Trauma Practice Questions

Q: Flail chest means fracture of:

Four ribs on two sides. ### 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.

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

5% Dextrose. 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).

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

Pain on passive plantarflexion of the foot. **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.

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

A. **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.

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

Ringer Lactate. **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.

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

C3. **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 1

Flail chest means fracture of:

Accepted Answer

Four ribs on two sides

Answer

Two ribs on the same side

Answer

Two ribs on opposite sides

Answer

All ribs

Question 2

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

Accepted Answer

5% Dextrose

Answer

Normal saline

Answer

Dextrose normal saline

Answer

All of the above

Question 3

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

Accepted Answer

Pain on passive plantarflexion of the foot

Answer

Tingling and numbness

Answer

Skin changes

Answer

Absent pulses

Question 4

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

Accepted Answer

Physical burn injury to the airways above the larynx

Answer

Circulatory shock

Answer

Physical burn injury to the airways below the larynx

Answer

Circumferential burn

Question 5

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

Accepted Answer

A

Answer

B

Answer

C

Answer

D

Question 6

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

Accepted Answer

Ringer Lactate

Answer

Normal saline

Answer

5% Dextrose

Answer

Blood

Question 7

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?

Accepted Answer

Half of the calculated fluid should be given in the initial 8 hours.

Answer

Administer rapid normal saline infusion.

Answer

9 liters of Ringer's lactate should be given in the first 24 hours.

Answer

Urine output should be maintained at 25-30 ml/hr.

Question 8

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

Accepted Answer

C3

Answer

C5

Answer

C7

Answer

T1

Question 9

Which is the most important factor in the management of shock?

Accepted Answer

Deficiency of effective circulation

Answer

Blood pressure

Answer

Cardiac output

Answer

Central venous pressure (CVP) to 8 cm of water

Question 10

What is true about diaphragmatic injury?

Accepted Answer

Diagnostic laparoscopy is advised.

Answer

Chest X-ray is useful.

Answer

Conservative management is done in most cases.

Answer

Late complication is herniation of abdominal contents.

Trauma — MCQs

Trauma — MCQs

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