular space into the brain cells (intracellular space) via osmosis, significantly worsening **cerebral edema** and increasing intracranial pressure (ICP). Furthermore, hyperglycemia in the setting of acute brain injury can exacerbate neuronal damage through lactic acidosis. ### Analysis of Other Options * **Normal Saline (0.9% NaCl):** This is an **isotonic** crystalloid and the fluid of choice in head injuries. It stays within the extracellular compartment, maintaining blood pressure without causing brain cell swelling. * **Dextrose Normal Saline (DNS):** While it contains dextrose, the presence of 0.9% NaCl makes it hypertonic/isotonic enough to prevent the massive fluid shift seen with pure 5% Dextrose. However, it is still generally avoided unless the patient is hypoglycemic. ### NEET-PG High-Yield Pearls * **Fluid of Choice in Head Injury:** Normal Saline (0.9% NaCl) or Ringer's Lactate (though some prefer NS as RL is slightly hypotonic). * **Hypertonic Saline (3%):** Used specifically to reduce ICP in cases of cerebral edema or herniation. * **Avoid Hypotonic Fluids:** Never use 0.45% NS or 5% Dextrose in neuro-surgical patients. * **Target:** Maintain **Euvolemia** and avoid hypotension (SBP >100-110 mmHg) to ensure adequate Cerebral Perfusion Pressure (CPP).

Question 83: What is the earliest sign or symptom of compartment syndrome of the leg?

A. Tingling and numbness
B. Pain on passive plantarflexion of the foot (Correct Answer)
C. Skin changes
D. Absent pulses

Explanation: **Explanation:** Compartment syndrome occurs when increased interstitial pressure within a closed osteofascial space compromises local tissue perfusion. **Why Option B is Correct:** The **earliest and most sensitive clinical sign** of compartment syndrome is **pain out of proportion to the injury** and **pain on passive stretching** of the muscles within the affected compartment. In the leg, the anterior compartment is most commonly involved. Passive plantarflexion of the foot stretches the muscles of the anterior compartment (e.g., Tibialis anterior, Extensor hallucis longus), triggering intense pain. This sign precedes neurological deficits and vascular compromise. **Analysis of Incorrect Options:** * **A. Tingling and numbness (Paresthesia):** This indicates early nerve ischemia. While it is an early sign, it typically appears *after* the onset of ischemic pain. * **C. Skin changes:** Changes like pallor or tenseness are secondary signs. Tense "wood-like" swelling may be present, but it is less reliable than the patient's subjective pain response. * **D. Absent pulses (Pulselessness):** This is a **late and ominous sign**. Because the intracompartmental pressure rarely exceeds systolic arterial pressure, pulses usually remain palpable until irreversible tissue necrosis has occurred. **NEET-PG High-Yield Pearls:** * **The 6 P’s:** Pain (earliest), Pressure, Paresthesia, Pallor, Paralysis, and Pulselessness (latest). * **Diagnosis:** Primarily clinical. However, if the diagnosis is doubtful, **Stryker’s monitor** is used to measure intracompartmental pressure. * **Critical Threshold:** A Delta pressure (Diastolic BP – Compartment Pressure) **≤ 30 mmHg** is an indication for emergency fasciotomy. * **Gold Standard Treatment:** Urgent **double-incision four-compartment fasciotomy** of the leg.

Question 84: A patient with burns dies within 24 hours. What is the most probable cause?

A. Circulatory shock
B. Physical burn injury to the airways above the larynx (Correct Answer)
C. Physical burn injury to the airways below the larynx
D. Circumferential burn

Explanation: **Explanation:** In the management of burn patients, the timing of mortality is a high-yield concept for NEET-PG. Deaths occurring within the first 24 hours are primarily due to **respiratory complications** or **hypovolemic shock**. **Why Option B is Correct:** The most common cause of early death (within 24 hours) in burn victims is **Upper Airway Obstruction** resulting from physical burn injury to the airways **above the larynx**. The supraglottic airway acts as a heat sink; when it absorbs thermal energy, it develops rapid, massive edema. Because the pediatric or adult airway has limited cross-sectional area, this edema can lead to complete obstruction and asphyxia shortly after the injury. **Analysis of Incorrect Options:** * **Option A (Circulatory Shock):** While "Burn Shock" (hypovolemic) is a major concern in the first 24–48 hours, modern aggressive fluid resuscitation (Parkland Formula) has significantly reduced it as the *immediate* cause of death compared to airway compromise. * **Option C (Injury below the larynx):** Direct thermal injury below the vocal cords is rare because the upper airway efficiently cools inspired air. Lower airway damage is usually **chemical** (due to smoke inhalation/toxins) rather than physical/thermal, and typically causes respiratory failure (ARDS) after 24–48 hours, not immediately. * **Option D (Circumferential burn):** While a circumferential chest burn can restrict ventilation (requiring escharotomy), it is less frequently the primary cause of death within the first 24 hours compared to direct airway edema. **NEET-PG High-Yield Pearls:** * **Early death (<24-48 hrs):** Airway edema/Asphyxia and Hypovolemic shock. * **Late death (>48 hrs):** Sepsis (Most common cause overall) and Multi-Organ Dysfunction Syndrome (MODS). * **Indicator of Inhalation Injury:** Singed nasal hair, carbonaceous sputum, and soot in the oropharynx. * **Management:** Prophylactic intubation is indicated if there is any sign of impending upper airway obstruction.

Question 85: Under which step of the ABCDE approach for trauma care is cervical spine protection implemented?

A. A (Correct Answer)
B. B
C. C
D. D

Explanation: **Explanation:** In trauma management, the **ATLS (Advanced Trauma Life Support)** protocol follows a strict hierarchical sequence (ABCDE) to address life-threatening injuries in order of priority. **Why Option A is Correct:** The first step, **A (Airway with Cervical Spine Protection)**, mandates that while ensuring a patent airway, the cervical spine must be protected. The medical rationale is that any blunt trauma above the clavicle or high-energy mechanism is assumed to have a cervical spine injury until proven otherwise. Excessive movement during airway maneuvers (like head-tilt/chin-lift) can convert a stable fracture into an unstable one, leading to permanent quadriplegia or respiratory arrest. Therefore, **Manual Inline Stabilization (MILS)** or a rigid cervical collar is mandatory during this phase. **Why Other Options are Incorrect:** * **B (Breathing):** Focuses on gas exchange and lung expansion (e.g., tension pneumothorax, flail chest). By this stage, the spine should already be secured. * **C (Circulation):** Focuses on hemorrhage control and fluid resuscitation. * **D (Disability):** Involves a rapid neurological assessment (GCS and pupil reaction). While it assesses spinal cord function, the *protection* of the spine must occur at Step A. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard for Airway:** Endotracheal Intubation. * **Airway Maneuver in Trauma:** Always use the **Jaw Thrust** (avoids neck extension) instead of the Head-tilt/Chin-lift. * **Clearing the C-Spine:** In conscious patients, the **NEXUS criteria** or **Canadian C-Spine Rules** are used to clinically rule out the need for imaging. * **Definitive Airway:** Required if GCS ≤ 8.

Question 86: In cases of burn, which is the fluid of choice in the first 24 hours?

A. Ringer Lactate (Correct Answer)
B. Normal saline
C. 5% Dextrose
D. Blood

Explanation: **Explanation:** The management of burn shock focuses on replacing the massive fluid loss caused by increased capillary permeability. **Ringer’s Lactate (RL)** is the fluid of choice during the first 24 hours because it is an isotonic crystalloid that most closely mimics the electrolyte composition of human plasma. **Why Ringer’s Lactate is the Correct Choice:** 1. **Balanced Electrolytes:** It contains sodium, potassium, and calcium in physiological concentrations. 2. **Acid-Base Balance:** RL contains **sodium lactate**, which is metabolized by the liver into bicarbonate. This helps buffer the metabolic acidosis commonly seen in burn patients due to tissue hypoperfusion. 3. **Reduced Risk of Hyperchloremia:** Unlike Normal Saline, RL has a lower chloride concentration, preventing hyperchloremic metabolic acidosis. **Why Other Options are Incorrect:** * **Normal Saline (0.9% NaCl):** While isotonic, its high chloride content (154 mEq/L) can lead to hyperchloremic acidosis and may exacerbate renal vasoconstriction. * **5% Dextrose:** This is a hypotonic solution once glucose is metabolized. It does not stay in the intravascular space and can lead to cerebral edema and hyponatremia. * **Blood:** Acute burn shock is characterized by loss of plasma and electrolytes, not primarily red blood cells. Blood is only indicated if there is a concomitant traumatic hemorrhage. **High-Yield Clinical Pearls for NEET-PG:** * **Parkland Formula:** The most common resuscitation guide: **4 mL × Body Weight (kg) × % TBSA (Total Body Surface Area)**. Give half in the first 8 hours and the remaining half over the next 16 hours. * **Modified Brooke Formula:** Uses **2 mL/kg/% TBSA** of RL. * **Monitoring:** The best indicator of adequate fluid resuscitation is **Urinary Output** (Target: 0.5–1.0 mL/kg/hr in adults; 1.0 mL/kg/hr in children). * **Rule of Nines:** Used to quickly estimate the % TBSA in adults.

Question 87: A 50-year-old female has a second-degree deep burn involving 45% of total body surface area (TBSA). Regarding her management, which of the following statements is/are true?

A. Administer rapid normal saline infusion.
B. 9 liters of Ringer's lactate should be given in the first 24 hours.
C. Urine output should be maintained at 25-30 ml/hr.
D. Half of the calculated fluid should be given in the initial 8 hours. (Correct Answer)

Explanation: ### Explanation **1. Why Option D is Correct:** The management of major burns (TBSA >15-20%) follows the **Parkland Formula**, which is the gold standard for fluid resuscitation. According to this formula, the total fluid required in the first 24 hours is **4 ml × Weight (kg) × % TBSA**. The timing of administration is critical: * **First 8 hours:** Give **50%** of the total calculated volume (calculated from the *time of injury*, not the time of arrival). * **Next 16 hours:** Give the remaining **50%**. This front-loading of fluids is essential to counteract the massive capillary leak and intravascular volume depletion that occurs immediately after a thermal injury. **2. Why the Other Options are Incorrect:** * **Option A:** **Ringer’s Lactate (RL)** is the fluid of choice, not Normal Saline (NS). Large volumes of NS can lead to hyperchloremic metabolic acidosis. * **Option B:** While the exact volume depends on the patient's weight (not provided here), the Parkland Formula uses 4 ml/kg/%. For a 50 kg patient with 45% TBSA, the volume would be $4 \times 50 \times 45 = 9,000$ ml (9L). However, without the weight, this cannot be a universal truth, whereas the **timing rule** (Option D) is a fundamental principle of the protocol. * **Option C:** In adults, the goal for adequate resuscitation is a urine output of **0.5 ml/kg/hr** (approximately **30–50 ml/hr**). 25 ml/hr is the absolute lower limit and often indicates under-resuscitation. **3. High-Yield Clinical Pearls for NEET-PG:** * **Fluid of Choice:** Crystalloids (Ringer’s Lactate) are used in the first 24 hours. Colloids are generally avoided in the first 8–24 hours due to increased capillary permeability. * **Modified Brooke’s Formula:** Uses 2 ml/kg/% TBSA (often used to avoid fluid overload). * **Rule of Nines:** Used for quick TBSA estimation; remember that first-degree burns (erythema only) are **not** included in the calculation. * **Electrical Burns:** Target a higher urine output (**75–100 ml/hr**) to prevent acute tubular necrosis from myoglobinuria.

Question 88: A person might become quadriplegic if the injury to the spine is at which level?

A. C3 (Correct Answer)
B. C5
C. C7
D. T1

Explanation: **Explanation:** The level of spinal cord injury (SCI) determines the extent of motor and sensory loss. **Quadriplegia (Tetraplegia)** refers to the loss of function in all four limbs and the torso, resulting from injuries to the **cervical segments (C1 to C8)** of the spinal cord. **Why C3 is the correct answer:** An injury at the **C3 level** results in complete quadriplegia. More importantly, it is life-threatening because the **phrenic nerve**, which innervates the diaphragm, originates from the **C3, C4, and C5** nerve roots. An injury at or above C3 leads to respiratory paralysis, requiring immediate mechanical ventilation for survival. **Analysis of Incorrect Options:** * **C5:** While an injury here still causes quadriplegia, the patient retains some shoulder function (deltoid) and elbow flexion (biceps). The diaphragm usually remains functional as the C3 and C4 roots are intact. * **C7:** An injury at C7 allows for elbow extension (triceps) and some finger extension. The patient is still a quadriplegic but has significantly more upper limb utility than a C3 injury. * **T1:** The thoracic spine begins at T1. Injuries from **T1 downwards result in Paraplegia** (loss of function in the lower half of the body), as the nerve supply to the upper extremities (Brachial Plexus: C5-T1) remains largely intact. **High-Yield Clinical Pearls for NEET-PG:** * **Diaphragm Innervation:** "C3, 4, 5 keep the diaphragm alive." * **Autonomic Dysreflexia:** Most common in injuries at or above **T6**. * **Neurogenic Shock:** Characterized by the triad of hypotension, **bradycardia**, and peripheral vasodilation; typically seen in injuries above T6. * **Spinal Shock:** A physiological loss of all reflex activity below the level of injury; the end of spinal shock is marked by the return of the **Bulbocavernosus reflex**.

Question 89: Which is the most important factor in the management of shock?

A. Blood pressure
B. Cardiac output
C. Central venous pressure (CVP) to 8 cm of water
D. Deficiency of effective circulation (Correct Answer)

Explanation: **Explanation:** **1. Why "Deficiency of Effective Circulation" is correct:** Shock is fundamentally defined as a state of **cellular and tissue hypoxia** due to an imbalance between oxygen delivery and oxygen demand. The most critical factor in its management is addressing the **deficiency of effective circulation** (inadequate tissue perfusion). Regardless of the etiology (hypovolemic, cardiogenic, or distributive), the primary goal is to restore the microcirculation to ensure oxygen reaches the mitochondria. If effective circulation is not restored, the patient progresses from compensated shock to irreversible multi-organ dysfunction syndrome (MODS). **2. Why the other options are incorrect:** * **Blood Pressure (A):** BP is a poor indicator of early shock. Due to compensatory mechanisms (tachycardia and vasoconstriction), BP may remain normal even when tissue perfusion is severely compromised (Compensated Shock). * **Cardiac Output (B):** While important, CO alone doesn't guarantee tissue oxygenation. For example, in septic shock, CO may be high (hyperdynamic), but the "effective" circulation is poor due to peripheral shunting and maldistribution of flow. * **CVP to 8 cm of water (C):** CVP is a measure of right atrial pressure and fluid status, not a global measure of shock management. While used in resuscitation protocols (like Rivers’ Early Goal-Directed Therapy), it is a static parameter and often fails to predict fluid responsiveness accurately. **Clinical Pearls for NEET-PG:** * **Earliest sign of shock:** Tachycardia (except in neurogenic shock where bradycardia occurs). * **Best indicator of tissue perfusion:** Urine output (Target: >0.5 ml/kg/hr in adults) and decreasing Serum Lactate levels. * **Golden Hour:** The first 60 minutes following injury where prompt resuscitation significantly improves survival. * **End-point of resuscitation:** Normalization of lactate levels and base deficit, rather than just achieving a specific BP.

Question 90: What is true about diaphragmatic injury?

A. Diagnostic laparoscopy is advised. (Correct Answer)
B. Chest X-ray is useful.
C. Conservative management is done in most cases.
D. Late complication is herniation of abdominal contents.

Explanation: ### Explanation Diaphragmatic injuries are often clinically silent and can be easily missed during the initial evaluation of thoracoabdominal trauma. **1. Why Option A is Correct:** **Diagnostic Laparoscopy** is considered the gold standard for diagnosing occult diaphragmatic injuries, particularly in penetrating trauma to the "thoracoabdominal zone" (lower chest/upper abdomen). Since the diaphragm has a pressure gradient favoring the abdomen-to-thorax movement, even small tears do not heal spontaneously. Laparoscopy allows for direct visualization and immediate repair, preventing future complications. **2. Why the Other Options are Incorrect:** * **Option B:** While a Chest X-ray (CXR) is the initial screening tool, it is often **unreliable**. It may show a "nasogastric tube in the chest" or a "blurred hemidiaphragm," but it is normal in up to 50% of acute cases. Therefore, it is not definitively "useful" for excluding the injury. * **Option C:** Conservative management is **never** indicated. Diaphragmatic injuries must always be surgically repaired because the pleuroperitoneal pressure gradient ensures the defect will enlarge over time, leading to herniation. * **Option D:** While herniation is a complication, the question asks for what is "true" regarding management/diagnosis priorities. In the context of NEET-PG, the emphasis is on the **high index of suspicion** and the role of laparoscopy in preventing late sequelae. (Note: If multiple options seem plausible, the most definitive clinical guideline—laparoscopy for diagnosis—takes precedence). ### High-Yield Clinical Pearls for NEET-PG: * **Side Predilection:** Left-sided injuries are more common (80%) because the **liver protects the right hemidiaphragm**. * **Mechanism:** Blunt trauma usually causes large radial tears; penetrating trauma causes small linear tears. * **Sign of Choice:** The **"Grummelot’s sign"** (bowel sounds heard in the chest) is a classic clinical finding. * **Imaging:** On CT, the **"Dropped Lung Sign"** or **"Collar Sign"** (constriction of herniated organs) are pathognomonic. * **Surgical Approach:** Acute injuries are repaired via **Laparotomy**; chronic/latent presentations (hernias) are often approached via **Thoracotomy** due to adhesions.

Practice by Chapter

Initial Assessment of Trauma Patient

Practice Questions

Advanced Trauma Life Support (ATLS) Principles

Practice Questions

Chest Trauma

Practice Questions

Abdominal Trauma

Practice Questions

Head Trauma

Practice Questions

Spinal Trauma

Practice Questions

Extremity Trauma

Practice Questions

Vascular Trauma

Practice Questions

Genitourinary Trauma

Practice Questions

Burns Management

Practice Questions

Mass Casualty Management

Practice Questions

Damage Control Surgery

Practice Questions

Want unlimited practice?

Get full access to all questions, explanations, and performance tracking.

Start For Free

Trauma — MCQs

Trauma — MCQs

On this page

Practice by Chapter

Want unlimited practice?